[ Vol. 8 No. 3 ] (September - December 2007 )
Nutrition support education and computerization

Dr.Luisito Llido
Chairman, Nutrition Support Service, St. Lukes Medical Center, Philippines


Nutrition support has been recognized to be one of the components of the highest standard of care to the patient as shown by studies on patient care for the past fifteen to twenty years.(1,2) Its development runs parallel to the recognition that malnutrition is an ever present problem in the hospital setting.(3,4) With the increasing awareness of this problem there was an increase in the development and implementation of nutrition programs and teams is Europe, the US, the Americas, and finally Asia. Currently nutrition support has become a requirement for critical care management in all age groups and in all situations.(5,6) It has made the study of body composition, enteral and parenteral nutrition, and understanding of the pathophysiology as well as cellular and subcelluar changes of disease and nutrition interaction an indispensable part of providing total patient care.(7)

Nutrition support practice is still to be fully developed in most of the Asian countries(8) and in the Philippines the situation is as poignant as the rest of its Asian neighbors. The Philippine Society of Parenteral and Enteral Nutrition was founded in 1995, but it was only in 2004 that it was able to have its first national convention - a full 9 years of hibernation. The key to this breakthrough was the development of a nutrition support program, organization of a nutrition support team, and initiation of a training program in nutrition support in one of the key medical centers of the country. It took four year after the nutrition support program and team was initiated when the clinical dietitian was recognized to be an active part of the nutrition support process. Regular orientation, post graduate courses on nutrition, and mini-workshop in nutrition support (nutrition screening and assessment, enteral and parenteral nutrition) were held within the hospital. When the prevalence of malnutrition in the hospital was reported in 1995 it took four years for the hospital administration to realize and order that all nutrition support personnel see all critical care patients. While these slow developments were going on workshop and attempts by the medical nutrition industry to develop nutrition support teams in the different parts of the country were initiated and eventually failed.

The initiation of a nutrition workshop partnered by a medical nutrition company and this institution through its nutrition support team in 1999 and 2000 sparked the resurgence of interest in the rest of the country. Its key impact was the development of a nutrition support fellowship training program in 2001, which now produced both faculty and students in clinical nutrition. One year before this development, the initiation of a computerized system of nutrition surveillance was implemented by the nutrition support team in this institution which enabled identification of the nutritionally at risk patient. It further made the nutrition care of the patient more focused. After three years of implementation the compliance of standards of patient care was improved from 2% to almost a 98%.(9) Height and weight were diligently taken, critical care patients’ nutrition care plan were implemented with an increase in the number of patients seen and adequacy of intake assessed and corrected.(10) Referrals to the nutrition support team increased and were sustained. A weight management center was also set up with experience in bariatric surgery reported.(11)

These were the results of the establishment of a nutrition support fellowship training program:



a) Follow up of patients identified by the computerized nutrition surveillance system was better organized with scheduled visits done on a regular basis due to the presence of more personnel.
b) Communication of nutrition needs of both patients and physicians of other disciplines were increased and more in-depth in character. Awareness of the value of nutrition support was increased.
c) Increase in the number of personnel who provided the manpower in the organization and holding of the first congress in parenteral and enteral nutrition in 2004 and successive ones.
d) Initiation and publication of research in clinical nutrition focusing on outcome and quality of patient care
e) Provision of consultants and resource persons who organized workshops in clinical nutrition all throughout the country and are now member of several nutrition committees in major health societies/organizations in the country
f) Provision of consultants who now organize nutrition support programs and teams in other hospitals either through lectures, workshops, or as advisers.

Currently five major hospitals in the Philippines are benefiting from this program (three with computerized nutrition surveillance and five with specialists in clinical nutrition). It is the hope of the society (PHILSPEN) to further develop similar programs in the country. It further aims to strengthen the membership by establishing a certifying board in clinical nutrition for the nutrition support team member (physician, dietitian, nurse, and pharmacist) after they have completed the training program in nutrition support.

A new development was the development of a master of science in clinical nutrition which is focused on hospital practice and designed for physicians, dietitians, nurses, and pharmacists. This program was set up in 2005 and aimed to develop more practitioners in nutrition support who will deliver nutrition care to most of the institutions of the country. A partnership with the neighboring countries in Asia in developing a clinical education program that fosters rotation and sharing of experience either through exchange programs or out-of-country rotation would provide a lot of mileage in achieving the goal of increasing the number of clinical nutrition specialists not only in the Philippines, but in Asia.(8)

Three key ingredients for the success of nutrition support implementation were identified:
a) the presence of dedicated person(s) who either perform the nutrition support process of continuously monitor and improve the established programs - in other words: leaders!, b)supportive administration, and c) an active, ongoing training program in clinical nutrition which is attractive to all interested practitioners in clinical nutrition.(12)




1. Merritt R. Integration of nutrition support into patient care. In A.S.P.E.N. Nutrition Support Practice Manual, 2nd ed. Merritt R. (editor in chief); xviii (2005)
2. Coats K.G., Morgan, S.L., Bartolucci, A.A., Weinsier, R.L. Hospital associated malnutrition: a reevaluation 12 years later. Journal of the American Dietetic Association, 93, 27-33 (1993).
3. Butterworth CE Jr. The skeleton in the hospital closet. Nutrition 10, 42 (1994)
4. A.S.P.E.N. Board of Directors and Task on Standards for Specialized Nutrition Support for Hospitalized Adult Patients. Standards for specialized nutrition support: Adult hospitalized patients. Nutr Clin Pract; 17:384-391 (2002).
5. JCAHO. 2004 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). Oakbrook Terrace, IL, (2004).
6. JCAHO. 2004 Comprehensive Accreditation Manual for Long Term Care (CAMLTC). Oakbrook Terrace, IL: Joint Commission Resources, (2004).
7. Laviano A. Research in nutritional science: providing evidence to the clinical relevance of nutrition. Plenary lecture, 11th PENSA Congress, Seoul, Korea, (2005).
8. Saito H. What is the state to PEN in Asia? Plenary lecture, 11th PENSA Congress, Seoul, Korea.
9. Llido LO. The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000-2003. Clin Nutr; 25(1): 91-101 (2006).
10. Umali MN, Llido LO, Francisco EM, et al. Recommended and actual calorie intake of intensive care unit patients in a private tertiary care hospital in the Philippines. Nutition;22(4): 345-9 (2006).
11. Dineros H, Sinamban R, Siozon M, et al. Obesity surgery in the Philippines: experience in a private tertiary care hospital for years 2002 to 2004. Obes Surg; 17(1):82-7 (2007).
12. Howard P. Organizational aspects of starting and running an effective nutritional support service. Clin Nutr; 20(4):367-74 (2001).
13. Howard JP, Bruce J, and Powell-Tuck J. Nutritional support: a course for developing multidisciplinary clinical teams. Education Committee, British Association for Parenteral and Enteral Nutrition. J R Soc Med; 90(12):675-8 (1997).

The 12th PENSA Congress
October 18-20 2007
Century Park Hotel, Manila, Philippines
Page: 44-45