TNT - terapia de nutricion total

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Total Nutritional Therapy: A NutritionEducation Program for Physicians

29Nutr. Hosp. (2004) 19 (1) 28-33

Introduction

Estimates of malnutrition among hospitalized pa-tients at admission range from 20% to 55%2, 3. Amongpatients with normal nutritional status upon admis-

sion, approximately 50% may develop mild malnutri-tion while hospitalized4. One study found that no mo-re than 19% of patients medical records containedany information about nutritional status, and only15% of patients were weighed even though a scalewas available within 50 meters in 75% of cases1. Mal-nutrition is correlated with higher morbidity, morta-lity, and health care costs, yet is infrequently addres-sed1, 5, 6. Early nutrition intervention has been shown toreduce complications and to improve outcomes in sur-gical7, 8, pediatric9, and trauma patients10.

One reason why malnutrition is not addressed is alack of nutrition education for physicians.11 In theUnited States, 98% of medical schools report nutri-tion as a component of their education, yet most scho-ols do not require a single course on nutrition 12. InItaly, final-year medical and dietetic students took aclinical nutrition test, with 76% of the dietetic stu-dents passing, compared to only 18% of the medicalstudents. In contrast, 77% of medical students whohad taken a clinical nutrition curriculum passed.13 In astudy of fluid prescribing practices in Great Britain,only 56% of respondents reported checking fluid ba-lance charts during daily rounds. Less than 50% ofthese physicians knew the sodium content of 0.9% sa-line solution or the daily sodium requirement, and25% were misprescribing saline solution14.

Medical schools are beginning to respond to thisknowledge gap. Great Britain now has a nutrition cu-rriculum for all medical schools15. Both the Universityof Pennsylvania and the University of Arizona haveincreased their nutrition course requirements for medi-cal students12. The faculty at the University of Pennsyl-vania consists of dietitians and physicians from severaldepartments. In 1991, 80% of surveyed graduatingmedical students at the University of Pennsylvania sta-ted that their nutrition education was inadequate, whe-reas in 1998, only 10% stated that opinion16.

Several nutrition experts have also responded to thedearth of nutrition education available for physiciansby forming the Intersociety Professional NutritionEducation Consortium (IPNEC)17. Eight national so-cieties and 3 credentialing bodies are represented in

IPNEC. Its main objective is to establish educationalstandards for fellowship training of physician nutri-tion specialists (PNS). PNS are usually gastroentero-logists, but physicians from any discipline may worktowards this designation17. These specialists can thentrain other physicians on how to utilize nutrition as-sessment and therapy in patient care, an important butneglected area of physician education.

The lack of physicians with nutrition training is es-pecially critical in Latin America. Latin America hasapproximately 500 million inhabitants (1996 estima-te)18. The largest country, Brazil, has close to 200 mi-llion people18. The Director General of the Food and

Agriculture Organization of the United Nations esti-mates that 54 million Latin Americans suffer from ch-ronic malnutrition19. This is over 10% of the regionspopulation. In parts of Brazil, child malnutrition is ashigh as 15%20. Therefore, the need for physicians withnutrition knowledge is great. Dietitians are not alwaysavailable to aid physicians in Latin America and it iscrucial for physicians to be able to utilize nutrition as-sessment and therapy.

The Latin American Federation of Parenteral andEnteral Nutrition (FELANPE) partnered with AbbottLaboratories to develop Total Nutritional Therapy(TNT). TNT is a 2-day, 20-hour course with lectures,workshops, and case studies. The format was inspiredby the Advanced Trauma Life Support (ATLS) course.ATLS is a 2-day course developed by the AmericanCollege of Surgeons for physicians who do not routi-nely treat victims of trauma. ATLS training has beenshown to benefit patients with serious but survivableinjuries.21 Modeled on the successful format of ATLS,TNT seeks to improve physician knowledge of clinicalnutrition through a 2-day course and to increase theuse of nutritional therapy in clinical practice.

The TNT course was developed for physicians byphysicians. It emphasizes small group activities that

Results: The majority of physicians who completedthe survey increased their use of nutrition assessmentand time dedicated to nutrition therapy, and increasedthe number of their patients placed on nutrition the-rapy.

Conclusions: The TNT course has been shown to bean efficient model of clinical nutrition education for ge-neral physicians. The course should be considered as

part of the training of medical residents.(Nutr Hosp 2004, 19:28-33)

Keywords: Clinical nutrition. Hospital malnutrition.Medical education. Nutritional assessment. Subjective glo-bal assessment.

eficiente para la educacin de los mdicos generales ennutricin clnica. Este curso debera integrarse en la for-macin de los mdicos residentes.

(Nutr Hosp 2004, 19:28-33)

Palabras clave:Educacin mdica. Evaluacin nutricio-nal. Evaluacin subjetiva general. Malnutricin hospitala-ria. Nutricin clnica.


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promote interaction. It consists of 11 lectures, 5workshops, 5 case studies, and a 20- chapter manualand is taught over a 2-day period. Table I lists thecourse content. Members of the FELANPE educationboard and Abbott Laboratories developed the coursematerials. The course is taught by 4 instructors and acourse director. Instructors are physicians who havesuccessfully completed the course and post-course

test. The instructors emphasize the basic principles ofthe course. The course was piloted and audited in Me-xico City, Mexico in April 1997. Through 2002, 317TNT courses were offered in 16 Latin Americancountries and 8,214 physicians have completed TNT(table II).

Each course was limited to 32 participants to fostersmall group interactions and attention. Thirty daysprior to each course, TNT course organizers mailedthe course study materials, manual, and a pre-test toeach participant. The format of the course alternatedbetween lecture, small-group discussions on case stu-dies, and workshops. The workshops provided actual

practice with enteral and parenteral devices and pro-cedures. Active participation in workshops and casestudy discussions was strongly encouraged. At the

end of the course, a post-course test was given. Ins-tructors presented diplomas to participants with a sco-re of 70% or higher.

The objectives of this study are to report the resultsof the surveys completed in 1999 and 2000, 6 monthsafter TNT, to determine the impact of TNT on theawareness and knowledge of clinical nutrition and itsimpact on physician clinical practice.

Methods and Materials

Physicians were notified of the course offering byseveral methods. FELANPE and the nutrition socie-ties of each country in FELANPE mailed invitationsto their members. FELANPE advertised the course inits newsletter and in medical journals. Abbott repre-sentatives also informed physicians about the course.

During 1999 and 2000, TNT participants were sur-veyed 6 months after completing the TNT course inorder to assess the impact that TNT had had on theirmedical practice (table III). The survey questions were

about the physicians routine use of nutrition assess-ment and nutrition consultations, use of nutrition sup-port teams (NSTs), and membership in parenteral and

30 Dan L. Waitzberg y cols.Nutr. Hosp. (2004) 19 (1) 28-33

Table ITNT Course Content

Chapters Lectures Workshops Case studies

1. Nutritional Therapy Malnutrition/Consequences2. Cost Benefit of Nutrition Therapy Malnutrition/Consequences3. Body Composition Nutrition Screening Nutrition Assessment

and Assessment

4. Carbohydrates, Proteins, Lipids Nutrient Needs Fluid and NutrientRequirements5. Vitamins/Trace Elements Nutrient Needs Fluid and Nutrient

Requirements6. Water and Electrolytes Nutrient Needs Fluid and Nutrient

Requirements7. Metabolic Response to Stress Metabolic Response to Stress8. Nutrition in Critical Care Early Enteral Nutrition Critical Illness/Multiple

Therapy Trauma9. Cancer Colorectal Cancer10. Gastrointestinal Disease Short Bowel Syndrome11. Chronic Disease Type 2 Diabetes, Chronic

Obstructive PulmonaryDisease

12. Orders/Assessing Outcomes13. Enteral Nutrition Early Enteral Nutrition Therapy14. Enteral Formulas Formula Selection15. Gastrointestinal Access Enteral Access Enteral Access Devices16. Enteral Feeding Complications Preventing Complications Enteral Feeding Systems17. Parenteral Nutrition Parenteral Nutrition Therapy18. Central Venous Access Complications of Parenteral Central Venous Catheters

Nutrition Therapy19. Parenteral Complications Complications of Parenteral Central Venous Catheters

Nutrition Therapy20. Home Nutrition Therapy Summary: Optimizing Nutrition


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enteral nutrition associations. The physicians were al-so asked if they had begun NSTs and if they had incre-ased the time dedicated to nutrition therapy since at-tending the TNT course. These questions wereincluded to aid in determining if the TNT course hadhad an impact on their clinical practice. The 6-month

follow-up surveys were mailed to the 3,025 physiciansin Argentina, Brazil, Chile, Colombia, Mexico, andUruguay who had taken the TNT course during 1999or 2000. Survey results were compiled in Epi Info,version 6.04 (Centers for Disease Control, Atlanta).

Results

Six hundred seventy five physicians completed the6-month follow-up surveys in 1999 and 2000. The 6countries surveyed hosted 70% of the TNT coursesoffered through 2002 (table II). The response rate was22% (675/3,025). Twelve of the physicians were from

Argentina; 348 were from Brazil; 60 were from Chile;50 were from Colombia; 129 were from Mexico; and76 were from Uruguay.

Responses to 8 of the questions are shown in Figure1. Seventy-nine percent of the physicians reported in-creasing the time that they dedicated to nutrition the-rapy in their medical practice and 78% reported inclu-ding nutrition assessment in their practice aftercompleting the TNT course. Sixty-seven percent in-creased the percent of patients placed on nutrition the-rapy. Twenty-nine percent became new parenteraland enteral nutrition society members. Thirty-seven

percent reported creating nutrition support teams(NSTs) and 27% joined NSTs after attending the TNTcourse. Almost half (49%) of the physicians increasedNST consultations.

Discussion

The results of this survey completed 6 months after

the TNT course illustrate important changes in the cli-nical practice of physicians. Almost 80% of the physi-cians increased the time dedicated to nutrition therapyand included nutrition assessment in their clinicalpractice. More than two-thirds increased the numberof patients they placed on nutritional therapy. Manyphysicians joined a nutrition society or attended a nu-trition conference, and their use of nutrition supportteams (NSTs) increased. Based on their TNT training,physicians should be more likely to intervene earlywith nutritional therapy and thereby prevent compli-cations, decrease morbidity, mortality, and reduce he-alth care costs. Early nutrition intervention has de-

monstrated these benefits in previous studies1, 22. Theuse of NSTs has also been shown to reduce health ca-re costs23, 24.

In many hospitals, new NSTs were formed by TNTgraduates. One university hospital incorporated theTNT course as part of its medical residency program.The TNT course has also promoted the developmentof nutritional guidelines and protocols and stimulatedresearch on malnutrition. Most importantly, the sur-vey results indicate that TNT graduates are utilizingtheir nutrition knowledge in patient care.

Over 8,000 physicians have been trained in 16 LatinAmerican countries since April 1997. The TNT pro-

gram continues to be offered in many countries andwas recently updated (TNT 2.0). TNT webmaster isalrealy available at http://tninfo.net. From the 3,025surveys originally mailed during 1999 and 2000, 22%of participants responded. This response rate is com-parable to other researchers findings with surveys do-ne with one mailing25, 26. Changes in address, difficul-ties with electronic or postal mail, only one mailingsent, and physicians hectic work schedules may be re-asons why more physicians did not respond. It is ho-ped that with a web site, more responses may be obtai-ned for the 6-month follow-up survey, in the future.

SummaryJust as the ATLS course has been successful in re-

ducing mortality from trauma21, the TNT course mayhelp to remedy the gap in physician nutrition educa-tion. By becoming more aware of nutrition therapiesand support teams, physicians may incorporate thesemodalities into their clinical practice and impact mal-nutrition among hospitalized patients. Physicians whohave completed the TNT course can incorporate whatthey have learned in their practice and thereby help toreduce malnutrition and its effects.


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Table IINumber of TNT Courses and Participants by Country,

1997-2002

Country Number Number of

of Courses Physicians Attending

Argentina* 27 671

Bolivia 1 31Brazil* 56 1415Chile* 13 265Colombia* 57 1550Costa Rica 12 277Dominican Republic 5 142Ecuador 18 508El Salvador 14 480Mexico* 55 1143Panama 12 214Paraguay 2 60Peru 10 329Puerto Rico 1 26Uruguay* 15 543

Venezuela 19 560Total** 317 8214

* Denotes country surveyed.** Please note that these totals reflect the number of physicianswho have taken the course from 1997 through 2002, not only the3,025 physicians who were surveyed in 1999 and 2000.


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References

1. Waitzberg DL, Caiaffa WT and Correia MITD: Hospital mal-nutrition: the Brazilian national survey (IBRANUTRI): a

study of 4000 patients.Nutrition, 2001, 17:573-580.2. Edington J, Boorman J, Durrant ER et al: Prevalence of mal-nutrition on admission to four hospitals in England. The mal-nutrition prevalence group. Clin Nutr, 2000, 19:191-195.

3. Correia MI, Caiaffa WT, da Silva AL and Waitzberg DL: Riskfactors for malnutrition in patients undergoing gastroenterolo-gical and hernia surgery: an analysis of 374 patients. NutrHosp, 2001, 16:59-64.

4. Gonzlez Castela L, Coloma Peral R, Ascorbe Salcedo P et al:Current status of the degree of malnutrition in hospitalized pa-tients of the community of La Rioja. Nutr Hosp, 2001, 16:7-13.

5. Campbell SE, Avenell A and Walker AE: Assessment of nu-tritional status in hospital in-patients. QJM, 2002, 95:83-87.

6. Reilly JJ, Hull SF, Albert N, Waller A and Bringardener S:Economic impact of malnutrition: a model system for hospita-lized patients.JPEN J Parenter Enteral Nutr, 1988, 12:371-376.

7. Braga M, Gianotti L, Nespoli L, Radaelli G and Di Carlo V:Nutritional approach in malnourished surgical patients: aprospective randomized study.Arch Surg, 2002, 137:174-180.

8. Kudsk KA: Early enteral nutrition in surgical patients.Nutri-tion, 1998, 14:541-544.

9. Anderson C: Enteral feeding: a change in practice.Journal ofChildrens Health Care, 2000, 4:160-162.

10. Kudsk KA, Minard G, Croce MA et al: A randomized trial ofisonitrogenous enteral diets after severe trauma. Ann Surg,1996, 224:531-543.

11. Nightingale JMD and Reeves J: Knowledge about the assess-ment and management of undernutrition: a pilot questionnaire

in a UK teaching hospital. Clin Nutr, 1999, 18:23-27.12. Taren DL, Thomson CA, Koff NA et al: Effect of an integra-

ted nutrition curriculum on medical education, student clinicalperformance, and student perception of medical-nutrition trai-

ning.Am J Clin Nutr, 2001, 73:1107-1112.13. Guagnano MT, Merlitti D, Pace-Palitti V, Manigrasso MRand Sensi S: Clinical nutrition: inadequate teaching in medicalschools.Nutr Metab Cardiovasc Dis, 2001, 11:104-107.

14. Lobo DN, Dube MG, Neal KR et al: Problems with solutions:drowning in the brine of an inadequate knowledge base. ClinNutr, 2001, 20:125-130.

15. Jackson AA: Human nutrition in medical practice: the trainingof doctors. Proc Nutr Soc, 2001, 60:257-263.

16. Hark LA and Morrison G: Development of a case-based inte-grated nutrition curriculum for medical students.Am J ClinNutr, 2000, 72(Suppl 3):890s-897s.

17. Heimburger DC: The Intersociety Professional Nutrition Edu-cation Consortium. Training and certifying gastroenterolo-gists as physician nutrition specialists. J Clin Gastroenterol,2002, 34:505-508.

18. DHL Demographics. www.dhl.com. Accessed December 18,2002.

19. Food and Agriculture Organization of the United Nations. 54million people in Latin America and the Caribbean suffer hun-ger, says FAO Director-General. 24 April 2002. www.fao.org.Accessed December 16, 2002.

20. SEJUP (Servicio Brasileiro de Justica e Paz). Malnutritionworsens in the north and northeast of Brazil.News from Brazil2000, 396: April 21. www.oneworld.org. Accessed December18, 2002.

21. Olson CJ, Arthur M, Mullins RJ, Rowland D, Hedges JR andMann NC: Influence of trauma system implementation onprocess of care delivered to seriously injured patients in ruraltrauma centers. Surgery, 2001, 130:273-279.

32 Dan L. Waitzberg y cols.Nutr. Hosp. (2004) 19 (1) 28-33

Table IIITNT Participant Follow-up Survey after Six Months

First Middle Last

Name

Is there a nutrition support team (NST) in your hospital? s 1 = Yes; 2 = No

If yes, was it created after you took TNT? s 1 = Yes; 2 = NoAre you a member of the NST? s 1 = Yes; 2 = NoIf yes, did you become a member after you took TNT? s 1 = Yes; 2 = NoIf not, have you asked the NST for more consultations? s 1 = Yes; 2 = No

Have you included nutrition assessment routinely in examinations? s 1 = Yes; 2 = NoHave you increased the number of patients you place on nutrition therapy? s 1 = Yes; 2 = No

How many patients (on average) do you see on nutrition therapy per day? sDo you consult your TNT material in your daily practice? s 1 = frequently; 2 = moderately; 3 = rarelyAre you a member of your countrys Parenteral and Enteral Society? s 1 = Yes; 2 = No

If yes, did you become a member after TNT? s 1 = Yes; 2 = NoAfter you took TNT, did you attend any nutrition congresses? s 1 = Yes; 2 = No

Which one?Have you increased the time you spend on nutrition therapy? s 1 = Yes; 2 = No

If yes, how much time are you now spending? s 1 > 80%; 2 = 50-79%; 3 = 30-50%; 4 < 29%

How would you rate TNTs impact on your routine nutritional practice? s 1 = very important; 2 = important; 3 = notimportant

Would you like to receive a newsletter with TNT information? s 1 = Yes; 2 = NoDate of TNT course: __ / __ / __ City: _______________________________________________________________Street address: _______________________________________________________________________________________City:____________________________ State: ___________________________________________________________Country:_________________________ Zip code: ________________________________________________________Telephone:___________ Fax:____________ E-mail: _________________________________________________________Additional Comments: _________________________________________________________________________________


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22. Brugler L, DiPrinzio MJ and Bernstein L: The five-yearevolution of a malnutrition treatment program in a com-munity hospital. Jt Comm J Qual Improv, 1999, 25:191-206.

23. OBrien DD, Hodges RE, Day AT, Waxman KS and RebelloT: Recommendations of nutrition support team promote costcontainment.JPEN J Parenter Enteral Nutr, 1986, 10:300-302.

24. Ochoa JB, Magnuson B, Swintowsky M et al: Long-term re-duction in the cost of nutrition intervention achieved by a nu-trition support service.Nutr Clin Pract, 2000, 15:174-180.

25. McCahill LE, Krouse RS, Chu DZ et al: Decision making inpalliative surgery.J Am Coll Surg, 2002, 195:411-423.

26. Sun BC, Adams JG and Burstin HR: Validating a model ofpatient satisfaction with emergency care. Ann Emerg Med,2001, 38:527-532.


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