Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
Introduction:
Nutrition of the patient has become an important indicator of quality care in the
institution especially the hospital. The need for systems that will improve patient care through
inclusion of an effective nutritional management program has become an issue in the Philippine
hospital care set up where efficient utilization of resources is recognized to be a key in
maintaining hospital operations together with achieving optimum outcomes in patient care.
The development of the clinical nutrition program which is effectively implemented by a
nutrition support team has become the current issue in the fight against malnutrition
worldwide hence it is the objective of this paper to encourage the development of clinical
nutrition programs and nutrition support teams in the hospitals in the Philippines. The
following are the objectives of this proposal:
1. To develop a cadre of competent professionals who will be implementing the clinical
nutrition program
2. To address the problem of malnutrition in the hospital setting through the following
specific goals:
a. To decrease the number of complications
b. To decrease morbidity and mortality
c. To improve patient care
d. To improve quality of life of the patients especially the critically ill and geriatric
patient population
Malnutrition in the hospital is worldwide and exists in every hospital in the Philippines
Malnutrition is usually associated with a body mass index (BMI) of <18.5 (underweight)
or a BMI of 30 and above (obese). *1+ A grade of “C” with the nutrition assessment tool,
Subjective Global Assessment (SGA), indicates severe malnutrition. [2] The worldwide
prevalence of malnutrition in the hospital is between 38%-52%. (Table 1)[3-7]. A prevalence of
malnutrition survey in 2008 done by the Philippine Society of Parenteral and Enteral Nutrition
(PHILSPEN) showed that 48-53% of hospitalized patients in the country are malnourished. [8-9]
Worse, the premiere public hospital of the country showed a 42% severe malnutrition rate.
(Table 2) [9] With these data the ultimate conclusion would be: every hospital in the Philippines
has malnourished patients.
Table 1: Prevalence of malnutrition worldwide
Year
Author
Location
Prevalence
1974
Bistrian
US
50%
1977
Hill
England
44%
1979
Weinsier
US
48%
1984
Agradi
Italy
34%
1993
Larsson
Sweden
27%
1
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
1994
1995
1997
McWhirter Scotland
Fernando Philippines
Waitzberg Brazil
Table 2: Prevalence of malnutrition in the Philippines
Hospital
1. Marikina, Rizal (Amang Rodriguez Medical Center)
2. Lipa City, Batangas (Mary Mediatrix Medical Center)
3. Quezon City (St. Luke’s Medical Center)
4. Manila (Philippine General Hospital)
5. Pasig (The Medical City)
6. Alabang (Asian Hospital Medical Center)
7. Cabanatuan City (Premere Medical Center)
40%
48%
47%
BMI < 18.5
38%
48%
6%
4%
8%
15%
BMI > 30
15%
12%
14%
20%
9%
SGA “C”
42%
-
Malnutrition is associated with increased complications and hospital cost
Malnutrition predisposes hospitalized patients to develop complications like infection
especially in the elderly population [10] or post-operative complications like prolonged wound
healing or infectious complications [11-12]. Malnutrition in the critically ill patients is associated
with increased frequency of single or multi-organ dysfunction which if not corrected would lead
to single or multi-organ failure [12-13]. Morbidity and mortality would increase even after
discharge from the hospital. [14] All these problems would precipitate increased utilization of
resources, services, and eventually prolonged hospital stay [15]. The ultimate outcome is
increased cost which would be a major source of pressure on the hospitals’ finances.
Malnutrition detection and management is associated with decreased complications and
better outcome: better patient care and savings for both patient and institution
Severe malnutrition when identified early and managed accordingly would lead to
better outcome for the patient’s overall disease management. This is specifically seen in
surgical patients where the pre-operative nutritional build-up or post-operative nutrition
delivery was adequate and led to lesser complications and mortality. [16] Critical care patients
whose nutrition intake was increased showed reduced mortality rates by as much as 40% as
shown by a large critical care nutrition study done in 2008. [17] Geriatric patients also had
lower mortality rates after hospital discharge when their nutritional status was improved
through better care which included nutrition. [14]
Quality of life improved when nutrition was maintained as in enteral nutrition in cancer
patients (radiology oncology) placed with gastrostomy for adequate nutritional intake. [18]
Similar results were seen when patients were provided either with parenteral nutrition or in
combinations with oral supplementation or tube feeding [19].
2
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
Immune status which has a key role in wellness or in increasing complications through
depressed or heightened inflammatory state is directly influenced by nutrition. Emotionally
depressed patients had lower immune status manifested by decreased natural killer cell activity
[20], but when nutrition was improved through provision of adequate intake or and/or
nutraceuticals (currently referred to as pharmaconutrition) like glutamine, immune status
bounced back to effective levels. [21]
All of these improvements are the results of optimum patient care which produced
outcomes of reduced morbidity and mortality, reduction in the cost of delivering specialized
services like parenteral nutrition [22], and ultimately, increased savings for both patient and
hospital.
A clinical nutrition program with a nutrition support team (NST) delivers the most effective
malnutrition management in the hospital setting with positive outcomes:
The clinical nutrition program, also called the nutrition support process, has the
following components: (1) nutrition screening of all admitted patients, (2) nutritional
assessment of all identified “nutritionally at risk patients”, (3) nutrition care plan development
for the patients identified to be priority for care by the nutrition support team (NST), (4)
implementation of the nutrition care plan by the different members of the nutrition support
team (NST), (5) monitoring of the nutrition delivery process by the different members of the
NST, and (6) re-evaluation or termination of the nutrition delivery process as deemed fit by the
NST. [23]
This highly specialized and complex management system is best run by a nutrition
support team or NST which is a group composed of a physician, dietitian, nurse, and
pharmacist, who underwent specialized training for this type of service. [24-26] The physician is
the team leader and he/she integrates nutrition care into the over-all management process
with the dietitian, nurse, and pharmacist contributing their specific expertise.
The team delivers total nutrition care to the patient using standards recommended by
the Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN)[23] and developed by the
American Society of Parenteral and Enteral Nutrition (ASPEN) (Figure 1). [27] Currently the NST
is the de-facto “gold standard” when it comes to delivering nutrition support in the hospital
setting. [24] A current observation of PHILSPEN is: hospitals with active and effective NST’s
have been organized and run by graduates of the fellowship program in clinical nutrition. Those
whose teams were appointed by the hospital administration but did not undergo formal
training in clinical nutrition failed and this trend has been going on for the past ten to fifteen
years in the Philippines. [28]
3
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
The minimum requirements to qualify for the position as NST member are the following:
1) Physician – licensed to work as physician in the Philippines and a graduate of the fellowship
program in clinical nutrition, currently available only at St. Luke’s Medical Center, Quezon
City, Metro-Manila, Philippines [29]; preferably a fellow of the Philippine Board of Clinical
Nutrition [30] and member of PHILSPEN.
2) Clinical dietitian – licensed to practice as dietitian in the Philippines and a graduate of the
Master of Science of Clinical Nutrition program, currently available only at the School of
Nutrition, Philippine Women’s University, Taft Avenue, Metro-Manila, Philippines [31];
preferably a member also of PHILSPEN.
3) Nurse – licensed to practice as nurse in the Philippines and a graduate of the Master of
Science of Clinical Nutrition program, currently available only at the School of Nutrition,
Philippine Women’s University, Taft Avenue, Metro-Manila, Philippines [31]; preferably a
member of PHILSPEN and with minimum number of units in the certification for attending
basic nutrition support course(s) for nurses organized by PHILSPEN.
4) Clinical Pharmacist – licensed to practice as pharmacist in the Philippines and has training
as clinical pharmacist in any institution accredited to teach clinical pharmacy in the
Philippines, has minimum number of units in the certification for attending basic nutrition
support course(s) for pharmacists organized by PHILSPEN.
4
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
Credentialing of the members of the Nutrition Support Team:
A body is required to evaluate the competency of the members of the nutrition support
team in order to assure the highest quality of nutrition care delivery to the patient. In 2007 The
Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN) in keeping with its
mission/vision of delivering optimal nutrition to the patient [45] organized the Philippine Board
of Clinical Nutrition (PBCN) whose main goal is to promote the safe delivery of clinical nutrition
by certified professionals who have the necessary level of knowledge and skills to provide
quality care. [30] It is multidisciplinary in composition with each component member taking
responsibility over its specialty. The board’s long term goal is to certify all members of the
nutrition support team, namely: physician as Diplomate of the Philippine Board of Clinical
Nutrition or Certified Nutrition Support Specialist - Physician, dietitian as Certified Nutrition
Support Specialist - Dietitian, nurse as Certified Nutrition Support Specialist - Nurse, and
pharmacist as Certified Nutrition Support Specialist - Pharmacist. [46] It has already certified its
first batch of Diplomate of the Philippine Board of Clinical Nutrition in March 10, 2009. [30].
Some interdisciplinary credentialing issues still have to be smoothed out in the non-physician
members of the nutrition team.
The hierarchy of status and function of the nutrition support team is as follows:
a) Physician who is the team leader and a diplomate in clinical nutrition or master of science in
clinical nutrition graduates; gives the final decision in the nutritional management of the
patient. In levels of competence the diplomate is higher compared to the certified nutrition
support specialist – physician due to the level of intensive training in clinical nutrition the
diplomate has undergone.
b) Dietitian who is master of science in clinical nutrition graduate and will act as team leader if
no physician is qualified for the role of team leader; in charge of nutrition care delivery in
the area of nutrition care plan, diet formulation, enteral nutrition, and monitoring. The
Certified Nutrition Support Specialist – Dietitian has a higher competency level to that of the
master of clinical nutrition specialist, but not yet certified.
c) Nurse who is master of science in clinical nutrition graduate and will act as team leader if no
physician or dietitian is qualified for the role of team leader; in charge of nutrient delivery
and monitoring. The Certified Nutrition Support Specialist – Nurse has a higher competency
level to that of the master of clinical nutrition specialist, but not yet certified.
d) Pharmacist who is master of science in clinical nutrition graduate and will act as team leader
if no physician, dietitian, or nurse is qualified for the role of team leader; in charge of
parenteral nutrition. The Certified Nutrition Support Specialist – Pharmacist has a higher
competency level to that of the master of clinical nutrition specialist, but not yet certified.
5
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
Organizational Set Up of the Clinical Nutrition Program
This is the set up of the clinical nutrition program.
In the overall scheme of this set up if all members of the nutrition support team (NST) are
available, the clinical nutrition physician is the de-facto team leader of the program, however, if
he is not available the clinical dietitian becomes the team leader and the rest of the group are
the support group.
How does the Clinical Nutrition Program run?
These are the specific procedures and specialist(s) involved in the different procedures
of the clinical nutrition program:
1) Nutrition screening: On admission all patients undergo a nutrition screening process from
which the malnourished and/or “nutritionally at risk” of developing malnutrition and
nutrition related complications are identified. A nutrition screening form was developed by
PHILSPEN which is available from the PHILSPEN website. [26] This is performed by all nurses
who are in charge of the patients with supervision by the dietitian and nurse members of
the NST. To obtain details of the process go to the PHILSPEN website:
http://www.philspenonline.com.ph/nst_dev.html. then scroll down to “Part 1: Main
content of pdf file” and click on this file.
2) Nutrition assessment of the identified “nutritionally at risk” patients: These patients are
seen by the physician and clinical dietitian who then classify the patients as mild to severe
nutrition risk. The severe nutrition risk patients are given recommendations on nutrition
management. It is best practice if the hospital makes it a requirement to have all severely
malnourished and high risk patients be followed up by the nutrition support team. [27]
3) The nutrition care plan is composed of: nutrition requirement determination, nutrition
formula design, nutrition access decision, and manner of nutrient delivery. It is run through
6
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
a nutrition care plan form which guides the attending physician through the nutrition
management process. The form is usually accomplished by all the members of the team.
4) The nutrition care process is then delivered by each member of the team: nutrition
formulation by the clinical dietitian (enteral nutrition) or the clinical formulation (parenteral
nutrition) and nutrient delivery by the nurse.
5) Monitoring of the delivery process is then performed by all members of the team.
6) Based on the findings and evaluation of the whole monitoring process, revision of the
nutrition care plan or termination and shifting to the normal use of the gastrointestinal
tract is done after discussions and concurrence by all members of the team.
All these procedures are required to be documented for evaluation purposes of the
nutrition care process and for the patient’s record purposes. The current goal of hospitals to
have an international standards accreditation from agencies like the Joint Commission
International will be greatly helped by the implementation of a clinical nutrition program run by
a nutrition support team. [32]
The set up of the Nutrition Support Team or the Clinical Nutrition Section in relationship to
the Dietary Department:
The Dietary Department has been established and regulated by Republic Act 2674 in its
overall role in the hospital set up. It deals in all areas of food formulation and delivery whether
“therapeutic” or “standard” and mandates the minimum number of dietitians required per
specific number of beds in the hospital. The Clinical Nutrition Section was organized out of the
need to address nutrition management of the intensive care, surgical, oncology, or “difficult to
manage” patients which require close interaction with the physician, dietitian, nurse, and
pharmacist or in effect a “nutrition support team”. This group of patients may be small in
number, but they incur the highest utilization of hospital resources due to the nature of their
illness. The current training of the regular dietitian cannot meet this need.
Thus the clinical nutrition section supplements/completes the role of the dietary
department in its overall role in hospitalized patient care. The multidisciplinary function of the
team has been described to emphasize its role as intermediary in the complex care of the
intensive care or “difficult to manage” patient group by the medical and the rest of the hospital
staff. Its role within the dietary department is as a sub-section and in the context of direct
patient care, under the clinical nutrition services run by the medical staff.
The Nutrition Support Team and clinical nutrition program: evidence of effectiveness in
delivering both preventive and best practice outcome to patient care in the hospital setting:
Before 2008 the existing nutrition support teams in the Philippines were mainly in some
hospitals in Metro-Manila and Batangas numbering seven [9]. In spite of the few numbers the
following clinical nutrition processes were accomplished:
7
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
a) Nutrition surveillance: prevalence of malnutrition/focus on specific group of patients
Nutrition surveillance became standard practice when the prevalence of malnutrition was
noted to be worldwide. [3-7] Knowing who the normal and malnourished patients admitted
in the hospital made better appreciation of what to further provide for the patients while
they are either for wellness or for disease management. Awareness of who the
“nutritionally at risk” patients are made care of these patients better through prioritization
of services and inclusion of nutrition in the whole patient care process. Computerizing the
whole process has made the whole process more comprehensive and sustainable. [33] The
whole process is run effectively by a nutrition support team (NST) as shown in two private
tertiary care hospitals in the Philippines. [39]
b) Nutritional assessment and risk levelling of patients identified to be “at risk”
Performing nutritional assessment and risk levelling of patients especially surgical patients
has made it possible to actually predict post-operative complications as shown by a recent
study done in the Department of Surgery in Chinese General Hospital. [12]
c) Nutrition management in critical care improved by the NST:
The development of the NST has identified the problems of poor intake of ICU geriatric
patients, which was not identified before, [34] and the NST has made an improvement in
the critical care patients’ intake compared to the set up without an NST [35]. This was
corroborated by a recent survey of nutrition in critical care patients done in an international
setting. [17] Even the nutrient intake in pediatric intensive unit (PICU) patients was shown
by the NST to be inadequate [36] thus making the issue of inadequacy of intake in critical
care something to be looked into. It may be more frequent than previously thought.
d) Improvement of nutrient intake in the “nutritionally at risk” patients:
The capability of the NST to improve the intake of “nutritionally at risk” geriatric and
pediatric patients is due to the implementation of a nutrient monitoring system which
enables daily calorie counts and nutrient balances, thus making all caregivers aware of the
patient’s nutritional status and intake. [33] A report given at the PENSA congress in Manila
in 2007 showed the NST was able to improve the poor intake of ICU patients and
immediately place the patients’ intake at adequate levels or 75% of the computed
requirements. [36] Another reason why intake improved was due to the reduction of NPO
or “nothing per orem” orders and immediate resumption of diet once the indication for
NPO was addressed. [37]
e) Reduction in hospital costs due to improvement of outcome due to nutrition management
of both patient body composition and nutrition services:
Cost evaluation through comparison in malnourished and well nourished patients showed
decreased cost in patients with pneumonia, intestinal surgery, and post-surgical
complications. [15] Parenteral nutrition is expensive, however, when a nutrition support
team is involved, the costs related to its preparation and use decreased. [22]
8
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
f) Standardization of forms for use in the nutrition management process: Standard forms have
been designed by PHILSPEN and validated by members of the NST committee of the society
with the main goal of computerizing the data gathering process in all areas of the nutrition
support process (like malnutrition surveillance, profiling of admitted patients, cost effective
assessment, and other nutrition related data). [12,16] All of this information will guide
PHILSPEN and interested persons or societies in making decisions or recommendations on
policies or strategies that will improve the lot of the hospitalized and eventually the
intermediate/home care patient. [47]
Summary: The value of the clinical nutrition program and NST presence in the hospital
setting:
In summary, the ability to identify the “nutritionally at risk” patient early in the
management phase and to predict complications due to risk levelling tools make the NST and
the clinical nutrition program valuable preventive measures that would avoid any untoward
problems that arise out severe malnutrition or poor nutrition management. Active inclusion of
nutrition in the course of the patient management would also be more of benefit to the patient
rather than a liability. [24,25] Every hospital, therefore, with a viable clinical nutrition program
will have the following impact on patient care: preventive and interventional services, “best
practice”, and cost effectiveness.
The next realization is, in order to be effective, the program needs to be run by people
who are trained and certified to be competent in the practice of clinical nutrition. Fortunately
there are two areas where these people can be trained: the clinical nutrition fellowship training
program mainly for physicians at St. Luke’s Medical Center (established in year 2001) [29] and
the Master of Science in Clinical Nutrition in Philippine Women University (started in year 2006)
[38]. Early this year (2009), the credentialing body for clinical nutrition, Philippine Board of
Clinical Nutrition or PBCN officially credentialed the first batch of Diplomates in Clinical
Nutrition. [30]
The role of the PHILSPEN and clinical nutrition fellowship training program:
After year 2008 the number of NST’s in the Philippines increased dramatically to 18 or
22% (18 out of the 83 hospitals that need NST’s in the Philippines, Figure 2). [38] This is the
result of the efforts of PHILSPEN in partnership with the medical nutritional companies in the
Philippines.
9
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
The following accomplishments came out of this 10-year collaboration:
1. Development of a nutrition surveillance system: Through the initiative of PHILSPEN, a
simplified nutrition screening tool was developed to screen all patients admitted to the
hospital who are “nutritionally at risk”. A list of these patients is given to the NST which
follows up these patients. Nutritional assessment is done to determine which patients are
“low, moderate, or high risk” and the necessary recommendations are given. The form used
was also developed by PHILSPEN based on the Subjective Global Assessment tool, which
was validated for use internationally. [2] Forms for adult and pediatric patients are available
from the PHILSPEN website. [26] For the hospitals which can afford, computerization of
nutrition surveillance can be done as shown by a private hospital in the Philippines. [33] The
nutritional assessment form was validated and it was found to be easy to use and predicted
complications well. [12,16]
2. Nutrition intervention: defining the components of the nutrition care plan and
implementing these has led to better nutrient delivery to the “nutritionally at risk” patients.
A key factor is the use of “easy to use” forms which show the percentage intake of the
patient thus guiding the attending MD on the status of nutrition management of his patient.
Two studies done by the NST showed inadequate intake in geriatric patients in the ICU [34],
which improved when the NST took over [35].
10
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
3. Increased awareness of the value of nutrition support: As more studies with positive
outcomes of nutrition in disease management came up, the following responses, from plans
to actual implementation, by the medical staff, professional groups, and medical nutrition
industry have arisen: a) workshops in nutrition support were done throughout the country
(FRANC workshops of Fresenius Kabi Asia Pacific, TNT of Abbott Nutrition International,
Aesculap of BBraun, and IONS of Nestle Philippines), b) clinical nutrition policy and
guidelines were adopted in hospital departments, c) more focus on follow up of patients
with nutrition related problems like documenting impact of nutrition support on patient
care was accomplished, d) workshops in nutrition support are now sponsored by other
medical professional societies (practice focused), and e) implementation talks for pediatric
clinical nutrition training.
4. Credentialing: programs that equip NST members to deliver “optimum” nutrition care
delivery to the patient through training and credentialing are now available. First, a two
year Clinical Nutrition Fellowship training program designed for physicians was established
in St. Luke’s Medical Center [29]; second, a 33 unit Master of Science in Clinical Nutrition
designed for the multidisciplinary clinical nutrition team was set up as a Philippine Women’s
University – St. Luke’s Medical Center partnership [38]; and third, the establishment of the
Philippine Board of Clinical Nutrition, which credentialed the first batch of Diplomates of the
Philippine Board of Clinical Nutrition (PBCN) was done. [30]
5. Sustainability of the NST and clinical nutrition practice in the health care institutions: The
involvement of hospital administration in making NST and nutrition support a standard
component of patient care will definitely put everything in place. Installing the following
systems would further reinforce the process: a) Reimbursement of the services and
nutritional products given to the patient through the national health insurance system
(PHILHEALTH) and National Formulary, b) cooperative ventures between the hospitals,
PHILSPEN, and the medical nutritional industry in the area of continuing education
programs, research, and services improvement, and c) to professionalize the program by
only allowing personnel with master’s or diplomate titles to head or supervise these
nutrition care services.
The role of Philippine Women’s University and Master of Science in Clinical Nutrition [38]
With the realization that the practice of clinical nutrition requires more advanced
learning in both basic nutrition and hospital based practice, a new master of science in clinical
nutrition course was developed in collaboration with the St. Luke’s Medical Center Clinical
Nutrition Fellowship Training Program. This 44 unit course was designed for physicians,
dietitians, nurses, and pharmacists. Even non-nutrition related graduates who are interested in
clinical nutrition management or medical nutrition business could also enrol in this program.
The focus is on hospital based clinical nutrition practice thus full involvement in medical
11
Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
decision making and treatment is included in the curriculum. Nutrition is therefore integrated in
the total patient care process. Graduates of the program are trained to be competent in the
following areas: management of the clinical nutrition program, implementation of the program,
NST development, and administrative functions especially in the clinical nutrition department.
Conclusion and Recommendations:
In conclusion, malnutrition in the hospital is a major health issue that needs to be
addressed since it involves social responsibility, professional competence, and financial
accountability of the hospital industry of the Philippines. It needs a structured clinical nutrition
program to be able to meet the problem effectively and an NST to run the whole program
efficiently. The evidence regarding the value of NST is solid and as currently realized in the
hospital, institutions all around the world (as expressed by the mother societies in the specific
continents: US, Europe, Asia, and the Americas including Australia) [40-44], it needs to be
implemented in all hospitals if possible.
We therefore recommend the following action points:
e) To have a clinical nutrition program set up in every health care institution in the Philippines,
especially hospitals, which becomes a realistic goal if it comes with an implementation
order and supervision from the government, specifically the Department of Health,
f) To require an NST in every hospital in order to make the program run effectively
nationwide,
g) To have the NST be composed of a multidisciplinary team with the following composition:
physician, dietitian, nurse, and pharmacist all of who have been designated specific
credentialing by the Philippine Board of Clinical Nutrition.
The Hospital Malnutrition and Clinical Nutrition Program Task Force
Philippine Society of Parenteral and Enteral Nutrition (PHILSPEN)
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address the problem of malnutrition in the hospitals of the Philippines
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Proposal: The value of implementing a clinical nutrition program and nutrition support team (NST) to
address the problem of malnutrition in the hospitals of the Philippines
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