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Prevalence of Hospital Malnutrition in Latin

America: The Multicenter ELAN Study
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. Students 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

INTRODUCTION in Latin America. ELAN means Latin American Nutrition Study in

Portuguese and Spanish.
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 hospital- METHODS
ized patients are malnourished, with severe malnutrition being
present in 12.6% of the entire group.1 There are several risk factors This was a multicenter trial, designed and carried out by members
associated with the development of this carential syndrome, of of FELANPE in 13 countries: Argentina, Brazil, Chile, Costa Rica,
which low socioeconomic status, disease per se, older age, and Cuba, Dominican Republic, Mexico, Panama, Paraguay, Peru,
depression can be mentioned.1,2 Malnutrition has a negative im- Puerto Rico, Venezuela, and Uruguay. The protocol of the previ-
pact on the patients outcome by increasing morbidity, mortality, ous Brazilian study (Ibranutri) was thoroughly followed.1,12 In
length of hospital stay, and costs.39 Despite its high prevalence, each country, a national coordinator was named, and this person
malnutrition is seldom recognized and identified by medical with other participants were trained by one of the authors
teams.1,10,11 As a consequence, nutritional therapy is under- (M.I.T.D.C.). Nutrition assessment was performed with the Sub-
prescribed, thus increasing the problem. jective Global Assessment (SGA), and the evaluation protocol
In Latin America, a continent characterized by contrasts, where used by Destky et al.13 was followed. This is an essentially clinical
huge populations live in poverty, there are scarce resources dedi- assessment tool that covers various aspects of a patients nutri-
cated to health issues and, as a consequence, there is a lack of tional history from body weight changes to functional capacity
hospital beds. Therefore, it is extremely important to optimize the alterations. All the questions are important in categorizing nutri-
use of available beds. Adequate nutritional treatment in an attempt tion status, but it was suggested that the most important factors to
to prevent malnutrition-related morbidity and mortality may be an be considered should be changes in body weight and the severity
option to decrease hospital length of stay and costs. By decreasing of the disease. Body weight loss in the previous 6 mo greater than
hospitalization time, more hospital beds likely would become 5% is considered mild, that between 5% and 10% is considered
available to increase the number of patients receiving health care. moderate, and that greater than 10% is considered severe. The
However, the prevalence of hospital malnutrition has been ad- more severe the disease is, the greater the stress and, hence, the
dressed in only a few countries. Further, nutritional therapy is not greater the metabolic requirements. During the training sessions
included in governmental health care policies in most countries. and to fully comply with the SGA, several real patient cases were
Therefore, the Latin American Federation of Parenteral and En- presented and discussed among participants. Those who partici-
teral Nutrition (FELANPE) carried out a multicenter study, the pated in data collection were physicians, dietitians, nurses, phar-
ELAN Project, to assess the nutrition status of hospitalized patients macists, 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
Correspondence to: M. Isabel T. D. Correia, MD, PhD, Rua Goncalves The inclusion criteria for hospitals were 1) to be a general
Dias 332, Apto. 302, Belo Horizonte MG 30140-090, Brazil. E-mail: 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 0899-9007/03/$30.00

Elsevier Inc., 2003. Printed in the United States. All rights reserved. doi:10.1016/S0899-9007(03)00168-0
824 Correia and Campos Nutrition Volume 19, Number 10, 2003



Country n patients Moderate/severe Severe

Country malnutrition (%) malnutrition (%)
Argentina 1000
Brazil 4000 Argentina 61.9* 12.4*
Chile 525 Brazil 48.1* 12.6*
Costa Rica 199 Chile 37.0 4.6
Cuba 1361 Costa Rica 50.3* 18.1*
Dominican Republic 132 Cuba 39.0 10.1*
Mexico 335 Dominican Republic 60.3* 9.5*
Panama 700 Mexico 64.0* 13.0*
Paraguay 230 Panama 40.5 5.5
Puerto Rico 126 Paraguay 40.9 10.0*
Peru 352 Puerto Rico 39.2* 12.8*
Venezuela 188 Peru 50.0* 17.0*
Uruguay 200 Venezuela 48.7* 16.6*
Uruguay 51.0* 17.0*

* P 0.05.
ethical committee. The enrolled patients were older than 18 y and Not significant.
had not been hospitalized within the 6 mo before the study.
Obstetric and pediatric patients were excluded. Patients were ran-
domly assigned weekly throughout the study until the completion
of the predetermined sample size for each country. Sample size patients (7.3%); enteral nutrition to 530 (5.6%), and parenteral
was based on the population of each country, although, in some nutrition to 217 (2.3%).
countries such as in Cuba, the number of patients enrolled was Brazil and Costa Rica are the only countries where there are
larger because it was their interest to include more patients. In governmental policies concerning nutritional teams and the prac-
contrast, in Mexico, due to local problems, the number of patients tice of nutritional therapy. In Brazil these policies became man-
evaluated was insufficient to fully reflect the prevalence of mal- datory nationwide in 1998, after the publication of the first results
nutrition in that country. of the Brazilian (Ibranutri) study.1 In the Dominican Republic,
The statistical analyses were performed with SPSS 6.12 (1995; Paraguay, and Uruguay, the government does not pay for the
SPSS, Chicago, IL, USA). The statistical analysis included fre- nutritional therapy used, which is considered the responsibility of
quency distributions of all variables. The odds ratio was calculated the hospitals.
to determine the association between risk factors and malnutrition.
For continuous variables, Students t test was used; for univariate
analysis, the chi-square test was used. Statistical significance was DISCUSSION
defined as P 0.05. The variables identified as risk factors for
malnutrition by the univariate analysis were then entered in a Malnutrition is still highly prevalent among hospitalized patients
multiple regression analysis model. in Latin America in the beginning of the new millennium. Whereas
the Brazilian study1,12 that encompassed 4000 patients was carried
out in 1996, the other surveys showing identical overall rates of
RESULTS malnutrition were carried out between 1998 and 2000. These
results are similar to others reported in the literature, in a different
There were 9348 patients enrolled whose mean age was 52.2 period.11,14 17
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 men-
tioned in only 28.5% of cases. Weight at hospital admission was
obtained in only 26.5% of patients, and height was measured in Malnourished Well nourished
32.9%. Scales were available (within 50 m of the patients bed) in Risk factor (%) (%) Relative risk (CI)
74.9% of cases. Serum albumin was recorded in 26.5% of the
patients medical records. There were no statistically significant Age 60 y 53.0 47.0 1.55* (1.431.73)
differences between countries in terms of these data. Age older Internal medicine 52.1 47.9 1.57* (1.431.73)
than 60 y, the presence of infection or cancer, length of hospital- Infection 60.9 39.9 2.40* (2.162.60)
ization previous to the nutritional assessment, and internal medi- Cancer 65.6 34.4 2.68* (2.393.23)
cine patients were identified in the univariate analysis as signifi- LOS 2 d 33.0 67.0
cant risk factors for malnutrition (Table III). These variables were LOS 27 d 42.7 53.7 1.51* (1.311.73)
entered into the multivariate logistic regression model, which LOS 714 d 49.1 50.9 1.95* (1.682.26)
confirmed the association between these variables and malnutrition LOS 14 d 59.7 40.3 3.00* (2.613.45)
(outcome variable), as shown in Table IV.
Despite this high prevalence of malnutrition, nutritional therapy * P 0.05.
was being prescribed to few patients: oral supplementation to 683 CI, confidence interval; LOS, length of hospital stay
Nutrition Volume 19, Number 10, 2003 Prevalence of Hospital Malnutrition in Latin America 825

TABLE IV. task by using the ELAN results to reinforce the need to face the
challenge of hospital malnutrition and its devastating

Variable OR CI
The authors acknowledge the investigation leaders (country na-
Age 60 y 1.38* 1.281.54 tional coordinators) of the ELAN Collaborative Study: Adriana
Internal medicine 1.66* 1.491.86 Crivelli, MD (Argentina), Alfredo Matos, MD (Panama), Gabriela
Presence of infection 2.30* 2.042.59 Parallada, MD (Uruguay), Gertrudis Baptista, RD (Venezuela),
LOS 2.55* 2.193.02 Horacio Massotto, MD (Costa Rica), Jesus Barreto, MD (Cuba),
Presence of cancer 2.94* 2.553.39 Juan Kehr, MD (Chile), Rafael Figueredo, MD (Paraguay), Sergio
Echenique, MD (Peru), Victor Sanchez, MD (Mexico), Victoria
* P 0.05. Sone, MD (Dominican Republic), Zulma Gonzalez, MD (Puerto
CI, confidence interval; LOS, length of hospital stay; OR, odds ratio Rico), and their teams who so promptly accepted the task of
collecting data and interviewing the patients. They thank
FELANPEs affiliate societies that supported the idea and stimu-
Nutrition assessment was performed with the SGA instead of lated the teams to carry out the study. They also thank Ms. Inara
the classic anthropometric measurements.13 This method may be Fonseca for statistical support.
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 REFERENCES
who could have underestimated or overestimated the degree of
1. Waitzberg DL, Caiaffa WT, Correia MITD. Hospital malnutrition: the Brazilian
malnutrition. SGA was chosen after having been tested in the pilot national survey (Ibranutri): a study of 4000 patients. Nutrition 2001;17:573
study, when agreement across interviewers was greater than 80% 2. Green CJ. Existence, causes and consequences of disease-related malnutrition in
with the coefficient.12 Similar results were found by others, the hospital and the community, and clinical and financial benefits of nutritional
indicating that the SGA, when used appropriately by trained teams, intervention. Clin Nutr 1999;18(S):3
can be a reliable tool to assess nutrition status and predict mor- 3. Correia MITD, Waitzberg DL. The impact of malnutrition on morbidity, mor-
bidity, mortality, and length of hospital stay.3,13,16 tality, length of hospital stay and costs evaluated through a multivariate model
Several risk factors contribute to the development of malnutri- analysis. Clin Nutr 2003;22:235.
tion, such as low socioeconomic status, older age, the disease per 4. Hill GL, Haydock DA. Impaired wound healing in surgical patients with varying
degrees of malnutrition. JPEN 1989;10:550
se, length of hospital stay, and lack of medical awareness.1,2,11,18 In
5. Chandra RK, Kumary S. Effects of nutrition on the immune system. Nutrition
Latin America, most of these variables were confirmed as statis- 1994;10:207
tically significant risk factors for deteriorating nutrition status. As 6. Van Bokhorts-De Van Der Schueren MAE, Von Blomberg-Van Der Flier
reported in other series, medical awareness is one of the factors BMME, Fiezebos RK. Differences in immune status between well-nourished
that might contribute to the worsening of nutrition status of hos- head and neck cancer patients. Clin Nutr 1998;17:107
pitalized patients, especially of those in the hospital for longer 7. Robinson G, Goldstein M, Levin GM. Impact of nutritional status on DRG length
periods.1,3,11,17 Lack of medical awareness might be a consequence of stay. JPEN 1987;11:49
of the absence of formal nutritional education in graduate and 8. Chima CS, Barco K, Dewitt JLA, Maeda M, Teran JC, Mullen KD. Relationship
postgraduate training in most medical schools. In Latin America, of nutritional status to length of stay, hospital costs, and discharge status of
patients hospitalized in the medicine service. Aliment Pharmacol Ther 1997;11:
similar to what happens worldwide, very few Medical programs
include nutrition as a discipline of the medical curriculum.19 This 9. Allison SP. Malnutrition, disease, and outcome. Nutrition 2000;16:590
is later reflected in the lack of attention to nutritional issues. The 10. Butterworth CE. The skeleton in the hospital closet. Nutr Today 1974;9:4
ELAN study showed that the number of patients weighed and 11. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in
measured at admission was extremely low, despite the availability hospital. BMJ 1994;308:945
of scales near the patients beds. Also, references to nutrition status 12. Correia MITD. Inquerito Brasileiro de avaliacao nutricional hospitalar (Ibranu-
as simple as reports having lost weight, skinny, and malnour- tri): metodologia do estudo multicentrico. Rev Bras Nutr Clin 1998;13:30
ished were reported in the medical records in fewer than 25% of 13. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment
the patients, which led us to conclude that this is definitely not an of nutritional status? JPEN 1987;11:8
14. Bistrian BR, Blackburn GL, Vitale J, Cochran D, Naylor J. Prevalence of
issue considered throughout the patients stay in the hospital.
malnutrition in general medical patients. JAMA 1976;235:1567
Despite the high prevalence of malnutrition, nutritional therapy 15. Agradi E, Messina V, Campanella G, et al. Hospital malnutrition: Incidence and
was seldom prescribed to patients, thus reinforcing the fact that prospective evaluation of general medical patients during hospitalization. Ata
nutrition-related issues are not part of the patients routine care. Vitaminol Enzymol 1984;6:235
To worsen the situation, in most countries, there are no official 16. Coats KG, Morgan SL, Bartolucci AA, Weinsier RL. Hospital-associated mal-
guidelines concerning nutrition teams and the practice of nutri- nutrition: a reevaluation 12 years later. J Am Diet Assoc 1993;93:27
tional therapy. Brazil and Costa Rica are the exceptions. In Brazil, 17. Ek AC, Larsson J, Von Cchenck H, Throslun S, Unosson M, Bjurrulf P. The
for example, governmental regulations became mandatory after the correlation between anergy, malnutrition and clinical outcome in an elderly
presentation of the Ibranutri results to the Ministry of Health by the hospital population. Clin Nutr 1999;9:185
18. Roubenoff R, Roubenoff RA, Preto J, Balke W. Malnutrition among hospitalized
Brazilian Society of Parenteral and Enteral Nutrition.20,21
patients. A problem of physician awareness. Arch Intern Med 1987;147:1462
In conclusion, hospital malnutrition in Latin America is highly 19. Heimburger DC, Intersociety Professional Nutrition Education Consortium.
prevalent and should be addressed as an important health issue. Physician-nutrition-specialist track: if we build it, will they come? Am J Clin
Strategies should be created to stimulate governmental policies Nutr 2000;71:1048
and educational attitudes, similar to what has been done in Brazil. 20. Portaria 272. Brasilia: Ministerio da Saude do Brasil, April 8, 1998
The national societies with FELANPE will have a key role in this 21. Portaria 337. Brasilia: Ministerio da Saude do Brasil, April 14, 1999

(For an additional perspective, see Editorial Opinion)