Malnutrition definitions in clinical practice: To be E43 or not to be?

Undernutrition and dietary diversity score and associated factors among lactating mothers in Northwest Ethiopia

Background

Maternal undernutrition negatively influences both maternal and child health, as well as economic and social development. Limited research has been conducted on both the nutritional status and dietary diversity score among lactating mothers. Therefore, the present study aimed to determine the magnitudes of undernutrition and dietary diversity scores and their associated factors among lactating mothers in Bahir Dar City, Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted from March to May 2021. Systematic random sampling and interview-administered questionnaires were employed. Dietary diversity score and nutritional status were measured using a 24-h recall and body mass index (BMI), respectively. Data entry and analysis were performed using EpiData version 3.02 and SPSS version 24 software, respectively. Both the bivariable and multivariable binary logistic regression analyses were performed, and the strength of association was measured in terms of odds ratio.

Results

The prevalence of undernutrition and low dietary diversity scores among respondents were 13.5% (95% CI; 10.4, 17.2) and 64.8% (95% CI, 60.0, 69.4), respectively. The significant factors for undernutrition were being young [AOR = 2.30, 95% CI (1.09, 5.43)], having low dietary diversity score [AOR = 2.26, 95% CI (1.01,5.10)], having poor nutritional knowledge [AOR = 2.56, 95% CI (1.03, 6.51)], meal frequency less or equal to 3 times per day [AOR = 4.06, 95% CI (0.71, 9.65)], educational status being primary school [AOR = 3.20, 95% CI (1.01, 9.11)], and educational status of husband being secondary school [AOR = 2.28, 95% CI (1.25, 8.53)]. Age between 20 and 30 years [AOR = 1.46, 95% CI (1.01, 2.48)], being food insecure [AOR = 3.41, 95% CI (1.21, 9.63)], and being poorest [AOR = 2.31, 95% CI (1.02, 5.32)] were associated with the dietary diversity score.

Conclusion

A high prevalence of undernutrition and low dietary diversity scores were recorded in the current study area. Age, educational status of lactating mothers and their husbands, nutritional knowledge, dietary diversity, and meal frequency were significant factors associated with undernutrition. Age, food security, and wealth index were associated with the dietary diversity score.

Individual and contextual factors in the Swedish Nutrition Care Process Terminology implementation

BACKGROUND

Standardised terminologies and classification systems play an increasingly important role in the continuous work towards high quality patient care. Currently, a standardised terminology for nutrition care, the Nutrition Care Process (NCP) Terminology (NCPT), is being implemented across the world, with terms for four steps: Nutrition Assessment (NA), Nutrition Diagnosis (ND), Nutrition Intervention (NI) and Nutrition Monitoring and Evaluation (NME).

OBJECTIVE

To explore associations between individual and contextual factors and implementation of a standardised NCPT among Swedish dietitians.

METHOD

A survey was completed by 226 dietitians, focussing on: (a) NCPT implementation level; (b) individual factors; and (c) contextual factors. Associations between these factors were explored through a two-block logistic regression analysis.

RESULTS

Contextual factors such as intention from management to implement the NCPT (OR (odds ratio) ND 15.0, 95% Confidence Interval (CI) 3.9-57.4, NME 3.7, 95% CI 1.1-13.0) and electronic health record (EHR) headings from the NCPT (OR NI 3.6, 95% CI 1.4-10.7, NME 3.8, 95% CI 1.1-11.5) were associated with higher implementation. A positive attitude towards the NCPT (model 1 OR ND 3.8, 95% CI 1.5-9.8, model 2 OR ND 5.0, 95% CI 1.4-17.8) was also associated with higher implementation, while other individual factors showed less association.

CONCLUSION

Contextual factors such as intention from management, EHR structure, and pre-defined terms and headings are key to implementation of a standardised terminology for nutrition and dietetic care.

IMPLICATIONS FOR PRACTICE

Clinical leadership and technological solutions should be considered key areas in future NCPT implementation strategies.

A Model for Clinical Coder Satisfaction in Saudi Arabia Based on a Holistic Approach: Clinical, Professional and Organizational Dimensions

The quality of clinical coding influences not only hospital revenue but also the quality and efficiency of healthcare services. Assessing the coders' satisfaction is essential to optimizing the quality of clinical coding. This mixed-method study used a qualitative approach to propose the study model while testing the model through a quantitative approach. The relevant variables of the satisfaction model were assessed through a survey targeting clinical coders across the country on a timely basis. Fourteen experts participated in establishing the model with three dimensions: professional, organizational, and clinical. Each dimension has its relevant variables. One hundred eighty-four clinical coders participated in phase two. 34.5% were male, 61% held a diploma, 38% had a bachelor's and above, and 49.7% worked in hospitals having fully electronic health records. We found that organizational and clinical dimensions strongly correlate with coders' satisfaction. Noticeably, the most influencing variables were the availability of coding policies and the computer-assisted coding (CAC) system. The results show that the model explains the satisfaction of the clinical coders, and organizational and clinical-related variables are crucial. Although gender-based differences exist, training (regardless of the training mode), coding policies, and the CAC system substantially influence coders' satisfaction. A significant stream of the literature supports these findings. However, attempting a holistic approach to assess coders' satisfaction and affecting coding quality is the added value of this study. Optimizing clinical coding practice requires organization-wide initiatives and policies to regulate coding practices and standards to promote the quality and timeliness of clinical documentation. Training is indispensable not only for clinical coders, but physicians also need to understand the rationale and value of clinical coding. Better utilization of the outcomes of the coding process and adopting the CAC system are significant drivers to enhance coders' satisfaction.

Mechanism for development of malnutrition in primary biliary cholangitis

Primary biliary cholangitis (PBC) is a chronic cholestatic liver disease that is associated with impaired biliary excretion processes. Along with the development of cholestasis, there is a deficient flow of bile acids into the intestinal lumen causing malnutrition (MN) that is manifested in deficiencies of both macro- and micronutrients. The mechanism for development of trophological insufficiency is multifactorial. However, the trigger of MN in PBC is impaired enterohepatic circulation of bile acids. The ingress of bile acids with a detergent effect into the general bloodstream, followed by elimination via the kidneys and skin, triggers a cascade of metabolic disturbances, which leads to the gradual development and progression of calorie MN. The latter gradually transforms into protein-calorie MN (PСM) (as marasmus) due to the insufficient entry of bile acids into the duodenum, which is accompanied by a decrease in the emulsification, hydrolysis, and absorption of fats and fat-soluble vitamins, as well as disturbance of intestinal motility and bacterial overgrowth. Fat-soluble vitamin deficiencies complement PСM with vitamin and mineral MN. The development of hepatocellular failure enhances the progression of PСM due to the impaired protein synthetic function of hepatocytes in the advanced stage of PBC, which results in deficiency of not only the somatic but also the visceral pool of proteins. A mixed PСM form of marasmus and kwashiorkor develops. Early recognition of energy, protein, micronutrient, and macronutrient deficiencies is of great importance because timely nutritional support can improve liver function and quality of life in patients with PBC. In this case, it is important to know what type (energy, protein-calorie, vitamin, and vitamin-mineral) and form (marasmus, marasmus-kwashiorkor) of MN is present in the patient and how it is associated with the stage of the disease. Therefore, it is recommended to screen all patients with PBC for MN, from the early asymptomatic stage of the disease in order to identify and avoid preventable complications, such as fatigue, malaise, performance decrement, sarcopenia, osteoporosis, and hepatic encephalopathy, which will be able to provide appropriate nutritional support for correction of the trophological status.

Smart Management of Malnutrition Using Local Foods: A Sustainable Initiative for Developing Countries

Malnutrition is one of the major challenges the developing world is currently facing, whether it is caused by climate change, terrorism and conflict, or demographic shifts. Poverty is the main cause of malnutrition in this part of the world, and no progress is possible without the alleviation of poverty to reduce malnutrition. Reducing household vulnerability and increasing household resilience is the pathway to sustainable malnutrition management. Malnutrition has been a major threat to the health and development of children in developing countries, presenting as high levels of micronutrient deficiencies, stunting, and global acute malnutrition. The rates of malnutrition of all forms are above the thresholds accepted by the WHO in some regions. To this end, the resilience program on achieving nutrition in a developing country through at-home learning activities for nutritional rehabilitation and dietary promotion (known as FARN) reported, in this case, successful results from both statements from beneficiaries and non-beneficiaries on the reduction and management of malnutrition in their health centers. FARN activity encourages the consumption of locally available foods not only to eradicate malnutrition but also to protect the ecosystem and sustainable nutrition security. This is much like the saying, “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime” to the vulnerable people; parents' knowledge of their child's nutritional status and the use of local-based foods diets showed improvement, which is proof of the impact of the resilience program. It can be concluded that the resilience program through its activities at the level of the selected community significantly affected the factors and degree of persistence of malnutrition and the level of resilience of the populations. Thus, the FARN program showed resounding success in its ability to promote sustainable malnutrition management.

Malnutrition coding and reimbursement in the hospital setting

Professionals responsible for the nutrition care of hospitalized patients should understand the prevalence of malnutrition, how to accurately and consistently identify and communicate a diagnosis of malnutrition in the medical record, and the sophisticated payment systems used to reimburse hospitals for patient care. Insight into healthcare payment systems and the requirements for clarity, consistency, and accuracy can improve identification, coding, and billing for malnutrition. Hospitals receive reimbursement for services based on anticipated costs for diagnosis-based groups, and documenting the presence of a comorbidity, such as malnutrition, can increase the payment for a diagnosis. It is important to accurately document not only the supporting criteria used to diagnose malnutrition, but also the interventions used to address it during a patient's stay.

Malnutrition and liver disease in a developing country

Malnutrition is a highly prevalent and under recognized condition in developing countries of South Asia. The presence of malnutrition causes a severe impact on patients with liver cirrhosis. The etiology of cirrhosis differs in the South Asian region compared to the West, with hepatitis B and C still being the leading causes and the prevalence of nonalcoholic fatty liver disease increasing over time. Comorbid malnutrition worsens outcomes for cirrhosis patients. Urgent attention to address malnutrition is needed to improve patient outcomes. The etiology and pathophysiology of malnutrition in liver diseases is multifactorial, as reduction in liver function affects both macronutrients and micronutrients. A need for nutritional status assessment for liver disease patients exists in all parts of the world. There are many widely studied tools in use to perform a thorough nutritional assessment, of which some tools are low cost and do not require extensive training. These tools can be studied and evaluated for use in the resource limited setting of a country like Pakistan. Treatment guidelines for proper nutrition maintenance in chronic liver disease exist for all parts of the world, but the knowledge and practice of nutritional counseling in Pakistan is poor, both amongst patients and physicians. Emphasis on assessment for nutritional status at the initial visit with recording of vital signs is needed. Simultaneously, treating physicians need to be made aware of the misconceptions surrounding nutritional restrictions in cirrhosis so that patient education is done correctly based on proper scientific evidence.