Spain

INTRODUCTION

In 2011, the Spanish Society for Clinical Nutrition and Metabolism (SENPE) and Abbott Foundation started a Project to raise awareness on the problem of DRM among the policymakers and administrators and build an action plan to tackle DRM in Spain. This led to the creation of the másnutridos Project in 2012.

The Project was inspired by the Dutch model and included the following key points:

1. Education and training of health care professionals in the problem of DRM and the methods to detect and treat it
2. Nutritional screening across all the NHS and evaluation of DRM
3. Protocols of nutritional treatment in hospitals, nursing homes and primary care centres
4. Monitoring plan of care and nutritional treatments
5. Adequate codification of DRM to make the problem visible and obtain reimbursement in the hospitals
6. Process of outcome evaluation in health, taking into account quality and costs

In 2014, Spain joined the Optimal Nutritional Care for All campaign taking part in the first meeting in Brussels. The Spanish delegation included members of the MoH, regional governments and representatives of several professional societies, other than SENPE (Endocrinology, Pediatrics, Geriatrics and Nursing).

This meeting fostered the Project in two ways:

• Creating the Másnutridos Alliance in 2015 that included more stakeholders: scientific societies, patients associations, and the Councils of Nursing and Pharmacists.
• Strengthening our collaboration with the Ministry of Health, creating in 2015 a working group to build a Framework Document for the Approach of DRM in the NHS.

During these years, we have developed different tools for the dissemination of our project:

• másnutridos webpage
• Notebooks covering different topics (cost-effectiveness of nutritional treatment, screening tools, nutrition care plan in hospitals and primary care)
• Newsletters (so far, 19 newsletters have been quarterly distributed to more than 375 key stakeholders and másnutridos members covering the advances in the Project).

Currently (February 2019), másnutridos alliance includes 16 stakeholders and covers 75% of health care professionals in Spain:

• SENPE, Sociedad Española de Nutrición Clínica y Metabolismo
• Fundación Abbott
• AGP, Alianza General de Pacientes
• Consejo General de Colegios Oficiales de Farmacéuticos
• Consejo General de Enfermería
• SEEN, Sociedad Española de Endocrinología y Nutrición
• SEMFYC, Sociedad Española de Medicina de Familia y Comunitaria
• SEMERGEN, Sociedad Española de Médicos de Atención Primaria
• SEGG, Sociedad Española de Geriatría y Gerontología
• SEGHNP, Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica
• SEOR, Sociedad Española de Oncología Radioterápica
• SEMI, Sociedad Española de Medicina Interna
• AEC, Asociación Española de Cirujanos
• GERM, Grupo Español de Rehabilitación Multimodal
• AEHH, Asociación Española de Hostelería Hospitalaria
• SEDAR, Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor

The Spanish Malnutrition Awareness Week

Spanish másnutridos Alliance & the Optimal Nutritional Care for All campaign

Vision
In all the European countries, each individual at risk of malnutrition or malnourished should be systematically screened, evaluated and followed-up, and be able to benefit from high quality, equitable and appropriate nutritional care.

ENHA “The European Nutrition for Health Alliance” launched and supports the ONCA campaign (2014).
ENHA is a European platform of active partners in public health, health and social care; by developing and encouraging actions, ENHA tries to improve the quality of nutrition in its broadest possible sense, from basic food to nutritional support (adapted oral feeding, oral nutritional supplements, enteral and parenteral nutrition) and tackle malnutrition and the risk of malnutrition in Europe.
Concerning ONCA, ENHA firstly encourages and supports each member state to create and foster their own alliances and secondly brings members together twice a year to encourage exchanges and generate joint actions (good practices).
National alliances are composed of partners, concerned in the broadest possible sense by “Nutritional Care”, including the Public Authorities.

Why ONCA?
Disease-related malnutrition or malnutrition as a result of social, psychological or economic circumstances is a global public health problem.
In Europe, 33 million adults are at risk of malnutrition. This poses a significant financial impact for public health leading to additional costs of €170 billion /year.

Situation in Spain
Disease-related malnutrition (DRM), which many times is influenced by social, psychological or economic circumstances, concerns all care settings: hospitals, community and nursing homes. Adequate care plans including, quality food supply and medical nutrition treatment (including oral nutritional supplements, enteral and parenteral nutrition) should be available in all the clinical settings.

In Spain, we have some data on the prevalence of DRM and its costs in different clinical settings.

The PREDYCES study was performed in 2011 in 31 randomised Spanish hospitals including 1597 patients and showed a prevalence of 23,7% of patients at risk of malnutrition or malnourished (according to NRS 2002), that increased to 37% in elderly people over 70 years old. The prevalence was higher in patients with cancer (35%), cardiovascular (29%) and respiratory diseases (28%). This study also concluded that the cost of hospitalisation increased by at least 50% in patients with malnutrition (€6,572 vs. €9,089/patient) and that hospital stay increased twofold in these cases.

The DREAM +65 study included 1103 subjects over 65 years old in Madrid, from different clinical settings: 275 subjects from primary care centres, 278 from day centres, 281 from hospitals and 269 from nursing homes. Using the MNA screening-assessment instrument, the prevalence of malnutrition in hospitals was 21.7% and nutritional risk, 46.6%. The prevalence of malnutrition in the community was much lower, values being 2.1% in primary healthcare centres and 0.4% in daycare centres for the elderly, while the figures for nutritional risk were 10.9% and 4.7%, respectively. In nursing homes, the figures for malnutrition and nutritional risk were slightly lower than those for hospitals: 15.6% and 30.9%, respectively. There was a relationship between malnutrition and the degree of dependence, as well as the clinical setting, adjusted for age and sex.

másnutridos Alliance
After the first achievements in the fight against DRM with the Predyces Study (2010) and the Multidisciplinary Consensus (2011), the Spanish Society for Clinical Nutrition and Metabolism (SENPE) and Abbott Foundation started a Project to raise awareness among the policymakers and administrators on the problem of DRM and build an action plan to tackle DRM in Spain. This led to the creation of the másnutridos Project in 2012.

The Project was inspired in the Dutch model and included the following key points:

1. Education and training of health care professionals in the problem of DRM and the methods to detect and treat it
2. Nutritional screening across all the NHS and evaluation of DRM
3. Protocols of nutritional treatment in hospitals, nursing homes and primary care centres
4. Monitoring plan of care and nutritional treatments
5. Adequate codification of DRM to make the problem visible and obtain reimbursement in the hospitals
6. Process of outcome evaluation in health, taking into account quality and costs

In 2015, the Project evolved to másnutridos Alliance in 2015 with the inclusion of more stakeholders: scientific societies, patients associations, and the Councils of Nursing and Pharmacists. Currently, the Alliance includes 16 stakeholders and covers 75% of all health care professionals in Spain.

Highlights of the project over the past years:

2012
• Launch of másnutridos project
2013
• Creation of másnutridos regional network (37 representatives in 17 regions)
2014
• Spain joins ONCA campaign
• Launch of www.alianzamásnutridos.com
2015
• Creation of másnutridos Alliance, gathering 35% of healthcare professionals
• The Ministry of Health creates a workgroup on DRM
• Non-Law Proposition (NLP) on DRM in the Balearic Islands
• The autonomous community of Aragon elaborates a document for the approach to DRM
2016
• The Alliance grows: 50% of HCP
• Elaboration of DRM document by the Ministry of Health
• Canary Islands approves the implementation of nutritional screening in hospitals
• ONCA conference comes to Madrid
2017
• Adhesion of 6 new members, reaching 60% of HCP
• Patient’s manifesto signed by 26 organisms
• Non-Law Proposition (NLP) on DRM in the autonomous communities of Galicia and Andalucia
• The autonomous community of Galicia includes measures to approach DRM in hospitals’ management contracts
2018
• Adhesion of 4 new members: 75% of HCP
• Raise awareness to Her Majesty Queen Letizia
• Approval of a Non-Law Proposition (NLP) on DRM in the Congress of Deputies
• Non-Law Proposition (NLP) on DRM in the autonomous communities of La Rioja and Murcia
• DRM included in Pre-draft law on healthy habits in the autonomous community of Andalucia
• The Alliance is awarded the Medical Nutrition International Industry (MNI) Grant 2018
• Publication of a study from the Health Technology Assessment Agency of the Canary Islands offering positive conclusions about the implementation of nutritional screening in hospitals

Planned activities in 2019:
• National cost –economy study (MNI grant)
• Organization, along with the Regional Ministry of Health, of a seminar with the managers of the 7 main hospitals of the autonomous community of Galicia
• Publication of two new notebooks:
o Nutritional plan in care homes
o Nutritional plan in Pediatrics
• General, regional and local elections: meetings with new health authorities
• Launching of Alliance másnutridos new communication plan

References

1. Planas Vila M, Álvarez Hernández J, García de Lorenzo A, Celaya Pérez S, León Sanz M, García-Lorda P, Brosa M. The burden of hospital malnutrition in Spain: methods and development of the PREDyCES® study. Nutr Hosp. 2010 Nov-Dec; 25(6):1020-4.
2. Álvarez-Hernández J, Planas Vila M, León-Sanz M, García de Lorenzo A, Celaya-Pérez S, García-Lorda P, Araujo K, Sarto Guerri B; PREDyCES researchers. Prevalence and costs of malnutrition in hospitalized patients; the PREDyCES Study. Nutr Hosp. 2012 Jul-Aug; 27(4):1049-59.
3. García de Lorenzo A, Álvarez Hernández J, Planas M, Burgos R, Araujo K. Multidisciplinary consensus work-team on the approach to hospital malnutrition in Spain. Multidisciplinary consensus on the approach to hospital malnutrition in Spain. Nutr Hosp. 2011 Jul-Aug;26(4):701-10.
4. Alvarez Hernández J, García de Lorenzo A. Coding of hospital hyponutrition: the validity of a statement. Nutr Hosp. 2008 Nov-Dec;23(6):529-30.
5. Cuerda C, Álvarez J, Ramos P, Abánades JC, García-de-Lorenzo A, Gil P, De-la-Cruz JJ. Prevalencia de desnutrición en sujetos mayores de 65 años en la Comunidad de Madrid. Estudio DREAM + 65. Nutr Hosp. 2016 Mar 25;33(2):101.
6. Martín Folguera T, Alvarez Hernández J, Burgos Peláez R, Celaya Pérez S, Calvo Hernández MV, García de Lorenzo A, García Luna PP, Irles Rocamora JA, Lajo Morales T, Luengo Pérez LM, Mellado Pastor C, Olveira Fuster G, Pérez Portabella C, Vidal Casariego A; Grupo de Trabajo de Gestión de SENPE. Analysis of the relevance and feasibility of quality indicators in nutrition support. Nutr Hosp. 2012 Jan-Feb;27(1):198-204.
7. Martín Folgueras T, Ballesteros Pomar MD, Burgos Peláez R, Calvo Hernández MV, Luengo Pérez LM, Irles Rocamora JA, Olveira G, Vidal Casariego A, Alvarez Hernández J. Organization and management of clinical nutrition in Spain. How do we assess the quality of our activities? Nutr Hosp. 2017 Jul 28;34(4):989-996.
8. Álvarez Hernández J. Cost-effectiveness studies, a necessary tool in clinical nutrition in the XXI century. Nutr Hosp. 2017 Mar 30;34(2):253-254.
9. Álvarez Hernández J, León Sanz M, Planas Vilá M, Araujo K, García de Lorenzo A, Celaya Pérez S. PREVALENCE AND COSTS OF MALNUTRITION IN HOSPITALIZED DYSPHAGIC PATIENTS: A SUBANALYSIS OF THE PREDYCES STUDY. Nutr Hosp. 2015 Oct 1;32(4):1830-6.
10. Planas M, Álvarez-Hernández J, León-Sanz M, Celaya-Pérez S, Araujo K, García de Lorenzo A; PREDyCES® researchers. Prevalence of hospital malnutrition in cancer patients: a sub-analysis of the PREDyCES® study. Support Care Cancer. 2016 Jan;24(1):429-35.
11. Alvarez J. Nutrition screening: looking for the efficiency. Nutr Hosp. 2018 Apr 3;35(2):249-251.
12. Alvarez J. Nutrition screening in health care, an unavoidable necessity. Our unresolved matter. Endocrinol Diabetes Nutr. 2018 Aug – Sep;65(7):377-379.
13. Alvarez J. 9th Jesús Culebras Lecture: “The value of clinical nutrition”. Nutr Hosp. 2018 Dec 3;35(6):1467-1478.
14. Cuaderno 0: Coste-efectividad de la intervención nutricional. (accesed 20th February 2019, http://www.alianzamasnutridos.es/uploads/cuadernos/pdf/d939b55519166bab0056782ee1b550aa.pdf)
15. Cuaderno 1: Cuaderno nº1. Herramientas de cribado nutricional para Hospitales, Residencias y Comunidad . (accesed 20th February 2019, http://www.alianzamasnutridos.es/uploads/cuadernos/pdf/eadb6d997e5e3e77931bc9e25744ca22.pdf)
16. Cuaderno 2: Hacia la desnutrición cero en centros hospitalarios: plan de acción. (accesed 20th February 2019, http://www.alianzamasnutridos.es/uploads/cuadernos/pdf/6671d5f27855212d2ccda512ad4d26f1.pdf)
17. Cuaderno 3: Hacia la desnutrición cero en la comunidad. (accesed 20th February 2019, http://www.alianzamasnutridos.es/uploads/cuadernos/pdf/31ee933ace70596d550d2692b1e44045.pdf)