HOSPITAL MALNUTRITION IN VIET NAM: PREVALENCE, ASSOCIATED RISK FACTORS AND APPROPRIATE SCREENING TOOLS Tran Quoc Cuong Doctor of Medicine, Master of Medical Sciences Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Exercise and Nutrition Sciences Faculty of Health Queensland University of Technology, Australia 2018 Keywords Malnutrition, Hospital, Acute Care Setting, Prevalence, Subjective Global Assessment (SGA), Viet Nam, Nutrition Screening Tool, Validity, Reliability, Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screening (NRS-2002), Mini Nutrition Assessment Short Form (MNA-SF), Body Mass Index (BMI), Foodservices, Ho Chi Minh City, Associated Risk Factors, Dietary Intake, Feasibility, Acceptability, Malnourished, Patients, Underweight, Lower Middle Income Country, Southeast Asia, Medical Doctor Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools i Abstract Malnutrition among hospitalised patients is considered one of the most common and significant health issues in acute care settings worldwide. Studies have shown that it is associated with many adverse outcomes during and after hospitalisation, such as increased physical impairments, co-morbidities, hospital length of stay, readmissions, hospital costs, mortality, and decreased quality of life. It has been the focus of research and strategy implementation in high-income countries over the last few decades. However, in Viet Nam, a lower middle-income country, malnutrition in hospitalised patients has been a low priority given previous pressing public health issues, such as communicable diseases, malnutrition in the community, and micronutrient deficiencies.
Similarly, the focus on nutrition, dietary intake, and meal provisioning within the hospital system in Viet Nam has also been given limited attention. As a result, recommendations for hospital malnutrition prevention and treatment measures are limited, including recommendations for the most appropriate nutrition screening tools to be implemented. The prevalence of malnutrition in adults within the community has recently decreased significantly, with overweight, obesity, and non-communicable diseases increasing leading to a higher demand for hospital use. This research provides evidence to assist the Vietnamese Government and health authorities to develop and implement appropriate policies, guidelines, and recommendations related to nutrition screening and meal provisioning in hospitals in the Vietnamese context.
This is especially important, as improvement of health care services and infrastructure is currently on the political agenda, including the establishment and improvement of nutrition and dietetic services. This research consists of three studies. The first study aims to determine the prevalence of malnutrition and the associated risk factors for hospital malnutrition in Viet Nam. The second study aims to investigate the dietary intake characteristics among hospitalised adults in acute care setting in Viet Nam.
The third study aims to determine the most appropriate nutrition screening tool for use in adults in acute care settings within the Vietnamese context. The first and second studies were conducted at the same time with the same participants (n=888) from six general public hospitals Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools iii in Ho Chi Minh City, Viet Nam using a cross-sectional survey in April and May 2016. The first study assessed the nutritional status and medical and socio-economic status of participants through physical examination and a review of their medical records, while the second study assessed the dietary intake of the participants using the 24-hour dietary recall method. Based on the results of the first study, the third study (a prospective validation study) was conducted in May 2017 in three general public hospitals in Ho Chi Minh City with a sample of adult patients (n=150) and medical doctors (n=40).
All of the studies were implemented with the support from Nutrition Centre in Ho Chi Minh City, Viet Nam. Four papers resulted from this research. Paper One describes the prevalence and associated risk factors of malnutrition among hospitalised adults in Viet Nam. Paper Two describes the characteristics of dietary intake among hospitalised adults in Viet Nam.
Paper Three presents the validity of four nutritional screening tools: Nutrition Risk Screening (NRS-2002), Malnutrition Screening Tool (MST),Malnutrition Universal Screening Tools (MUST), and Mini Nutrition Assessment Short Form (MNA-SF), against Subjective Global Assessment (SGA) for inpatient adults in Viet Nam. Finally, Paper Four presents the validity, reliability, and feasibility of nutrition screening tools NRS-2002 and MST administered by medical doctors in Viet Nam. The findings of this research show malnutrition among hospitalised adults in acute care setting to be a significant health problem in Viet Nam, with a prevalence of 34. Hospital malnutrition was not only associated with clinical characteristics, such as longer length of stay with OR:1.2); admitted via emergency with OR:1.4); higher in some medical conditions, such as oncology (46.6%); and higher in level one hospitals (37.1%); it was also found to be associated with the socio-economic status of the patient, including poverty and marginal poverty household status (OR: 1.5), respectively), and employment status (for persons who did not or omitted work in the last six months) with OR:1.
One other important risk factor for malnutrition is dietary intake, and this research is the first of its kind to explore hospital dietary intake in a lower middle- income country setting in the Southeast Asia region. The study found that patients in Viet Nam with a low dietary intake were more likely to be malnourished compared iv Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools to patients who were well-nourished with OR:2.The majority of participants had low dietary intake (mean energy intake 850 Kcal/day or 3550 kJ/day), and only a very small number (4.2%) met their nutritional requirements (35Kcal/ideal body weight). The main contributors to the low dietary intake of hospitalised patients in Viet Nam included the number of meal occasions (with patients/participants consuming 3-4 meals(including snacks)/day and 5-6 meals/day with an OR of 0.40) compared to participants with ≤ 2 meals/day), having food restrictions (for example, for medical reasons, with OR: 1.8)), and how food was accessed (with those who purchased food from hospital canteens having an OR of 2. Purchasing food from the hospital canteen was one of the major sources of food for hospitalised patients.
This research found that most of the food consumed by patients in the hospital was self-provided including home-cooked (27.7%), bought from outside the hospital (13.6%), bought from the hospital canteen (16.8%), or a combination of these (39.3% of food was provided by the hospital, despite having better nutritional value compared to other sources. To identify the patients most at risk of malnutrition, the validity of commonly used, and previously validated screening tools were explored within the Vietnamese context. These screening tools were not necessarily applicable to the Vietnamese context due to differences in body composition, nutrition status, disease patterns, and healthcare systems. The results show that the NRS-2002, MST combined with BMI (< 18.5kg/m2),and MUST showed moderate/fair validity compared to the reference method, Subjective Global Assessment (SGA or BMI < 18.
BMI alone at < 21kg/m2 had moderate validity, but was lower compared to other screening tools and could be used in circumstances where the resources are significantly constrained. MST alone and MNA-SF showed poor validity due to low sensitivity (41.0% for MST and MNA-SF respectively). The two most valid nutrition screening tools found in the study One, NRS- 2002 and MST combined with BMI, were assessed regarding their validity, reliability, and feasibility as administered by medical doctors. NRS-2002 was selected because it showed the best values for areas under the curve (AUC), sensitivity, and specificity.
Both MUST and MST combined with BMI had similar values for AUC, sensitivity, and specificity. However, MST combined with BMI was Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools v selected because it requires less calculation for the percent of weight loss. Thus, it is less burdensome for users. Medical doctors have been designated by the Ministry of Health to carry out this screening.
The results indicated that both NRS-2002 and MST (combined with BMI) were valid, reliable, and feasible for use by medical doctors for nutrition screening in hospitals in the resource sparse Vietnamese context. Additional activities are required to make nutrition screening more feasible, such as the provision of standard equipment for measuring weights and heights in hospitals, the development of nutrition screening protocol, and training for medical staff regarding nutrition screening. This research firstly confirms the current international evidence indicating that, regardless of the national income status and geographic location, malnutrition is a common issue among hospitalised patients in acute care settings and is associated with a range of clinical and personal factors and dietary intake. The results of this research also provide evidence and insights into areas for improvement within nutrition and dietetics services in hospitals in Viet Nam.
The identification of the high prevalence of hospital malnutrition and its related issues indicates the presence of significant under-estimated but modifiable issues that are present in most hospitals in Viet Nam, and that directly contribute to medical treatment outcomes. This realisation contributes to a better awareness of the need to establish comprehensive and effective nutrition and dietetics systems in hospitals to provide nutrition care to optimise outcomes for all patients, not just those requiring therapeutic intervention. The research also highlights that nutrition and dietetic intervention is required across the continuum of care prior to hospital admission, during hospitalisation, and after hospital discharge. These findings show that appropriate consolidation and development of the nutrition workforce in Viet Nam in hospitals and other health care facilities and settings, as well as the development of guidelines, standards, and recommendations from health authorities are required.
Furthermore, by confirming the validity, reliability, and feasibility of highly validated screening tools, this research shows that BMI, a commonly used indicator for malnutrition in hospitals in Viet Nam, is not an optimal indicator for identifying the risk of malnutrition due to it slower sensitivity compared to that of other screening tools. This study confirms that internationally recognised tools are vi Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools appropriate for use, specifically the NRS-2002 and MST combined with BMI (< 18. Finally, by providing evidence about the current inadequacy (low energy and nutritional value) of meals available to patients in hospital in Viet Nam via a dispersed and voluntary foodservice system and its association with malnutrition, this research shows that the foodservice systems in hospitals in Viet Nam are currently inappropriate. In the short term, it is recommended that appropriate guidance be developed and distributed for all foodservice providers on hospital grounds.
In the long-term, hospitals will need to fully provide both normal and therapeutic meals for all patients as part of standard care to achieve the best treatment outcomes for patients. This can be done by covering the cost of meals via universal medical insurance. Further research is indicated to explore the impact of infrastructure, resources, policies, and beliefs on the prevention and treatment of malnutrition in hospitals; to conduct intervention studies for the prevention and treatment of malnutrition utilising a model hospital approach; to explore malnutrition with other patient groups, such as infants and children, pregnant women, patients admitted to emergency and rehabilitation departments, and in other health care settings; and finally, periodically conducting surveillance on this issue to improve the quality of nutrition and dietetics services in hospitals. This research found malnutrition to be a common issue for hospitalised patients, and that hospital foodservices have a role to play.
It is essential that Vietnamese hospitals improve foodservices to optimise nutrition interventions, improve outcomes, and reduce costs. In addition, validated malnutrition screening tools developed in contexts very different to Viet Nam can be applied in the Vietnamese context, indicating that the development of new tools is not necessary. These findings are potentially transferable to other lower middle-income countries in the Southeast Asia region. Hospital Malnutrition in Viet Nam: Prevalence, Associated Risk Factors & Appropriate Screening Tools vii A Note Regarding Format This dissertation is a thesis by published papers.