Nutr Hosp. 2014;30(2):425-435 ISSN 0212-1611 • CODEN NUHOEQ S.V.R.318

Nutrición Hospitalaria Original / Valoración nutricional

State of malnutrition in hospitals of Ecuador Sylvia Gallegos Espinosa', Marcelo Nicolalde Cifuentes1, Sergio Santana Porbén2; for the Ecuadorian Group for the Study o f Hospital Malnutrition* 'School o f Nutrition and Dietetics. Faculty o f Public Health. Polytechnical School o f Chimborazo. Riobamba. Chimborazo. Ecuador. 2Vicepresidency. Board o f Governors. Cuban Society o f Clinical Nutrition and Metabolism. *The composition o f the Ecuatorian Group fo r the Study o f Hospital Malnutrition is presented in the Annex to this document.

Abstract Rationale: Hospital m alnutrition is a global health problem affecting 30-50% of hospitalized patients. There are no estimates of the size of this problem in Ecuadorian hospitals. Hospital m alnutrition might influence the quality of medical assistance provided to hospitalized populations. Objectives-. To estimate the current frequency of malnutrition among patients admitted to Ecuadorian public hospitals. Materials and methods: The Ecuadorian Hospital M alnutrition Study was conducted between November 2011 and June 2012 with 5,355 patients (Women: 37.5%; Ages > 60 years: 35.1%; Length of stay < 15 days: 91.2%) admitted to 36 public hospitals located in the prominent cities of 22 out of the 24 provinces of the country. Malnu­ trition frequency was estimated by means of the Subjec­ tive Global Assessment survey. Results: Malnutrition affected 37.1% of the surveyed patients. Malnutrition was dependent upon patient’s age and education level; as well as the presence of cancer, sepsis, and chronic organic failure. Hospital areas showed different frequencies of hospital malnutrition. Health condition leading to hospital admission influenced nega­ tively upon nutritional status. Malnutrition frequency increased as length of stay prolonged. Conclusions: Malnutrition currently affects an impor­ tant proportion of patients hospitalized in public health institutions of Ecuador. Policies and actions are urgently required in order to successfully deal with this health problem and thus to ameliorate its negative impact upon quality of medical care.

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D01:103305/nh.20143 02.7559 Key words: Hospital malnutrition. Length o f stay. Epide­ miology. Cancer. Subjective Global Assessment.

ESTADO DE LA DESNUTRICIÓN EN LOS HOSPITALES DEL ECUADOR Resumen Justificación: La desnutrición hospitalaria constituye un problema global de salud pública que afecta entre el 30-50% de los internados. En el Ecuador no se tienen esti­ mados de la magnitud de este problema. La desnutrición hospitalaria pudiera influir en la calidad de la prestación de asistencia médica a la población hospitalizada. Objetivos: Estimar la frecuencia corriente de desnutri­ ción entre los pacientes internados en los hospitales públi­ cos del Ecuador. Material y Método: El Estudio Ecuatoriano de Desnu­ trición Hospitalaria se condujo entre Noviembre del 2011 y Junio del 2012 en 5355 pacientes (Mujeres: 37,5%; Edades>60 años: 35,1 %; Estadía 60 years represented a third o f the sam ple. G ram m ar and ju n io r h igh ed u ca­ tion levels w ere prevalent am ong the surveyed patients.

Sylvia Gallegos Espinosa et al.

I : Azuay. 2: Bolivar. 3: Cañar. 4: Carchi. 5: Chimborazo. 6: Cotopaxi. 7: El Oro. 8. Esmeraldas. 9: Galápagos. 10: Guayas. 11: Imbabura. 12: Loja. 13: Los Ríos. 14: Manabí. 15: Morona Santiago. 16: Ñapo. 17: Orellana. 18: Pastaza. 19: Pichincha. 20: Santa Elena. 21: Santo Domingo de las Tsáchilas. 22: Sucumbíos. 23: Tungurahua. 24: Zamora Chinchipe. Image taken from: http://es.wikipedia.org/wiki/Ecuador/. Image is used and distributed under the terms of the GNU Free Documentation License, Ver­ sion 1.2 or any later version published by the Free Software Foundation; with no Invariant Sections, no Front-Cover Texts, and no Back-Cover Texts. Additional information on geographical area and population of Ecuadorian provinces can be found at: http://www. inec.gob.ec/cpv/.

Fig. 1 .—Provinces o f Ecuador. The country is comprised o f 24 provinces distributed between the Pacific coast, the Andes, and the Amazonia. Ecuador holds a population o f 14,483,499 inhabi­ tants over a 283,520 squared kilometers area.

R o u g hly 10.0% o f the patients w ere inclu d ed w ithin the “U ndeterm ined” category o f education. G eneral S urgery (32.6% ) and In tern al M edicine (51.7% ) services concentrated the surveyed hospital­ izations. M ore than 90.0% o f the patients had stayed at least 15 days in hospital. G astrointestinal diseases, o rth o p ed ic and traum a illnesses, and respiratory illn esses co n c en trated 53.0% o f the patien ts in the study sam ple. Infection was present in a quarter o f the su rv ey ed patients, m ostly from th e very m om ent o f ho sp ital adm ission. C ancer affected only 3.4% o f the sam ple. Chronic organic failure was present in 8.2% of the patients. M ore than 20.0% o f the patients had been already operated upon, w hile another 9.2% w as w aiting for com pletion o f surgical program. E stim ated frequency o f h ospital m aln u tritio n w as 37.1% (95% Cl: 35.8% -38.4% ). A ccording with SGA score, patien ts w ere distrib u ted as follow s: “A ” : 6 3 .0% ; “B ” : 29.1% ; and “C ” : 7.9% ; respectively, as show n in figure 2. T able III show s the association betw een SG A score and B ody M ass Index (BM I) current value calculated for 4,884 o f the surveyed patients (am ounting to 91.2% o f study sam ple). A strong association w as found betw een SG A score and B M I current value: 84.2% of

State of malnutrition in hospitals of Ecuador

the patients w ith (B + C) SG A scores had BM I values < 18.5 K g .n r2, in co n tra st w ith o nly 33.8% o f those with “A ” scores (O R = 10.48; p < 0.05; 95% Cl: 7.7514.19). T able IV show s the in fluence o f d em o g rap h ic and clinical features o f the patient upon SG A score. SG A score was dependent upon age (< 60 years: 30.9% vs. > 60years: 48.5% ; D = -17.6% ; x 2= 162.0; p < 0.05) and ed u catio n level (x2 = 99.75; p < 0.05). M aln u tritio n concentrated am ong patients w ith gram m ar and ju n io r h igh lev els o f in stru ctio n , as w ell as those included w ithin the “U ndeterm ined” category (OR = 0.812; p < 0.05; 95% C l: 0 .7 7 3 -0 .8 5 1 ; o d d s-ratio estim ated by m eans o f lo g istic reg ressio n tech n iq u es). L ik ew ise, h o sp ital m aln u tritio n w as in flu en ced by presen ce o f cancer (Present: 64.5% vs. Absent: 36.1% ; D = 28.4% ; X2 = 61.0; p < 0 .0 5 ), infection ( Present: 47.8% vs. Absent: 33.5% ; D = 14.3%; x2 = 88.60; p < 0.05), and ch ro n ic o rg an ic failu re (Present: 58.2% vs. Absent: 35.2% ; D = 23.0% ; x 2= 91.48; p < 0.05); respectively. In addition, patients going through different stages o f surgical program differed am ong them regarding the observed frequencies o f m alnutrition (x2 = 119.51; p < 0.05), being the p roportion o f (B + C) SG A scores higher in those in w hom no surgical option o f treatm ent w as considered. Table V shows the distribution o f hospital malnutrition in relation to hospitalization area. H ospital areas exhib­ ited varying m alnutrition frequencies (x2 = 144.22; p < 0.05), with higher frequencies am ong wards o f Internal M edicine and other medical specialties. T able VI show s m alnutrition regarding health condi­ tion leading to adm ission. M alnutrition was heteroge­ neously distributed am ong different health conditions (X2 = 395.79; p < 0.05). O bserved estim ates o f m alnu­ tritio n fo r h em ato lo g ical d iseases, ch ro n ic liv er d iseases (in clu d in g liv er cirrh o sis), cancer, kidney ch ro n ic disease, resp irato ry illn esses and D iab etes m ellitus surpassed the globally estim ated value fo r the study sample. Finally, figure 3 shows the influence o f hospital LOS upon n u tritio n al status. M aln u tritio n frequency in creased as LOS prolonged, from an initial value o f 31.2% in the first 24 hours o f hospitalization, to reach 64.7% am ong those patients with LOS betw een 16-30 days (D = 33.5% ; p < 0.05).

Discussion T his article has presented the results o f the E cuado­ rian Study o f Hospital M alnutrition: the first concerted effort aimed to expose the m agnitude and ram ifications o f this health problem in public health institutions o f the country. A s such, the E cu ad o r E L A N Study distincts itself from others conducted in the Latin am erican region for encom passing the public m edical care centers o f all (but one of) the provinces o f the country; and for being the culm ination o f a M astery in N utrition

Nutr Hosp. 2014;30(2):425-435

429

Table II Demographies and clinical features o f the surveyed population. Numbers and (between brackets) percentages o f subjects fo r the corresponding level o f distribution are shown Feature

Observedfindings

Sex

Female: 2756 [51.5] Male: 2599 [48.5]

Age

< 60 years: 3474 [64.9] a 60 years: 1881 [35.1]

Education level

Grammar: 2770 [51.7] Junior high: 1395 [26.1] High school: 118 [2.2] University: 441 [8.2] Senior technician: 62 [ 1.1 ] Undetermined: 569 [ 10.6]

Health condition leading to admission

Gastrointestinal diseases: 1396 [26.1] Orthopedic and trauma illnesses: 790 [14.7] Respiratory diseases: 654 [12.2] Heart and blood vessels: 525 [9.8] Diabetes mellitus: 460 [8.6] Urological illnesses: 411 [7.7] Neurological and psychiatric illnesses: 190 [3.5] Cancer, leukemias and lymphomas: 180 [3.4] Chronic kidney disease: 139 [2.6] Chronic liver disease: 67 [1.3] Gynecological illnesses: 68 [1.3] Burns: 40 [0.7] Hematological diseases: 33 [0.6] Others*: 402 [7.5]

Infection’

Present: 1338 [25.0] • Present on admission: 1323 [98.9] • Developed during admission: 15 [ 1.1 ]

Organic chronic failure

Present: 438 [8.2]

Surgical program

Completed: 1197 [22.3] Programmed: 498 [9.3] Not considerated: 3660 [68.4]

Hospitalization area

General Surgery: 1748 [32.6] Other surgical specialties’: 129 [2.4] Orthopedics and Trauma: 336 [6.3] Internal Medicine: 2769 [51.7] Other medical specialties’: 373 [7.0]

Length of stay

Up to 24 hours: 1142 [21.3] Between 2-3 days: 1875 [35.0] Between 4-7 days: 1226 [22.9] Between 8-15 days: 641 [ 12.0] Between 16-30 days: 289 [5.4] More than 30 days: 182 [3.4]

^Hernia of varying etiology I topology (168), snake biting (40), HIV/aids (53), dengue (26). 5HIV/aids cases are included. ’Urology (44), Neurosurgery (43), Cardiovascular surgery (31), Otorhinolaryngology (9), Ophthalmology (2). ’Gastroenterology (91), Cardiology (68), Neumology (57), Nephrology (51), Neurology (31), Endocrinology (26), Oncology (23), Infectology (18), Dermatology (4), Hematology (3), Psychiatry (1). Size of the study serie: 5355. Source: Records of the Ecuadorian ELAN Study of Hospital Malnutrition. Records closed on: December 3 1th, 2012.

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Nutr Hosp. 2014;30(2) :425-435

Sylvia Gallegos Espinosa et al.

Table i n Association between Body Mass Index (BM1) and Subjective Global Assessment (SGA) score. Data recovered from 4,884 patients was distributed according with BMI calculated value and score assigned with SGA. Nature o f association was assessed by means o f statistical tests based on the chi-square distribution."1Strength of association was estimated after calculation o f the corresponding odds-ratio.” Proportions of patients with a specified SGA score with BMI values on one side or the other o f the selected cut-off point are shown SGA BMI, Kg.m2

Totals B +C

18.5

Totals

in Public Health project led by the School o f N utrition and D ietetics o f the F aculty o f P ublic H ealth at the E SP O C in R iobam ba (C him borazo) w ith the students acting as surveyors in the research units. T he estim ated frequency o f hospital m alnutrition is co n siste n t w ith find in g s p reviously reported by the

A

278

52

330

[84.2]

[15.8]

[6.7]

1538

3016

4554

[33.8]

[66.2]

[93.3]

1816

3068

4884

[37.2]

[62.8]

[100.0]

X 2= 335.564952; p < 0.05. OR= 10.4837 [7.7477-14.1861] Size of the study serie: 5355. Source: Records of the Ecuadorian ELAN Study of Hospital Malnutrition. Records closed on: December 31th, 2012.

Table IV Influence o f dem o graphical a n d clinical fe a tu re s o f the p a tie n t upon the nutritional status o f the p atient F eature

(B + C) score1

Interpretation

Sex • Male • Female

37.5 36.6

X2= 0.39; p > 0.05 OR, = 0.9651 [0.8637-1.0784]

Age •