APPLIED NUTRITIONAL INVESTIGATION

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

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

TABLE I. TABLE II.

PATIENT DISTRIBUTION ACCORDING TO COUNTRY PREVALENCE OF MALNUTRITION ACCORDING TO COUNTRY

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
TABLE III.
sample. The prevalence of malnutrition in each country can be
seen in Table II. Despite the high prevalence of malnutrition,
VARIABLES CONSIDERED RISK FACTORS FOR MALNUTRITION
reference to the nutrition status of the patients was registered in
(UNIVARIATE ANALYSIS)
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
TABLE IV.
VARIABLES CONSIDERED RISK FACTORS FOR MALNUTRITION
ACCORDING TO MULTIVARIATE ANALYSIS
Variable OR CI
Age 60 y 1.38* 1.281.54
Internal medicine 1.66* 1.491.86
Presence of infection 2.30* 2.042.59
LOS 2.55* 2.193.02
Presence of cancer 2.94* 2.553.39
* P 0.05.
CI, confidence interval; LOS, length of hospital stay; OR, odds ratio
Nutrition assessment was performed with the SGA instead of
the classic anthropometric measurements.13 This method may be
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
who could have underestimated or overestimated the degree of
malnutrition. SGA was chosen after having been tested in the pilot
study, when agreement across interviewers was greater than 80%
with the coefficient.12 Similar results were found by others,
indicating that the SGA, when used appropriately by trained teams,
can be a reliable tool to assess nutrition status and predict mor-
bidity, mortality, and length of hospital stay.3,13,16
Several risk factors contribute to the development of malnutri-
tion, such as low socioeconomic status, older age, the disease per
se, length of hospital stay, and lack of medical awareness.1,2,11,18 In
Latin America, most of these variables were confirmed as statis-
tically significant risk factors for deteriorating nutrition status. As
reported in other series, medical awareness is one of the factors
that might contribute to the worsening of nutrition status of hos-
pitalized patients, especially of those in the hospital for longer
periods.1,3,11,17 Lack of medical awareness might be a consequence
of the absence of formal nutritional education in graduate and
postgraduate training in most medical schools. In Latin America,
similar to what happens worldwide, very few Medical programs
include nutrition as a discipline of the medical curriculum.19 This
is later reflected in the lack of attention to nutritional issues. The
ELAN study showed that the number of patients weighed and
measured at admission was extremely low, despite the availability
of scales near the patients beds. Also, references to nutrition status
as simple as reports having lost weight, skinny, and malnour-
ished were reported in the medical records in fewer than 25% of
the patients, which led us to conclude that this is definitely not an
issue considered throughout the patients stay in the hospital.
Despite the high prevalence of malnutrition, nutritional therapy
was seldom prescribed to patients, thus reinforcing the fact that
nutrition-related issues are not part of the patients routine care.
To worsen the situation, in most countries, there are no official
guidelines concerning nutrition teams and the practice of nutri-
tional therapy. Brazil and Costa Rica are the exceptions. In Brazil,
for example, governmental regulations became mandatory after the
presentation of the Ibranutri results to the Ministry of Health by the
Brazilian Society of Parenteral and Enteral Nutrition.20,21
In conclusion, hospital malnutrition in Latin America is highly
prevalent and should be addressed as an important health issue.
Strategies should be created to stimulate governmental policies
and educational attitudes, similar to what has been done in Brazil.
The national societies with FELANPE will have a key role in this
(For an additional perspective, see Editorial Opinion)
Prevalence of Hospital Malnutrition in Latin America 825
task by using the ELAN results to reinforce the need to face the
challenge of hospital malnutrition and its devastating
consequences.
ACKNOWLEDGMENTS
The authors acknowledge the investigation leaders (country na-
tional coordinators) of the ELAN Collaborative Study: Adriana
Crivelli, MD (Argentina), Alfredo Matos, MD (Panama), Gabriela
Parallada, MD (Uruguay), Gertrudis Baptista, RD (Venezuela),
Horacio Massotto, MD (Costa Rica), Jesus Barreto, MD (Cuba),
Juan Kehr, MD (Chile), Rafael Figueredo, MD (Paraguay), Sergio
Echenique, MD (Peru), Victor Sanchez, MD (Mexico), Victoria
Sone, MD (Dominican Republic), Zulma Gonzalez, MD (Puerto
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-
lated the teams to carry out the study. They also thank Ms. Inara
Fonseca for statistical support.
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