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A lettuce leaf, a slice of bread, a slice of sausage and a tea that is disgusting – these are the culinary memories of patients from the hospital stay. And it’s not that they mistake the ward at the clinic for last minute holidays. Patients in Polish hospitals are starving. They are losing weight, they are losing their muscles. They come back home weakened and with infections that the malnourished organism does not have the strength to fight, and sometimes they die because of this. We talk about the fate of Polish hungry patients with Dr. Anna Uklala, assistant professor at the Department of Human Nutrition at the Medical University of Warsaw.
Zuzanna Opolska, Medonet: Apparently Polish patients lose weight in hospitals ?! This is a common phenomenon?
Dr Anna Ukleja from the Medical University of Warsaw: Some patients are malnourished on admission to hospital, but this mainly affects those with chronic cancer. And in the vast majority of them, as much as 70 percent. this malnutrition is exacerbated in just 10-14 days in hospital. In addition, malnutrition also occurs in every third person who did not have this problem at all on the day of admission to the hospital!
And what do hospitals say?
Unfortunately, this situation does not arouse much interest among Polish clinicians. Although we have known for over 30 years that malnutrition associated with the disease worsens the results of treatment and increases its costs, we do not do anything to prevent it.
Who, apart from cancer patients, has the best chance of dying in hospital?
First of all, patients with chronic diseases of the digestive system, including chronic diseases of the liver, pancreas, inflammatory bowel diseases in the exacerbation phase, digestive and absorption disorders, and patients with cancers of the digestive system. Patients are also at risk of chronic diseases of the circulatory system (heart failure), diseases of the urinary system (chronic renal failure), respiratory system diseases (COPD), neurodegenerative diseases (dementia, Alzheimer’s disease, Parkinson’s disease) and elderly patients.
Or almost everyone.
Yes, and a separate group consists of patients after major injuries and major operations, especially those performed on the digestive system. In them, the main cause of inpatient malnutrition is the administration of drips with saline and glucose for over a week, which is treated as … nutrition. It completely ignores the fact that both fluids contain neither a gram of protein nor a gram of fat, with an average requirement of 60g of protein, 65g of fat and 2000kcal per day. Only 10 days of such “fluid therapy” causes a deficiency of 600g of protein, 650g of fat, about 1900g of glucose and about 18kcal in the patient (usually already malnourished), which leads to severe innutrition worsening the course of the disease and treatment results!
There are legends about cold and monotonous hospital meals. What is the hospital diet like today? I do not mean the postoperative one, but one for the average patient whose diet requires no restrictions.
Most often it is unbalanced both quantitatively and qualitatively. It does not contain any information on the content of protein, carbohydrates and fat, which does not allow you to monitor nutrition and assess the coverage of protein and energy requirements. The daily food ration in the hospital should provide 1800 – 2200 kcal, 60 g of protein and 65 g of fat, including no more than 10 percent. saturated fat. The energy value and protein content of the DRP (Daily Food Ration) should be given for each of the three main meals. Only in this way can the degree of coverage of the patient’s needs be assessed and indications for support or nutritional treatment can be established.
Anyone doing this?
Hospitals lack nutritionists who are the only professional group prepared to provide nutritional care, including nutritional and dietary assessment, nutritional education of patients and staff, and nutritional counseling aimed at preventing malnutrition and adapting diets to disorders caused by the disease. It is the dietitians who should be responsible for the nutrition of patients during and after hospitalization. Unfortunately, nutritional counseling is not a procedure financed by the National Health Fund, and dietitians are not included in the employment structure in hospitals and specialist clinics. A stay in a hospital could also be used to disseminate the principles of healthy eating and its importance in the prevention and treatment of diseases, but there is no one to do it.
Theoretically, the nutritional status of each patient admitted to the hospital can be monitored. This is achieved by a questionnaire marked with the symbols SGA (Subjective Global Nutrition Assessment) and NRS (Numerical Rating Scale) 2002, which was developed five years ago by the Ministry of Health and published in a special regulation. Are patients diagnosed in this regard?
Unfortunately, nutritional assessment is often overlooked. And if it is carried out, it is wrong, or its result is not taken into account at all in the further management of the patient. This does not allow the achievement of the objective of the aforementioned regulation, which was the early identification of malnourished patients or those at risk of malnutrition and appropriate nutritional intervention. Other problems include: the lack of knowledge of doctors and nurses about the need for nutrients and the ability to provide food that meets the needs of each patient, regardless of their clinical condition, the lack of interest in most doctors, nurses and hospital administration as part of the treatment of patients. As well as the routine fasting of patients in most acute gastrointestinal diseases and in the perioperative period.
Where did the term “hospital malnutrition” come from and how to define it?
For years, the nutritional status of patients has not been studied at all, nor has it been taken into account how it affects the outcomes of disease treatment. It was not until 1955 that two American surgeons Rhoads and Alexander from the University of Pennsylvania in Philadelphia proved and drew attention to the fact that most of the patients admitted to the hospital lose weight, are weakened, the functioning of their organs deteriorates, and immunity decreases. They also showed that the nutritional status of patients continues to deteriorate during hospitalization, what they termed hospital malnutrition. Among the main reasons they mentioned: the lack of interest of doctors and nurses in the nutritional status of patients and prolonged, even over two weeks, intravenous use of crystalline fluids containing no protein or energy components such as carbohydrates and fats, which in fact amounts to starvation.
What happens to the body of such a malnourished patient?
The patient is losing weight due to a loss of muscle and fat. Muscle strength weakens, immunity decreases, which is caused by the death of lymphocytes in the intestinal mucosa. There is anemia caused by a deficiency of iron, folic acid and vitamin B12, the concentration of albumin in the blood decreases, digestive and absorption disorders occur due to the disappearance of the mucosa of the small intestine, the intestinal barrier function is weakened due to an increase in the permeability of the intestine to bacteria and their toxins, and impairment activities of all organs and systems.
Are there any more problems?
Yes. Increase in infection rates due to decreased immunity, impaired wound healing, more frequent dehiscences of intestinal anastomoses, increased complication rates, extended hospital stay, and increased mortality. The economic consequences of unrecognized and untreated malnutrition are extremely important and often overlooked.
How much do we lose by starving patients?
The costs of treating malnourished patients correlate with a greater number of complications, longer hospitalization and the need for additional treatment of complications, which causes a 2-3 times higher cost of treating malnourished patients compared to properly nourished patients.
According to the results of a study conducted in Spain and published in 2016, the total average cost of treating malnourished patients was 45,2 percent to 102 percent higher than that of properly nourished patients. A study in the Netherlands showed that 76 euros invested in screening nutritional status and treating malnutrition can reduce hospital stay by 1 day with a daily treatment cost of 433 euros per stroke patient up to 900 euros per day per heart attack patient. Disease-related malnutrition affects 33 million people in Europe, and costs € 170 billion! Perhaps it is worth getting interested in the nutritional status of the patient and taking appropriate measures to prevent malnutrition in general, and hospital malnutrition in particular.
Where do you need to start?
Early diagnosis is most important in the prevention of any disease, including hospital malnutrition. In this case, it is about the risk of malnutrition or the presence of already existing malnutrition on admission to the hospital.
How to predict that malnutrition may occur in a patient who is admitted to hospital in a normal condition?
According to the guidelines of the European Society of Clinical Nutrition and Metabolism (ESPEN), the risk of malnutrition occurs when a properly nourished patient, due to disease, surgery or trauma, plans to withhold oral nutrition and replace it with hydration for a period longer than 7 days. days. Malnutrition requiring urgent nutritional treatment is defined as when the unintentional weight loss is at least five kilograms in six months, or three kilograms within just three months of onset, no food intake for 3 days, or Grade B or ≥ 3 NRS points 2002. In each of these cases, the next step should be to develop and implement a nutrition plan that meets the needs of the patient and is tailored to the clinical situation. Whether this is really the case can be assessed by every patient who has been treated in the hospital in the last four years.
Are we already doing something with this problem?
In 2003, the Council of Europe, concerned about the high level of hospital malnutrition, adopted a resolution whose main goal is to ensure proper nutritional care supporting pharmacological or surgical treatment of patients. The resolution recognizes as particularly important: the establishment of a new medical specialty called clinical nutrition, which is now an important element in the treatment of patients, the establishment of departments of clinical nutrition at universities and the introduction of specialization in clinical nutrition for adults and children, routine screening of the nutritional status of all patients admitted to the hospital , treating the definition of “disease-related malnutrition” as a clinical diagnosis requiring treatment, establishing national standards of nutrition in hospitals and requiring suppliers to include information on the energy value and protein, fat and carbohydrate content of individual meals and the daily food ration, regardless of whether the food supplier is a hospital kitchen or catering.
Only that none of these problems can be solved without introducing the subject: nutrition of a healthy and sick person to the curriculum of medical studies. And without the employment of dietitian specialists in hospitals.
Dr. n. med. Anna Ukleja, academic teacher, assistant professor at the Department of Human Nutrition of the Medical University of Warsaw and a lecturer in the field of clinical dietetics and clinical nutrition. He has many years of experience in feeding patients at the cardiology department. Author of many publications in the field of dietetics.