505860

research-article2013

PENXXX10.1177/0148607113505860Journal of Parenteral and Enteral NutritionKlek et al

Original Communication

Prevalence of Malnutrition in Various Political, Economic, and Geographic Settings Stanislaw Klek, MD, PhD1; Zeljko Krznaric, MD, PhD2; Riza Haldun Gundogdu, MD, PhD3; Michael Chourdakis, MD4; Gintautas Kekstas, MD5; Triin Jakobson, MD6; Piotr Paluszkiewicz, MD, PhD7; Darija Vranesic Bender, MD, PhD8; Mehmet Uyar, MD, PhD9; Kubilay Demirag, MD, PhD9; Kalliopi Anna Poulia, PhD10; Andrius Klimasauskas, MD5; Joel Starkopf, MD, PhD6; and Aleksander Galas, MD, PhD11

Journal of Parenteral and Enteral Nutrition Volume 39 Number 2 February 2015 200­–210 © 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607113505860 jpen.sagepub.com hosted at online.sagepub.com

Abstract Background: Disease-related malnutrition (DRM) represents a critical public health concern. Therefore, Fight Against Malnutrition (FAM) should be a state priority, but the degree to which this is true appears to differ considerably among European countries. The aim of this study was to put the problem into perspective by comparing the prevalence of malnutrition in countries from opposite parts of the continent. Methods: Six countries—Croatia, Estonia, Greece, Lithuania, Poland, and Turkey—participated in the study. A short questionnaire was used to assess DRM: its prevalence, the current situation in hospitals, regulations for reimbursement, and general healthcare circumstances. Data from ESPEN’s NutritionDay 2006 were used to broaden the perspective. Results: At admission in October 2012, 4068 patients were assessed. The study was performed in 160 hospitals and 225 units with 9143 beds. The highest proportions of patients with 3 or more points on the Nutritional Risk Screening 2002 were observed in Estonia (80.4%) and Turkey (39.4%), whereas the lowest were in Lithuania (14.2%). The provision of nutrition support was best in Turkey (39.4% required intervention, 34.4% received intervention) and Poland (21.9% and 27.8%, respectively). Nutrition support teams (NSTs) are active in some countries, whereas in others they virtually do not exist. Conclusion: The prevalence of malnutrition was quite high in some countries, and the nutrition approach differed among them. It could be the result of the lack of reimbursement, inactive or nonexistent NSTs, and low nutrition awareness. Those facts confirmed that the continuation of FAM activities is necessary. (JPEN J Parenter Enteral Nutr. 2015;39:200-210)

Keywords malnutrition; disease-related malnutrition; Fight Against Malnutrition

Clinical Relevancy Statement Disease-related malnutrition (DRM) represents a critical public health concern worldwide. Numerous surveys indicate a prevalence of 20%–30% at the time of admission to hospital. The impact of important aspects, such as the policy of the state, its economy, as well as the historical burden, which may influence the prevalence of DRM, has rarely been analyzed. Our study proved that all those factors do have an important impact on the problem and that DRM represents an issue, comparable in terms of scale, worldwide. Moreover, the research showed that the intensity and methods adopted to fight malnutrition differ significantly among countries. This appears to be directly associated with real successes in some countries, and little progress elsewhere. This should be discussed in an open forum, so that countries can learn from each other.

Introduction

From 1General Surgery Unit, Stanley Dudrick’s Memorial Hospital, Skawina, Poland; 2School of Medicine, University of Zagreb, Croatia; 3General Surgery and Gastrointestinal Surgery, Atatürk Teaching and Research Hospital, Ankara, Turkey; 4School of Medicine, Aristotle University of Thessaloniki, Greece; 5Vilnius University Hospital Clinic of Anaesthesia and ICU, Vilnius, Lithuania; 6Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia; 7Department of Gastrointestinal Surgery, Lublin Regional Cancer Centre, and Department of Surgery and Surgical Nursing, Medical University, Lublin, Poland; 8Center of Clinical Nutrition, University Hospital Zagreb, Zagreb, Croatia; 9Department of Anesthesiology and Intensive Care, Ege University Hospital, Izmir, Turkey; 10Laiko Hospital, Athens, Greece; and 11Department of Epidemiology, Jagiellonian University Medical College, Krakow, Poland. Financial disclosure: None declared. Conflicts of interest: Stanislaw Klek acts as a lecturer and consultant for B Braun, Fresenius Kabi, Nutricia Polska Ltd, Nestle, and Baxter. The other authors declare no potential or actual personal, political, or financial interest in the material, information, or techniques described in the article. Received for publication June 16, 2013; accepted for publication August 8, 2013.

Disease-related malnutrition (DRM), which can be both cause and consequence of acute or chronic illness, is a critical public This article originally appeared online on November 4, 2013. health concern worldwide, costing European governments up Corresponding Author: to US$125 billion every year.1,2 Stanislaw Klek, MD, PhD, Stanley Dudrick’s Memorial Hospital, Malnutrition is caused primarily by poor nutrient intake and General Surgery Unit, 32-050 Skawina, 15 Tyniecka Street, Poland. Email: [email protected] metabolic dysregulation stemming from acute or chronic Downloaded from pen.sagepub.com at NANYANG TECH UNIV LIBRARY on May 21, 2015

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Table 1.  Description of Hospitals, Units, and Patients. Parameter

Lithuania

Poland

Turkey

Greece

Croatia

Estonia

Total

Hospitals Hospital units Beds in units Patients Nonrespondersa (presented as % of all units)

4 10 1095 140 2 (16.6%)

116 143 5280 1005 11 (7.1%)

24 38 1015 769 2 (5%)

6 14 512 327 2 (12.5%)

9 16 285 1786 0

1 4 956 41 0

160 225 9143 4068 17 (7%)

a

Number (percentage) of hospital units that did not reply.

inflammation, but it can also be an effect of disease and/or its treatment.3-5 Patients in the hospital and in the community often fail to meet their daily requirements for energy, protein, and micronutrients, which leads to undernutrition.5-8 The latter increases morbidity, mortality, hospital readmissions, and length of hospital stay.5-8 Over the past 20 years, it has been demonstrated that malnutrition occurs in 20%–60% of hospitalized patients and may deteriorate during the hospital stay, but it also is frequent among outpatients (7%–16%).3-13 It is surprising that the problem of malnutrition often passes ignored or unnoticed. It is also very often untreated, even if recognized. Both of the world’s leading clinical nutrition societies, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the European Society for Clinical Nutrition and Metabolism (ESPEN), have undertaken many activities to change this situation and to focus attention on malnutrition and its consequences. European activities were named Fight Against Malnutrition (FAM) and include conferences at international-level (Prague 2009, Brussels 2010, and Warsaw 2011) or national-level workshops and educational actions. They are dedicated not only to medical specialists such as physicians, dietitians, pharmacists, and nurses but also, and more important, to politicians, health authorities, and journalists. In addition to this, in 2006 ESPEN launched its flagship activity, NutritionDay (ND), which has been performed annually ever since.13 ND was created as a longitudinal survey of the incidence of malnutrition and soon became a worldwide event that has helped to gather unique data about the nutrition status of more than 135,000 patients on almost all continents. According to its 2006 results, the prevalence of malnutrition was lowest in Hungary, Austria, and Germany, whereas the highest rates were in the United Kingdom, the rest of the Western region, the rest of the Southern region, as well as Bulgaria, Czech Republic, Poland, Romania, and the Nordic countries.13 Surprising as it was, particularly for the Nordic countries, which actively participated in nutrition activities, it was also stimulating. National clinical nutrition societies (so-called PEN societies) and members of ESPEN performed a variety of

activities to raise nutrition awareness among specialists and in the general population. The implementation of nutrition screening, reimbursement of clinical nutrition support in various settings, and the introduction of nutrition support teams (NSTs) into daily practice were considered as mainstays to improve awareness of the problem and to be the first steps in its resolution. Since its founding, A.S.P.E.N. has focused its strategic efforts on reducing the incidence of malnutrition in hospitalized patients. Its actions include creation of the A.S.P.E.N. malnutrition toolkit (allowing healthcare professionals to diagnose DRM), forming the Alliance to Advance Patient Nutrition (together with other leading societies), raising awareness (by organizing online activities, webinars, chats, and expert meetings), and education (on-site and online learning). In 2012, some of ESPEN member countries with a higher prevalence of malnutrition decided to re-evaluate the situation and at the same time to compare opposite regions of Europe. To achieve this goal, the ND assessment, during which all hospitalized patients, independent of the length of stay or their progress within it, are evaluated over 1 day, was supported by the additional analysis of the nutrition status of patients newly admitted to the hospital. The aim of this study was not only to analyze the prevalence of malnutrition but also to compare the situation in 6 countries located in distant parts of Europe, better to illustrate the problem of malnutrition in this region.

Methods The multicenter study was performed in Croatia, Estonia, Greece, Lithuania, Poland, and Turkey. The south of Europe was represented by Croatia, Greece, and Turkey, and the north by the other 3 (Table 1). Representatives of national PEN societies were asked to collect the historical data from ND and to perform an additional short survey on admissions on 1 selected day within the study period. The survey was designed to assess the prevalence of malnutrition on admission to the hospital and used a simple and concise questionnaire, presented in Figure 1. The questionnaire included

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Journal of Parenteral and Enteral Nutrition 39(2) Nutritional Assessment Questionnaire: October 2012

1. P  lease write down the number of all patients admitted to the unit (units, hospital) on 9th October 2012: …………………………………………………. 2. P  lease write down results of the nutritional assessment of the patients admitted to unit on 9th October 2012 (number of patients): According to the NRS scale: 0 pts - ………………. patients 1 pts - ………………. patients 2 pts - ………………. patients 3 pts - ………………. patients

4 pts - ………………. patients 5 pts - ………………. patients 6 pts - ………………. Patients 7 pts - ………………. patients

According to the SGA scale: A - …………………… patients B - …………………… patients C - …………………… patients 3. H  ow many of the patients, who received 3 or more points in NRS scale or B/C in the SGA scale, received nutritional treatment: Enteral nutrition - ………………………. patients Parenteral nutrition - ………………………. patients Enteral and parenteral nutrition - ………………………. patients 4. Did the risk of complications due to nutrition disorders was taken into consideration while planning treatment of the basic illness? Yes - ……………… patients No - ……………… patients 5. Who in the unit/hospital is responsible for patients’ nutrition assessment Physician Dietician Nurse Someone else – please state who ………………………………………… 6. Do you have a Nutrition Support Team in your hospital? Yes No 7. Number of beds in the unit: ……………………. 8. Hospital unit profile …………………………………. Please return the questionnaire to ………………………..

Figure 1.  The questionnaire used for the study.

Table 2.  Initial Screening. No. 1 2 3 4

Question

Yes

Is body mass index < 20.5? Has the patient lost weight within the past 3 months? Has the patient had a reduced dietary intake in the past week? Is the patient severely ill (eg, in intensive therapy)?

No        

If the answer is “Yes” to any question, the screening in Table 3 is performed. If the answer is “No” to all questions, the patient is rescreened at weekly intervals. If the patient is scheduled for a major operation, for example, a preventive nutrition care plan is considered to avoid the associated risk status. Reprinted with permission from Elsevier.14

questions assessing the number of patients admitted to the hospital unit, their nutrition status according to the Nutritional Risk Screening 2002 (NRS 2002, presented in Tables 2 and 3) and/or Subjective Global Assessment (SGA; Figure 2), the implementation of clinical nutrition (enteral nutrition [EN], parenteral nutrition [PN], or both), the person responsible for nutrition assessment, the presence/absence of an NST, and the medical profile of the unit. Training in the use of the NRS and SGA was performed by PEN society representatives in those cases where the scale was not already in use. In countries like Poland, where nutrition screening is mandatory from a legal point of view, no additional training was performed prior to the study.

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Table 3.  Final Screening. Impaired Nutrition Status Absent Score 0 Mild score 1

Moderate score 2

Severe score 3

Score: Age

Severity of Disease (≈ Increase in Requirements)

normal nutrition status

Absent Score 0 Mild score 1

weight loss > 5% in 3 months or food intake below 50%–75% of normal requirement in preceding week

normal nutrition requirements   hip fracturea ; chronic patients, in particular with acute complications: cirrhosis,a COPDa; chronic hemodialysis,b diabetes,b oncologyb major abdominal surgery,a stroke,a severe pneumonia,b hematologic malignancyb

weight loss > 5% in 2 months or BMI Moderate score 2 18.5–20.5 + impaired general condition or food intake 25%–60% of normal requirement in preceding week weight loss > 5% in 1 month (> 15% in Severe score 3 head injury,a bone marrow 3 months) or BMI < 18.5 + impaired transplantation,a intensive care patients (APACHE > 10)b general condition or food intake 0%– 25% of normal requirement in preceding week + Score: = total score if ≥ 70 years: add 1 to total score above = age-adjusted total score Score ≥ 3: the patient is nutritionally at-risk and a nutrition care plan is initiated

Score < 3: weekly rescreening of the patient. If the patient, eg, is scheduled for a major operation, a preventive nutrition care plan is considered to avoid the associated risk status. NRS 2002 is based on an interpretation of available randomized clinical trials.

A nutrition care plan is indicated in all patients who are (1) severely undernourished (score = 3), (2) severely ill (score = 3), (3) moderately undernourished + mildly ill (score 2 + 1), or (4) mildly undernourished + moderately ill (score 1 + 2).

 

Nutrition risk is defined by the Prototypes for severity of disease present nutrition status and risk of impairment of present status, due to increased requirements caused by stress metabolism of the clinical condition.

Score=1: a patient with chronic disease, admitted to hospital due to complications. The patient is weak but out of bed regularly. Protein requirement is increased but can be covered by oral diet or supplements in most cases.

Score = 2: a patient confined to bed due to illness, eg, following major abdominal surgery. Protein requirement is substantially increased but can be covered, although artificial feeding is required in many cases. Score = 3: a patient in intensive care with assisted ventilation, etc. Protein requirement is increased and cannot be covered even by artificial feeding. Protein breakdown and nitrogen loss can be significantly attenuated.

BMI, body mass index; COPD, chronic obstructive pulmonary disease; NRS 2002, Nutritional Risk Screening 2002. Reprinted with permission from Elsevier.14 a Indicates that a trial directly supports the categorization of patients with that diagnosis. b Diagnosis based on the prototypes given below.

Participants were asked to assess their country’s nutrition situation with respect to the legal regulations on reimbursement, the implementation of nutrition screening, and the general medical scenario (number of hospitals, their situation, actions to fight malnutrition, etc) (Tables 4 and 5). The study was performed between October 1, 2012, and January 10, 2013. The inclusion criterion was the possibility of the evaluation of an inpatient on the day of admission. Exclusion criteria included refused consent and patients admitted to the unit before the examination time.

Outcome Measures The main goals of the study were as follows: 1. To assess prospectively the prevalence of malnutrition on admission to hospital (using the study questionnaire) 2. To assess the prevalence of malnutrition in the whole patient population for that unit (using ND data) 3. To compare present data with the historical data from 2006

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Figure 2.  Subjective Global Assessment. Table 4.  Description of Each Participating Country. Parameter

Lithuania

Population, millions No. of hospitals Therapeutic options available and reimbursed in hospitals Therapeutic options available and reimbursed in other settings (home, long-term) Nature of funding for healthcare

public health system

National nutrition guidelines

U

Poland

Turkey

Greece

3 187 none

38 743 EN, PN

75 1366 EN, PN

none

EN, PN

EN (partial EN, PN (partial reimbursement) reimbursement)

public health public health system system A

A

11.3 131 EN, PN

public health system/private sector U

A, available; EN, enteral nutrition; PN, parenteral nutrition; U, unavailable.

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Croatia

Estonia

4.3 54 EN, PN

1.3 55 none

EN (only oral artificial diets)

none

public health system U

public health system U

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Table 5.  Profiles of Participating Units. Type of Unit

No. of Participating Units

General surgery Intensive care unit Internal medicine Pediatrics Oncologic surgery Oncology Laryngology Neurology Psychiatry Gynecology Urology Ophthalmology

69 62 20 19 17 10 9 6 4 4 4 1

4. To assess the execution of nutrition screening at hospitals 5. To evaluate the quality of the provision of clinical nutrition services (including the presence of NSTs, and reimbursement options) Patients who scored 3 or more points on the NRS 2002 or those assessed as B or C using the SGA were categorized as malnourished.

Sample Size and Statistical Analysis The statistical analysis was performed using the SPSS v.19 (SPSS Inc, Chicago, IL) software package. The χ2 test was used if the expected frequency was < 5 in < 20% of cells; otherwise, Fisher’s exact test was performed. A P value < .05 was accepted as being statistically significant. A prior calculation of sample size was not performed due to insufficient data on the number of hospital units, the incomparable situations between countries, and the lack of past data on prevalence in the participating centers.

Results All 6 participating countries provided the required data (Table 1). In total, 4068 patients were assessed using the 2012 questionnaire (Poland 1005, Croatia 1786, Turkey 769, Greece 326, Lithuania 140, Estonia 41). The study was performed in 160 hospitals and 225 units with 9143 beds. More than 1000 patients evaluated in 2006 using ND questionnaires formed the historic regional control group. The rate of nonresponse was acceptably low (Table 1).

Poland At the time of the study, the population of Poland was 38 million. There were 743 hospitals with 183,040 beds in the

country; 526 (70.6%) of those were public entities. The mean length of hospital stay was 5.8 days. There is only 1 state insurance company. The state healthcare expenses reach 7% of gross domestic product (GDP). The reimbursement of nutrition care covered all costs of PN and enteral tube feeding in hospital, long-term, palliative, and home care. The use of oral nutrition supplements was not reimbursed, however. POLSPEN, the Polish Society for Parenteral, Enteral Nutrition and Metabolism, succeeded in the implementation of obligatory screening for malnutrition (with either NRS 2002 or SGA) on admission to the hospital. This was in the form of a regulation issued as the law by the Ministry of Health and effective on January 1, 2012. The same regulation recommended the founding of NSTs at every hospital, but introduction of this element was postponed until 2014 because of insurance company objections. Poland has participated in ND since 2006. The ND survey performed in 2006 showed that 36.5% of patients reported weight loss before admission, and 36.1% had lost more than 8 kg in 3 months.

Turkey At the time of the study, the population of the country was close to 75 million. In Turkey, there are 1366 hospitals with a varying number of beds (between 50 and 1200). Of these, 136 are teaching hospitals, 500 are private hospitals, and the rest are state hospitals. In 74 of the teaching hospitals, there is a NST (54.4%). In 2010, the Ministry of Health published “Guidelines for Safe TPN Administration” in collaboration with the Turkish Society for Parenteral and Enteral Nutrition (KEPAN) and compelled each hospital to follow the guidelines. Turkey has participated in ND every year since 2006. In 2011, 2213 patients from 96 units were recorded. There is reimbursement for EN and PN in Turkey: •• In hospitalized patients, all the necessary equipment, nutrition mixtures, and other expenses are covered by the government (Social Security Institution of Republic of Turkey). •• For outpatients, all the necessary equipment, nutrition mixtures, and other expenses are covered if a medical report from a state hospital is available. The national PEN society has been very active in the field of FAM. In 2009, KEPAN conducted a study titled “Nutritional risk of hospitalized patients in Turkey.”15 According to Turkish ND 2006 data, 54% of patients had weight loss before admission, and 24% lost more than 8 kg in 3 months. In 2011, those data were reported as 48% and 29%, respectively.

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Croatia At the time of the study, the population of Croatia was close to 4.3 million. There are 56 hospitals with a varying number of beds. Similar to other countries, the insurance system is based on a single, state insurance company. The reimbursement of nutrition care covers all costs of oral nutrition supplements, PN, and enteral tube feeding in the hospital as well as in the home setting. The Croatian Society of Clinical Nutrition is making efforts to raise awareness of the importance of early detection of nutrition risks, in order to prevent and treat malnutrition successfully. Croatia has participated in ND every year since 2006, with a total of 14 (25%) hospitals and 1 nursing home participating and 1084 patients recorded.

Lithuania The population of Lithuania is close to 3 million people. There are 187 hospitals with 35,600 beds across the country. Again, the insurance system is based on a single, state insurance company. The latter does not reimburse for nutrition for inpatients or home patients. Hospitals are reimbursed for the main treatment procedure (such as surgery), and hence, not much money can be designated for nutrition purposes. There are plans to implement a diagnosis-related group (DRG) system in Lithuania in 2013, which should improve the situation. In 2006, there were no NSTs acting in Lithuanian hospitals. Only 20% of patients reported weight loss before admission, and in one-fifth, it was significant. PN was more often used than EN.

Greece At the time of the study, the population in Greece was about 11.3 million people. Healthcare is provided by the National Healthcare Service, called ESY, or by the private sector. According to the statistics published by the World Health Organization in 2012, from 2000 to 2009, the Greek total expenditure on health rose from 7.8% to 10.6% of the total GDP, whereas in 2011, total health spending accounted for 10.2% of GDP due to the reduction of costs caused by the economic crisis.10 In 2009, the number of hospital beds per 100,000 population in the country was 48 and the total number of hospitals in ESY in June 2010 was 131, with a total of 35,000 beds.11 In July 2011, due to the economic crisis, it was decided by the government to reduce the number of hospitals to 83, with a reduction in the bed number to 33,000.12 According to the Organisation for Economic Co-operation and Development (OECD) Health Data published in 2012, the number of physicians per capita in Greece exceed the relevant number in any other OECD member, reaching 6.1 practicing physicians per 1000 population in 2010, nearly double the OECD average of 3.1.13 Despite the oversupply of physicians, there is an undersupply of nurses, accounting for only 3.3 per

1000 population, vs an average of 8.7 in OECD countries, resulting in an inefficient allocation of resources. Until 2012, neither NSTs nor nutrition screening or assessment were mandatory in Greek hospitals. New legislation that was voted in by the Greek parliament in March 2012 now gives emphasis on nutrition screening and support in hospitals. In addition, it includes a strong suggestion for the foundation of an NST in all public hospitals. It is unfortunate that in the majority of public hospitals, this legislation has not yet been adequately adopted, resulting in a persistently very low percentage of nutrition screening or assessment and still only few NSTs. During hospitalization, the cost of enteral or parenteral feeding is fully reimbursed, if this need is well documented. For homecare, due to austerity measures, the reimbursement of EN support has recently been limited to 400 euros per month (from 1000), whereas PN is still fully reimbursed. Greece at first participated in ND with a very limited number of patients, and the 2006 data are too few for reliable conclusions. By 2011, the importance of hospital malnutrition was clear, with 45% of the participants reporting weight loss in the past 3 months, including 16.8% with weight loss in excess of 8 kg.

Estonia The population of Estonia is close to 1.3 million; there are 55 hospitals with 7588 beds. The Estonian health insurance system is based on solidarity—all insured people have the same rights. Some other inhabitants have the same rights as taxpayers, such as children and pregnant women from the 12th week of pregnancy. If the health service provider has a contract with the Estonian Health Insurance Fund, all costs are directly reimbursed to it by the fund, including costs for EN and PN during hospital stay. It is unfortunate that expenses for home EN and PN are not covered by the Estonian Health Insurance Fund. None of the Estonian hospitals has a NST. Estonia did not participate in ND until 2012.

The Prevalence of Malnutrition in Participating Countries between 2006 and 2012 In 2012, the highest proportions of patients in whom there were indications for nutrition support and who were diagnosed to this effect on admission (3 or more points on NRS 2002) were observed in Estonia (57.4%), Turkey (39.4%), and Greece (32.8%), and the lowest were in Lithuania (14.2%) and Poland (21.9%). These differences were statistically significant (P < .05). The prevalence of malnutrition assessed with the SGA was highest in Estonia (42.5%), Greece (42.5%), and Turkey

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(41.2%), whereas in Poland it reached 23.2% (Lithuania did not use the SGA for assessment). Severe malnutrition (SGA score C) was diagnosed in 19.7% of Turkish patients, in 9.9% of Polish patients, and in 9.4% of Greek patients. These differences were also statistically significant (P < .05). The proportion of significantly undernourished patients appeared to fall in Poland between 2006 and 2012 from more than 36% to 23.2%. In Turkey and Greece, the apparent proportion increased: from 24% to 41.1%, and from 16.8% to 42.5%, respectively. Those comparisons, however, are biased by different tools used for assessment and its execution. Results are presented in Tables 5 and 6.

Screening Execution Nutrition screening was mainly performed by physicians (Estonia 100%, Poland 88.8%, Turkey 81.6%, Croatia 75%, Lithuania 60%, and Greece 57.1%) and dietitians (Greece 42.9%, Lithuania 40%, Turkey 39.4%, Poland 14.6%, Croatia 12.5%). Nurses rarely participated in the process (Turkey 15.7%, Poland 14.6%, Croatia 12.5%, Estonia, Greece, and Lithuania 0%).

NSTs NSTs form a vital part of hospital activity in Poland (72.4% with NSTs) and Turkey (68.4%) but are almost unknown in the other countries: Greece 0%, Estonia 0%, Croatia 8.9%, and Lithuania approximately 10% (P < .05). When compared with 2006, the number of active NSTs in Poland grew from 52% to 72.4%. The present situation in Croatia also represents an improvement. The situations in Greece and Estonia have not changed over these years.

Provision of Nutrition Support The execution of clinical nutrition was best in Turkey (39.4% required nutrition intervention according to the NRS 2002 and 34.4% received it), Lithuania (14.2% and 30%, respectively), Poland (21.9% required, 27.8% received), Greece (32.8% and 19.9%, respectively), Croatia (34.4% and 24.4%, respectively), and Estonia (80.4% and 20.6%, respectively). EN was the popular method of intervention in Lithuania, Estonia and Turkey (30%, 29.3% and 21.8% received this method of treatment, respectively). It was less often used in Croatia (18%), Poland (14.2%) and Greece (13.8%). PN was used most frequently in Poland (8.2%) and Turkey (7.5%), was rarely used in Greece (4.6%) and Estonia (4.9%), and was not used at all in Lithuania (0%) (Table 7). When compared with 2006, the relative use of EN and PN appears to have remained almost the same in Poland and Croatia. This could not be assessed for the other countries due to the lack of reliable data.

Discussion Disease-related malnutrition is a critical public health concern for European Union governments, which must cover up to US$125 billion in associated costs every year.1 It is a common cause and consequence of disease with a significant negative impact not only on economics but also on the effectiveness of treatment and quality of life.2 Malnutrition increases complication rates, morbidity, mortality, hospital readmissions, and the length of hospital stay.5-8,16-19 It may be described as “a state of nutrition in which a deficiency, excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome.”20 It affects all age groups, but older people and cancer patients are particularly at risk: a large-scale survey showed that the risk is 40% greater in people older than 65 years compared with people younger than 65 years.3,4 A very high prevalence of malnutrition was also found in cardiology and pulmonology departments in the present study; much depends on the populations admitted and the unit’s profile. Patients in hospitals and in institutions are particularly at risk, because they often fail to meet their daily needs for energy, protein, and micronutrients. Large-scale studies show that about 1 in 4 (18%–28%) hospital patients are malnourished or at risk of malnutrition.21-26 The world’s leading clinical nutrition societies have always actively participated in actions to fight malnutrition. A.S.P.E.N.’s actions include its malnutrition toolkit and generally raising awareness through broad-based education. A.S.P.E.N. has participated with other prestigious organizations to form an interdisciplinary partnership, the Alliance to Advance Patient Nutrition. This includes the Alliance Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), A.S.P.E.N. itself, and the Society of Hospital Medicine (SHM), whose mission is to help improve coordinated nutrition therapy for hospital patients. ESPEN has also actively participated in activities aimed at changing the situation. ESPEN’s activities include education (courses, Life-Long Learning® training, workshops, and regional activities), scientific research, and actions to raise awareness, performed under FAM. One of the main annual events is ND, which was launched in 2006. It is a longitudinal survey on the incidence of malnutrition and overall nutrition status in hospitals and other healthcare settings. Since 2006, data from more than 140,000 patients from all over the world have been collected. The 2006 analysis showed that the prevalence of malnutrition was lower in Hungary, Austria, and Germany than in apparently comparable countries elsewhere in Europe.13 This came as a surprise for some of those concerned and stimulated new activities. Our study reassesses the situation 6 years later. In 2012, the highest proportions of patients with 3 or more points according to the NRS 2002 were observed in Estonia

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Table 6.  Nutrition Screening Results. Parameter NRS 2002 score (all patients assessed)  0  1  2  3  4  5  6  7 At risk (≥ 3 points)

Lithuania

Poland

Turkey

Greece

Croatia

Estonia

Statistic Test  

76 (54.3%) 19 (13.6%) 25 (17.9%) 15 (10.7%) 2 (1.4%) 1 (0.7%) 1 (0.7%) 1 (0.7%) 20 (14.2%)

573 (57.0%) 114 (11.4%) 97 (9.6%) 71 (7.1%) 65 (6.4%) 38 (3.8%) 18 (1.8%) 29 (2.9%) 221 (21.9%)

264 (34.3%) 102 (13.3%) 100 (13.0%) 102 (13.3%) 99 (12.8%) 67 (8.7%) 23 (3.0%) 12 (1.6%) 303 (39.4%)

145 (44.5%) 30 (9.2%) 45 (13.8%) 46 (14.1%) 38 (11.7%) 18 (5.5%) 4 (1.2%) 1 (0.8%) 107 (32.8%)

SGA score

nobody assessed

assessed in assessed in assessed in 404 (40.2%) 379 (49.3%) 287 (88.0%) patients patients patients 310 (76.7%) 223 (58.8%) 165 (57.5%) 54 (13.3%) 88 (23.2%) 95 (33.1%) 40 (9.9%) 68 (17.9%) 27 (9.4%) 94 (23.2%) 156 (41.2%) 122 (42.5%)

 A  B  C   B+C

— — — —

Hospitals with NST Hospitals without NST Who assessed the patient in the unit?  Physician  Nurse  Dietitian

1 (10.0%)

84 (72.4%)

26 (68.4%)

0 (0%)

9 (90.0%)

32 (27.6%)

12 (31.6%)

6 (100%)

257 (14.3%) 468 (26.2%) 448 (25.1%) 329 (18.4%) 187 (10.4%) 86 (4.8%) 10 (0.6%) 1 (0.1%) 613 (34.3%)

nobody assessed — — — —

5 (8.9%)

1 (2.4%) 5 (12.2%) 3 (7.3%) 17 (41.5%) 9 (22.0%) 6 (14.6%) 0 (0%) 0 (0%) 33 (80.4%)

χ2 = 871.797; df = 35; PCHI < .000001

χ2 =130.386; df = 5; PCHI < .000001 assessed in 41   (100.0%) patients 17 (41.3%) χ2 = 65.109; df = 6; PCHI < 15 (36.5%) .000001 9 (21.9%) 24 (58.4%) χ2 = 47.27; df = 3; PCHI < .000001 0 (0%) PF < .001

51 (91.1%)

1 (100%)  

6 (60.0%) 0 4 (40.0%)

127 (88.8%) 21 (14.6%) 21 (14.6%)

31 (81.6%) 6 (15.7%) 15 (39.4%)

8 (57.1%) 0 (0%) 6 (42.9%)

12 (75.0%) 2 (12.5%) 2 (12.5%)

1 (100%) 0 (0%) 0 (0%)

PF = .030

CHI, χ2 test; df, degrees of freedom; F, Fisher’s exact test; NRS 2002, Nutritional Risk Screening 2002; NST, nutrition support team; SGA, Subjective Global Assessment.

Table 7.  Utilization of Clinical Nutrition Support. Parameter

Lithuania

Poland

Turkey

Greece

Croatia

No. of patients diagnosed at risk (NRS 2002 ≥ 3) who received nutrition afterward EN

6 (30%)

279 (27.8%)

265 (34.4%)

65 (19.9%)

435 (24.4%)

16 (39.0%) χ2 = 76.555; df = 5; PCHI < .000001

6 (30%)

143 (14.2%)

168 (21.8%)

45 (13.8%)

0 0

83 (8.2%) 53 (5.3%)

58 (7.5%) 39 (5.1%)

15 (4.6%) 5 (1.5%)

48 (2.7%) ONS 274 (15.3%) 67 (3.8%) 46 (2.6%)

12 (29.3%) χ2 = 119.743; df = 15; PCHI < .000001 2 (4.9%) 2 (4.9%)  

PN Both (EN + PN)

Estonia

Statistic Test

CHI, χ2 test; df, degrees of freedom; EN, enteral nutrition; NRS 2002, Nutritional Risk Screening 2002; ONS, Oral Nutritional Supplements; PN, parenteral nutrition.

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(80.4%) and Turkey (39.4%), whereas the lowest were in Lithuania (14.2%). The apparently alarming finding in the case of Estonia is almost certainly a selection bias as 60% of the study population were in the intensive care unit (ICU) (34%) or the cancer surgery department (26%) of a single specialist teaching hospital, and it is most unlikely that this is representative of the country as a whole. The disappointing results from Greece and Turkey are, however, more likely to reflect a general picture accurately. The NRS results are supported by SGA assessments where these were done (Estonia 42.5%, Greece 42.5%, Turkey 41.2%, Poland 23.2%). Severe malnutrition (SGA score C) was diagnosed in 19.7% of Turkish patients, in 9.9% of Polish patients, and in 9.4% of Greek patients. Although the SGA and NRS differ in form and the questions asked (eg, the SGA assesses the patient’s medical status, whereas the NRS concentrates on the nutrition risk) in 2 countries, Poland and Turkey, both scales showed almost the same proportion of patients, described as either malnourished or at nutrition risk. Only in Greece did the NRS and SGA results differ, perhaps because the SGA was mostly assessed by physicians and the NRS by dietitians. Although there were numerical differences between the scores in Estonia, both tools returned high figures, reflecting the severity of the patients’ profiles (ICU). The proportion of significantly undernourished patients in Poland appeared to fall between 2006 and 2012 from more than 36% to 23.2%, and it is legitimate to consider this explained by the many actions to fight malnutrition undertaken over the last few years, including implementation of obligatory screening in hospitals, educational activities at various levels (from general practitioners to specialized medical areas), and publishing relevant ESPEN and POLSPEN guidelines. In Turkey, the proportion with malnutrition appeared to increase from 24% to 41.1%. This is not the impression of the clinicians concerned and may reflect a selection bias (as in Estonia), and it demonstrates the difficulties of comparing data obtained in different ways. In particular, the ND 2006 report captured weight loss of only > 8 kg and would have missed weight loss of > 10% in smaller subjects. The Turkish Society is certainly very active in steps to improve the situation (education, public awareness, etc) and better results are expected soon. Other than in Greece, nutrition screening was performed mostly by physicians (Estonia 100%, Poland 88.8%, Turkey 81.6%, Lithuania 60% of all assessments) and dietitians (Greece 42.9%, Lithuania 40%, Turkey 39.4%, and Poland 14.6%). The low participation of Polish dietitians in screening activities is the result of their unstable legal situation as far as the medical profession is concerned. In Poland, the status of dietitian has never been established with a formal regulation and their services are not reimbursed—this has led to belittlement

of that profession. On the other hand, the high participation of physicians in Estonian and Turkish screening can be explained by the patients’ profile (mostly ICU patients), whereas in Poland it has been a long tradition for physicians to deal with clinical nutrition. It was disappointing to find out that NSTs are still not a routine part of hospital activity in 4 of our 6 countries (Greece and Estonia 0%, Croatia and Lithuania < 10%). In Poland, the number grew systematically since 2006; this can be reasonably explained by FAM activities and attempts to issue a regulation on the obligatory presence of NSTs in hospitals. A similar process has occurred in Turkey. Two years ago, the situation in Greece changed considerably. The new PEN society, GreSPEN, immediately undertook numerous activities to raise awareness at almost all levels, including within legislation. These actions resulted in the society receiving the MNII Award for 2012, and their results should be easily observed in the upcoming years. The execution of clinical nutrition appears to have been best in Turkey, Poland, and Greece, and this can be directly attributed to the stress put on education by PEN societies. Adherence to guidelines has contributed to the proportionally high usage of EN in Croatia, which shows the high quality of nutrition therapy in this country. In Poland, the EN:PN ratio was 50:50, which was similar to 2006 findings. EN was less frequently used not only in Poland but also in Estonia (17.6%), Greece (13.8%), and Lithuania (4.2%), whereas PN was the most popular in Poland (8.2%) and Turkey (7.5%). The commendably large number of patients in Croatia (more than 15%) who stood to benefit from oral nutrition supplements naturally reflects in part the facility for reimbursement, a method practically unavailable for Polish patients. The authors recognize the limitations of the study, which is hampered by the small numbers of patients recruited from the 2 smallest countries and their likely “center-selection” bias. Moreover, the national PEN societies in Lithuania and Estonia are relatively young (1998 and 2008, respectively), which has inevitably had some adverse influence on their ability to raise nutrition awareness. Another limitation of the study is the comparison of new data on admission with ND data from 2006, which come from any day after admission and were assessed differently. The 2 sorts of data are different for many reasons and they cannot be used as a control group for the purpose of the study. Nonetheless, the study provides the reader with a unique insight into the situation across the continent as well as a starting point for further analyses. The study confirms that the prevalence of malnutrition varies between different hospital settings in Europe and that the approach to addressing hospital malnutrition differs no less, this being an original observation. The authors advocate the approach of A.S.P.E.N. and the cooperation of national PEN societies within ESPEN in the fields of education and science and in actions directed at

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Journal of Parenteral and Enteral Nutrition 39(2)

the healthcare system, such as in FAM, and believe that together these help to improve the situation. It is clear that a lot still remains to be done to reduce the prevalence of disease-related malnutrition, its complications, and its economic burden.

Acknowledgments Stanislaw Klek was the coordinator of the trial. He was responsible for its conception and contributed to the experimental design, data interpretation, and writing of the article. All authors critically revised the intellectual content of the study and contributed to the writing of the article, data and statistical analysis, and data collection. The authors would also like to acknowledge the participation of the following persons: Erdem Yaka, Ethem Murat Arsava, Tarkan Karakan, Zekeriya Ülger, Tarık Nursal, Mehmet Özdoğan, Cem Parsak, Recep Aktimur, Gökhan Yağcı, Ali Uzunköy, Pars Tunçyürek, Bülent Saka, Levent Güngör, Kemal Yandakçı, İbrahim Kurt, Murat Özkalkanlı, Hülya Ulusoy, Atilla Şencan, Selda Seçkiner, Ali Aydın Altunkan, Aygen Türkmen, Derya Hopancı Bıçaklı, Çiler Zincircioğlu (Turkey), Ana Kunovic (Croatia), Dina Ljubas Kelecic (Croatia), Aristea Baschali, Dimitris Karagiannis, Zoi Bouloubassi, Karakatsanis Anestis, and Apostolos Tsapas (Greece).

Statement of Authorship All authors state that they have made substantial contributions to the study and that they give their approval to the final version of the article.

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