It is time for us to look beyond calories and protein for sustainable solutions to malnutrition.
- Tara Thomas Tarcza
- Apr 5, 2021
- 9 min read
Updated: Apr 6, 2021
In my work as an acute care dietitian, I have seen firsthand the poor health outcomes faced by many Canadians, but I did not fully appreciate the role that social determinants of health played once the patient is outside the hospital walls. Throughout the MHST601 course I have broadened my understanding of the implications that these disparities can have on nutrition status and disease. Studying the material in the course while working as a front-line clinician has helped me to apply the learnings in a real-world way. Understanding the importance of the discharge plan and the integration of nutrition care into it is essential for prevention of readmission to hospital within 30 days (Tappenden et al. 2013). Research indicates that the discharge home is the most vulnerable stage in a patient’s recovery and nutrition care shortcomings need to be addressed to improve outcomes and health overall (Tappenden et al. 2013).
I spend a great deal of time working in the intensive care and Respiratory inpatient unit providing nutrition consultation. Most of the admissions on the Respiratory unit (prior to the pandemic) related to acute exacerbations of Chronic Obstructive Pulmonary Disease (COPD). COPD is a chronic disease that can lead to significant costs to the individual and the health care system (Osman et al, 2017). This disease can lead to unintentional weight loss and malnutrition, which requires nutrition expertise to treat (Collins et al. 2019). Development of COPD is multifactorial and there are many interconnected risk factors I have discussed previously; however, this post will address income and education as they are independently related to risk of admission to hospital with COPD (Osman et al. 2017; Eisner et al. 2011).
Socioeconomic status (SES) (which will be used to refer to low income and low education – less than grade 12 graduation) is one of the most powerful determinants of health in general as well as for COPD (Gershon et al. 2012; Pandolfi et al. 2015). A prospective multi-centre cohort study over three years in Canada, determined that malnutrition was associated with SES, affecting more than 60% of participants (Allard et al. 2015). This same study identified that the most frequent primary diagnosis associated with malnutrition was respiratory in nature (Allard et al. 2015). The causative association between malnutrition and COPD is complex and likely both a cause and consequence of severe respiratory disease (Collins et al. 2019).
COPD is known to be inflammatory in nature and creates a catabolic state which contributes to weight loss and muscle wasting (Scoditti et al. 2019). Similarly, many patients report a significant fear of shortness of breath and intake of food, often preventing them from eating adequately leading to poor nutrition (Scoditti et al. 2019). People with COPD typically have a high incidence of malnutrition and require nutrition intervention as part of their hospital stay (Mete et al. 2018). My role in nutrition care typically involves finding ways to meet the metabolic needs of the patient to help treat malnutrition and prevent further deterioration in their health status.
Outpatients with COPD have found that malnutrition is amenable to treatment, resulting in significant improvements in both nutritional intake and nutritional status (Collins et al. 2019). It is interesting to consider that management of malnutrition in the home setting is connected to SES (Collins et al. 2019). A common form of treatment for malnutrition in hospitalized patients is the use of oral nutrition supplements (ONS), and I commonly use this therapy with patients with COPD as many find that they can tolerate fluids better while experiencing dypsnea (Smith et al. 2020). Despite the known benefits of ONS to treat malnutrition, those patients with severe malnutrition are least likely to be using ONS before coming into hospital (Allard et al. 2015). Lack of ONS use at home is hypothesized to be linked to income and ability to make good dietary choices in those with COPD (Scoditti et al. 2019). Similarly, research by Allard et al. (2015) indicates that most patients with severe malnutrition are not using ONS before coming to hospital despite use in hospital on a previous admission.
When I work with a COPD patient with malnutrition, we can often see improvements in their eating and prevention of weight loss through routine monitoring of meal and ONS intake and weight measurement during their admission. Many of our nutrition goals are met during the admission and we observe the patient getting better and heading home. There is risk that the improvements seen during an inpatient stay may be lost once the person is at home without adequate support (Tappenden et al. 2013). Acknowledging that patients with lower levels of SES are vulnerable and at higher risk for adverse health inequity and poor outcomes needs to be taken into consideration when the discharge planning is underway. Community follow up is essential in reducing hospital readmissions and is not always arranged prior to the patient going home (Tappenden et al. 2013).
The upending theory of the Social Ecological Model (SEM) as described by Golden et al. (2015) has intrigued me throughout this course as I realize that I am a clinician who prefers upstream initiatives and taking an intersectoral approach to promoting health. The figure below is considered an “Inside out” SEM of policy and environmental change.
Putting the environment at the centre of the model versus the individual in the traditional model highlights some of the ways that malnutrition and COPD could be addressed by reducing socioeconomic disadvantages. During the admission, I create comprehensive nutrition care plans to support the patient, which are intended to extend when they leave the hospital. Tappenden et al. (2013) note that to improve quality of care, the nutrition management needs to continue through admission to discharge and beyond. Yet, use of ONS is not covered by private or public insurance benefits unless it is used as a sole source of nutrition for the patient (Ontario, 2021). Unexpectedly COPD is not included in the many chronic diseases that the Ontario government provides financial support for special diets. By adding COPD to the list of diagnosis that provides additional funding under the Special Diet Allowance through the Ontario Disability Support Program could be a step in the right direction to providing some additional money each month that could help with purchasing ONS when the patient is home from hospital recovering.
Improved access to community support would go a long way in improving outcomes for patients with COPD and malnutrition, as we know that patients with malnutrition and lower incomes are more likely to be readmitted to hospital after 30 days of an admission (Fingar et al. 2016). People living with COPD experience frequent admissions to hospital due to exacerbations of their disease and require extensive follow up care in the community (Mittmann, 2008). Home care services available in my community do not typically consider the patient’s nutrition status, and often patients do not go home with any formal support in place to help them with meal preparation and grocery shopping. Many patients with COPD face significant barriers due to their frailty and deconditioning that prevent them from doing these tasks (Scoditti et al. 2019).
This responsibility will then fall to the family, which may not be feasible for some people depending on their situation, which puts them at further disadvantage. Our hospital has created a program in recent years to support patients who need help with meals. The “Meals to Go” program is available at a low cost to any patient or family member. Hospital prepared meals are frozen and ready for purchase from a menu based on patient satisfaction surveys of most enjoyed meals (Royal Victoria Regional Health Centre, 2018). This program has been very successful, in combination with the traditional “Meals on Wheels” program that offers one hot meal daily. The only limitation of the program is that they are unable to support a delivery service currently. There are opportunities in the works to expand their program to offer this, however the financial aspect has been challenging to find a way to offset this fee for some patients.
In a similar context, our Patient Food Services department created a “Food Club” program to incorporate the organization sphere of the SEM. This program came out of a need expressed by our clinical dietitian team to find ways for patients with malnutrition and financial constraints to be able to continue with their prescribed nutrition care when they leave the hospital. Given the research by Tappeneden et al. (2013) indicating that use of ONS is associated with reduced length of stay in hospital and decreased 30-day readmission, it was a program that was well supported by our senior leadership. The food club allowed the food services department to sell the supplements at a 20% mark up from cost to ensure a profit but at a significantly lower than retail price. We engaged full backing from our product representatives in this initiative and patients and families benefitted.
Future opportunities to improve nutrition health for patients with COPD and malnutrition involves specialized menus to optimize energy and protein and supporting those with dyspnea who can only tolerate smaller amounts of food at frequent intervals (Fletcher & Sorenson, 2018). In 2018, our hospital embraced the theme “Food is Medicine. Eat Your Medicine” as promoted by the Canadian Malnutrition Task Force to advocate and promote nutrition care in the treatment of malnutrition. We have had a lot of success in the hospital but have seen gaps in our ability to meet the needs of the patients once they leave the hospital.
source: Tara Thomas Tarcza, Canadian Malnutrition Awareness Week 2018.
As I navigate through the final week of MHSTS601, I am reminded about the important role that interpersonal factors play in the SEM. I recognize that educating the family and supports at home in the nutrition care plan is crucial to successfully keeping patients well at home and can help create improved health equity for people with COPD and will make this a priority in provision of care moving forward (Tappenden et al. 2013). Below you can find a copy of a handout and video that is available to use for patient education (Canadian Malnutrition Task Force, 2021). They both highlight some key strategies that families and patients need to be aware of to ensure they understand that “food is medicine, too".
Canadian Malnutrition Task Force, 2021.
Income and education can lead to negative health problems, COPD and malnutrition included (Braveman & Gottlieb, 2014; Allard et al. 2015; Eisner et al. 2011). Acknowledging that social determinants of health contribute to malnutrition is an important part of creating sustainable treatment plans for dietitians to consider. Thinking about the social factors the patient experiences before and after their hospitalization is essential to creating a patient-centred nutrition care plan (Allard et al. 2015). We need to recognize at a societal level that these factors shape health and are as important as the patient’s vital signs (Braveman & Gottlieb, 2014).
References:
Allard, J., Keller, H., Khursheed, J., Laporte, M., Duerkson, D., Gramlich, L., Payette, H., Bernier, P., Vesnaver, E., Davidson, B., Teterina, A., & Lou, W. (2015). Malnutrition at Hospital Admission – Contributors and Effect of on Length of Stay: A prospective Cohort Study from the Canadian Malnutrition Task Force. Journal of Parenteral and Enteral Nutrition.
Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it's time to consider the causes of the causes. Public Health Reports, 129(Suppl 2), 19-31. https://doi: 10.1177/00333549141291S206
Canadian Institute for Health Information. (1996-2021). COPD: A focus on high users - infographic. https://www.cihi.ca/en/copd-a-focus-on-high-users-infographic
Canadian Institute for Health Information. (1996-2021). Hospitalization rates for COPD across Canadian cities.
Canadian Malnutrition Task Force. (2021). Raising Awareness: Public. https://nutritioncareincanada.ca/prevention-and-awareness/public-infographics
Collins, P., Yang, I., Chang, YC., & Vaughan, A. (2019). Nutritional support in chronic obstructive pulmonary disease (COPD): an evidence update. Journal of Thoracic Disease. 11(Suppl 17):S2230-S2237 https://jtd.amegroups.com/article/view/32746/22942
Eisner, M., Blanc, P., Omachi, T., Yelin, E., Sidney, S., Katz, P., Ackerson, L., Sanchez, G., Tolstykh, I., & Irinarren, C. (2011). Socioeconomic status, race and COPD health outcomes. Journal of Epidemiol Community Health. 65(1): 26-34. https://doi: 10.1136/jech.2009.089722
Fingar, K., Weiss, A., Barrett, M., Elixhauser, A., Steiner, A., Guenter, P., & Hise Brown, M. (2016). All-cuas readmissions following hospital stays for patients with malnutrition, 2013. Agency fo Healthcare Research and quality.
Fletcher, H. & Sorensen, J. (2018, September 27). Hospital Foodservice Standards & Practices to prevent malnutrition [PowerPoint slides].
Gershon, A., Dolmage TE., & Stephenson, A. (2012). Chronic Obstructive Pulmonary Disease and SocioEconomic Status: A Systematic Review. Journal of Chronic Obstructive Pulmonary Disease. DOI: 10.3109/15412555.2011.648030
Golden, S., McLeroy, K, Green, L., Earp, J., & Lieberman, L. (2015). Upending the social ecological model to guide health promotion efforts toward policy and environmental change. Health Education & Behavior. 42(1 Suppl):8S-14S.
https://doi.10.1177/1090198115575098
Mete, B., Pehlivan, E., Gülbaş, G., & Günen, H. (2018). Prevalence of malnutrition in COPD and its relationship with the parameters related to disease severity. International journal of chronic obstructive pulmonary disease, 13, 3307–3312. https://doi.org/10.2147/COPD.S179609
Mittmann, N., Kuramoto, L., Seungal, J., Haddon, M., Bradley-Kennedy, C., & Fitzgerald, M. (2008). The cost of moderate and severe COPD exacerbations to the Canadian healthcare system. Respiratory Medicine, 102(3), 413-421.
Osman, S., Ziegler, C., Gibson, R., Mahmood, R., & Moraros, J. (2017). The Association between Risk Factors and Chronic Obstructive Pulmonary Disease in Canada: A Cross-sectional Study Using the 2014 Canadian Community Health Survey. International Journal of Preventive Medicine, 1-7.
https://doi:10.4103/ijpvm.IJPVM_330_17
Pandolfi, P., Zanasi, A., Musti, M. A., Stivanello, E., Pisani, L., Angelini, S., & Hrelia, P. (2015). Socio-Economic and Clinical Factors as Predictors of Disease Evolution and Acute Events in COPD Patients. Plos One, 10(8), e0135116. https://doi:10.1371/journal.pone.0135116
Royal Victoria Regional Health Centre. (2018). Patient Information – Patient Meals.
Scoditti, E., Massaro, M., & Garbarino, S. (2019).Role of Diet in Chronic Obstructive Pulmonary Disease Prevention and Treatment. Nutrients. 11, 1357.
Smith, T. R., Cawood, A. L., Walters, E. R., Guildford, N., & Stratton, R. J. (2020). Ready- Made Oral Nutritional Supplements Improve Nutritional Outcomes and Reduce Health Care Use-A Randomised Trial in Older Malnourished People in Primary Care. Nutrients, 12(2), 517. https://doi.org/10.3390/nu12020517
Tappenden, K., Quartara, B., Parkhurst, M., Malone, A., Fanjiang, G., & Ziegler, T. (2013). Critical Role of Nutrition in Improving Quality of Care: An interdisciplinary call to action to address adult hospital malnutrition. Journal of Parenteral and Enteral Nutrition. 37 (4), 482-497.
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