title: Health insurance or subsidy has universal advantage for management of hospital malnutrition unrelated to GDP.
abstract: OBJECTIVE
  Protein-energy and micronutrient malnutrition are global public health problems which, when not prevented and severe, require medical management by clinicians with nutrition expertise, preferably as a collectively skilled team, especially when disease-related. This study aimed to investigate barriers and facilitators of clinical nutrition services (CNS), especially the use of oral, enteral (EN) and parenteral (PN) nutrition in institutional and home settings.
  
  
  METHODS
  An international survey was performed between January and December 2014 in twenty-six countries from all continents. Electronic questionnaires were distributed to 28 representatives of clinical nutrition (PEN) societies, 27 of whom responded. The questionnaire comprised questions regarding a country's economy, reimbursement for CNS, education about and the use of EN and PN.
  
  
  RESULTS
  The prevalence of malnutrition was not related to gross domestic product (GDP) at purchasing power parity (PPP) per capita (p=0.186). EN and PN were used in all countries surveyed (100%), but to different extents. Reimbursement of neither EN nor PN use depended on GDP, but was associated with increased use of EN and PN in hospitals (p=0.035), although not evident for home or chronic care facilities. The size of GDP did not affect the use of EN (p=0.256), but it mattered for PN (p=0.019).
  
  
  CONCLUSIONS
  A worldwide survey by nutrition support societies did not find a link between national economic performance and the implementation of medical nutrition services. Reimbursement for CNS, available through health insurance systems, is a factor in effective nutrition management.
authors.affiliation: Stanley Dudrick's Memorial Hospital, General Surgery Unit, Poland. Email: klek@poczta.onet.pl; st.klek@gmail.com.
authors.forename: Stanislaw
authors.initials: S
authors.lastname: Klek
authors.affiliation: School of Medicine, Aristotle University of Thessaloniki, Greece.
authors.forename: Michael
authors.initials: M
authors.lastname: Chourdakis
authors.affiliation: Nutrition Services Department, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
authors.forename: Dima Abdulqudos
authors.initials: DA
authors.lastname: Abosaleh
authors.affiliation: Maestría en Nutrición, Universidad Católica del Uruguay, Montevideo, Uruguay.
authors.forename: Alejandra
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authors.lastname: Amestoy
authors.affiliation: DMC BundangJesaeng Hospital, Seohyundong, Bundang, Gyeong Gi-Do, Seoul, Republic of Korea.
authors.forename: Hyun Wook
authors.initials: HW
authors.lastname: Baik
authors.affiliation: Universidad Central de Venezuela, Facultad de Medicina, Unidad Soporte Nutricional Hospital Universitario de Caracas.
authors.forename: Gertrudis
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authors.lastname: Baptista
authors.affiliation: Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy.
authors.forename: Rocco
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authors.affiliation: Teikyo University School of Medicine, Tokyo, Japan.
authors.forename: Ryoji
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authors.affiliation: Intensive Care Unit, Central Army Gatot Soebroto Hospital, Jakarta, Indonesia.
authors.forename: Josef
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authors.affiliation: Diabetes Research Unit, Faculty of Medicine, University of Colombo, Sri Lanka.
authors.forename: Ranil
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authors.lastname: Jayawardena
authors.affiliation: Universidad de las Ciencias Médicas de La Habana, Hospital Universitario Pediátrico Juan Manuel Márquez, La Habana, Cuba.
authors.forename: Rafael Jimenez
authors.initials: RJ
authors.lastname: Garcia
authors.affiliation: School of Medicine, University of Zagreb, Croatia.
authors.forename: Zeljko
authors.initials: Z
authors.lastname: Krznaric
authors.affiliation: Department of Nutrition and Dietetics and Department of Medicine, Monash University Central Clinical School, Prahran, Australia.
authors.forename: Ibolya
authors.initials: I
authors.lastname: Nyulasi
authors.affiliation: Universidad Católica del Uruguay Dámaso Antonio Larrañaga, Montevideo, Uruguay.
authors.forename: Gabriela
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authors.lastname: Parallada
authors.affiliation: St. Luke's Medical Centre, BGC, Taguig, Manila, Philippines.
authors.forename: Eliza Mei Perez
authors.initials: EM
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authors.affiliation: Medical Academy University Clinic for General Surgery Department for perioperative nutrition, Belgrade, Serbia.
authors.forename: Marina
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authors.lastname: Panisic-Sekeljic
authors.affiliation: Intensive Care Unit, Italian Hospital of Buenos Aires, Buenos Aires, Argentina.
authors.forename: Mario
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authors.affiliation: Mary Medical Centre in Groenkloof, Pretoria, South Africa.
authors.forename: Arina
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authors.affiliation: Hospital Lic. Adolfo LópezMateos ISSSTE, Nutrition and Metabolic Unit, México City.
authors.forename: Isabel Martinez
authors.initials: IM
authors.lastname: Del Rio Requejo
authors.affiliation: Care Hospitals Banjara Hills, Hyderabad, India.
authors.forename: Ravinder
authors.initials: R
authors.lastname: Reddy
authors.affiliation: Institute for Nutrition Research and Critical Care Department, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Israel.
authors.forename: Pierre
authors.initials: P
authors.lastname: Singer
authors.affiliation: Section of Nutrition, Department of Medicine, The Medical City Hospital, Pasig City, Manila, Philippines.
authors.forename: Marianna
authors.initials: M
authors.lastname: Sioson
authors.affiliation: Department of Gastroenterology at Cleveland Clinic Florida, Tampa, USA.
authors.forename: Andrew
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authors.lastname: Ukleja
authors.affiliation: Serhal Hospital, Head of Clinical Nutrition and Dietetics Department, Beirut, Lebanon.
authors.forename: Carla
authors.initials: C
authors.lastname: Vartanian
authors.affiliation: School of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.
authors.forename: Nicolas Velasco
authors.initials: NV
authors.lastname: Fuentes
authors.affiliation: Departamento de Gastroenterologia da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil.
authors.forename: Dan Linetzky
authors.initials: DL
authors.lastname: Waitzberg
authors.affiliation: La Clinique de l'Amitié à Ouagadougo, Burkina Faso.
authors.forename: Steve Leonce
authors.initials: SL
authors.lastname: Zoungrana
authors.affiliation: Jagiellonian University Medical College, Chair of Epidemiology and Preventive Medicine, Department of Epidemiology, Krakow, Poland.
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mesh_terms: D004750:Enteral Nutrition; D059066:Gross Domestic Product; D006761:Hospitals; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D044342:Malnutrition / Q000628:therapy*; D044623:Nutrition Therapy / Q000191:economics*; D009752:Nutritional Status; D010288:Parenteral Nutrition; D012051:Reimbursement Mechanisms; D011795:Surveys and Questionnaires