Nutrition Therapy in the Adult Hospitalized Patient

B. Nutritional assessment

Types of Surveillance Systems
Journal of Nursing Administration , 22 3 , Quality of hospice care for individuals with dementia. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses, such as diarrhoea and pneumonia, and leads to quicker recovery from illness. Journal of Nursing Scholarship , 39 4 , On the other hand, apart from the figures, more general information on production systems exists at local level, and this can be useful for identifying relevant indicators of causes, or for simplifying monitoring of the situation. Nutrition support protocols and their influence on the delivery of enteral nutrition: The matrix lists the high-level expected results 'the UNDAF outcomes' , the outcomes to be reached by agencies working alone or together and agency outputs.

WHO African Region: Ethiopia

Public health surveillance

Extensive clinical experience does not support any of these concerns. When feasible, we suggest that all percutaneous gastrostomy tubes be placed to the right of the midline, close to the level of the umbilicus. A variety of measures can help secure the enteral access device at the time of placement A nasal bridle fashioned from a 5-French neonatal feeding tube or a commercial device with magnetic-tipped flexible rods and surgical ribbon may be used to secure a nasoenteric tube placed through the nose.

A recent meta-analysis showed that the use of a nasal bridle nearly eliminates displacement Although an abdominal binder is helpful in protecting the percutaneous gastrostomy tube, it should be loose enough to avoid crushing the access device and positioned with support at the level of the skin to prevent excess side torsion to the gastrostomy tract Ultimately, whenever possible, the reason s for inadvertent removal of the tube e.

How soon, at what dose, and with which formula should enteral nutrition be initiated in the hospitalized patient? The timing of initiation of EN in the hospitalized patient especially critically ill patients in an ICU setting is based on two categories of studies in the literature, early vs.

In meta-analyses by Marik and Doig comparing early vs. Tolerance determines how quickly and how aggressively to increase EN delivery. Trophic feeding may not be appropriate in patients who are at extremes of age, BMI, or disease severity Such a regimen should maintain lean body mass while depleting the fat mass, with no increase in adverse outcomes Such a regimen was shown to be associated with significant reductions in infection and hospital LOS compared with full caloric feeding Indications for use of specialized formulae are limited, and their use should be reserved for certain subsets of hospitalized patient populations.

The vast majority of hospitalized patients requiring EN will tolerate a standard polymeric formula with or without fiber. Pre-operative patients awaiting major elective surgery and critically ill patients admitted to a surgical ICU may benefit from an arginine-containing immune-modulating formula also containing fish oil, glutamine, and antioxidants. How should adequacy and tolerance of EN be assessed in the hospitalized patient?

Patients on EN should be monitored daily by physical exam to detect the presence of bowel sounds, passage of stool and gas, abdominal distention, and volume status Caloric and protein target goals should be clearly identified and intake and output should be followed to determine the percent of goal calories delivered. Increased delivery of calories to reduce the deficit is associated with improved outcome. Such patients should be monitored closely for up to 5 days for electrolyte abnormalities hypokalemia, hypophosphatemia, and hypomagnesemia , and volume status after feeding is initiated It is not clear whether risk of refeeding syndrome is more common with EN or PN The use of feeding protocols with nursing directives is an important strategy for improving the timeliness, adequacy, and safety of delivering EN Important elements of nurse-driven protocols include the use of universal EN connectors, monitoring by focused physical exam, consideration of fluid volumes, management of GRVs, rates for advancement of EN based on tolerance, and measures to reduce risk of aspiration.

A volume-based feeding strategy identifies the volume to be delivered over a 24 h period and empowers the nurse to increase the rate to make up for interruptions in delivery A multi-strategy top-down protocol has been described for use in critically ill patients based on the presumption that these patients are at increased risk of feeding intolerance and that multiple strategies can be used with the initiation of EN to promote better tolerance including the use of volume-based feeding, elevation of the head of the bed, chlorhexidine mouth washes, small bowel feeding, and the use of prokinetic medications Multiple strategies are utilized together with the initiation of EN and then individually removed as tolerance is achieved.

Furthermore, the practice of checking GRV is not well standardized, the values are difficult to interpret, and expense involved with allocation of health-care resources nursing time is substantial The use of GRVs as a monitor increases the likelihood of tube clogging tenfold Lowering the cutoff value does not protect the patient from aspiration but instead simply turns off the delivery of EN.

Bundling individual strategies may be more effective in changing outcome Differences in definition mostly account for the wide range of incidence. Much of what is referred to as diarrhea in hospitalized patients on EN actually represents low-volume fecal incontinence. Although most cases are mild and self-limited, diarrhea in the hospitalized patient on EN may result in electrolyte imbalance, dehydration, perianal skin breakdown, and wound contamination Although factors associated with the formula e.

There is abundant data to recommend stopping prokinetics in individuals who develop non- C. When an underlying cause cannot be identified and diarrhea persists, the addition of a fermentable soluble fiber supplement e. The prebiotic effect of the soluble fiber helps foster a more balanced and biodiverse gut microbiome How should complications of enteral feeding in the hospitalized patient be assessed and treated?

Daily cleaning with mild soap and water is important to avoid the drying desiccating effects on the skin from hydrogen peroxide or scented alcohol-based soaps For the first 4 days following tube placement, the external bolster, if present, should be positioned up against the anterior wall with a single layer of gauze underneath against the skin.

If unsuccessful, a nonenteric-coated pancreatic enzyme tablet e. Use of a carbonated soft drink is an acceptable alternative, but the use of papain meat tenderizer should be avoided If still not corrected, a small-bore tube such as an ERCP catheter may be placed down through the feeding tube to the level of the clot and flushing attempts repeated. If still unsuccessful, before replacing the tube, mechanical de-clogging with a commercial corkscrew de-clogging device, a cytology brush, or a wire stylet should be considered albeit used with caution to prevent penetration of the sidewall of the tube and puncture of the intestinal wall Deterioration, breakdown, and increased drainage at the percutaneous access site should be evaluated carefully to rule out buried bumper syndrome, side torsion on the tract, absence of an external bolster, granulation tissue, or a tube site infection Hypergranulation tissue at the stomal-site should be treated with a topical high potency steroid ointment e.

We suggest treating tube site infections empirically using a broad-spectrum antibiotic administered either orally or through the tube rarely is a parenteral antibiotic needed Because of the high risk of contamination with skin organisms, culture of the tract or tissue is not recommended in routine situations.

Although most stomal-site infections are minor, severe infections including necrotizing fasciitis can occur and require rapid recognition to optimize management. Rarely does the tube need to be removed. For the patient with increased leakage to the point of severe skin injury, we suggest high-dose acid suppression, diverting the level of infusion of formula lower in the GI tract, simultaneous jejunal feeding with gastric aspiration, and involvement of a wound-care expert Occasionally, the tube will need to be removed and the tract allowed to close prior to placing a new tube in the same or different location.

When and how should PN be utilized in the hospitalized patient? The clinical benefit of PN in hospitalized patients other than those with PN-dependent intestinal failure, such as short bowel syndrome, chronic intestinal pseudo-obstruction, high-output enterocutaneous fistula has been difficult to demonstrate.

Three recent trials looked at the use of exclusive PN in the hospitalized patient. The Early Parenteral Nutrition in Insufficient Enteral Feeding EPaNIC trial showed that early provision of PN on the third day of hospitalization in a subset of patients in which there was a contraindication to enteral feeding because bowel was in discontinuity led to an increase in infectious morbidity and a reduced likelihood of being discharged alive from the ICU compared with controls in which PN was started on the eighth day The patients randomized to early PN showed only a 0.

All other outcome parameters ranging from infection and organ failure to hospital length of stay and mortality were no different between the two groups. In a multi-centered ICU trial of nearly 2, patients comparing EN with exclusive PN, there was no difference between the groups in clinical outcome In a well-nourished patient, particularly in the first week of hospitalization, the use of PN appears to provide no benefit over standard therapy and may actually cause net harm 4.

At some point in the patient at low nutritional risk, failure to provide nutrition therapy will lead to deterioration of nutritional status and adverse outcome. In an older study, Sandstrom showed increased mortality and hospital length of stay if standard therapy was continued beyond the first 2 weeks of hospitalization compared with receipt of PN Most societal recommendations indicate a reluctance to extend standard therapy beyond the first week of hospitalization, suggesting instead initiating PN in the patient at low nutritional risk beginning the second week of hospitalization In the patient at high nutritional risk with increased disease severity and evidence for deterioration of nutritional status, priorities of therapy change.

If EN is not feasible, PN is more likely to benefit these patients than standard therapy. Thus, in patients with high nutritional risk for whom EN is not feasible, PN should be initiated as soon as possible following admission. In patients with a diagnosis indicating PN dependence short bowel syndrome, chronic intestinal pseudo-obstruction , PN should be initiated immediately after admission unless there is evidence for ongoing bacteremia.

The addition of supplemental PN during the first week of therapy to patients already receiving EN, where the enteral feeding is not meeting caloric goals, appears to provide little benefit and may cause net harm Results showed that for study patients, PN added on the third day of hospitalization was associated with worse outcome with respect to virtually every clinical parameter except mortality compared with controls where PN was added beginning on the eighth day Specifically, significant increases in infection, organ failure, hospital and ICU length of stay, cost, and likelihood of being discharged alive were all worse with receipt of early supplemental PN Such strategy may result in some weight loss, but leads to better insulin sensitivity, avoids the effects of overfeeding, and may improve outcome.

In a meta-analysis of five RCTs involving patients with trauma, pancreatitis, and major abdominal surgery, the use of hypocaloric PN was associated with reduced infection and hospital length of stay compared with PN provided at goal feeds 20 vs.

As a result, the use of PPN is associated with increased use of IV lipid emulsions to decrease the osmolarity, decreased delivery of overall calories and protein, and increased likelihood for venous sclerosis Routine use of PPN is associated with increasing loss of venous access sites and abuses derived from inappropriate short-term PN.

In a patient receiving both EN and PN, careful transition feeding is necessary to avoid overfeeding as EN tolerance improves and the need for PN is decreased. Should specialized nutrition therapy be provided to a hospitalized patient at end-of-life?

However, nutrition therapy is likely to improve a cancer patient managed surgically who is cured from the malignancy but has altered GI anatomy or function post-operatively. The use of PN in the non-operative management of malignancy should be avoided, as it may lead to worse outcomes compared with standard therapy with no nutrition support 4. Provision of hydration and nutrition therapy is no different than provision of any other medical therapy, including mechanical ventilation, dialysis, and supplemental oxygen There is no difference between non-invasive and invasive therapy, and the distinction between ordinary and extraordinary therapy is meaningless.

Evidence suggests that, even though nutrition therapy may not be provided, the subsequent development of dehydration and starvation does not add to suffering as only a third of patients will sense any degree of hunger or thirst In those situations, minimal therapy with oral mouth care, rinses, candies, or throat lozenges will ameliorate symptoms.

Subtle goals and outcome benefits may be achieved by gastrostomy placement in certain end-of-life situations Quality of life for the family of the patient may improve with placement of a percutaneous gastrostomy, as the ease of providing medications, hydration, and nutrition is facilitated and frustration with anorexia and poor oral intake is reduced.

Percutaneous gastrostomy placement may allow transfer out of the hospital setting to a nursing home or skilled nursing facility closer to home A patient with malignant obstruction of the GI tract may benefit from gastrostomy placement through palliative decompression to reduce nausea and vomiting Gastroenterologists are trained to recognize indications and contraindications for a procedure.

Placing a percutaneous gastrostomy in a patient with poor prognosis at high risk for mortality seems like an exercise in futility to the clinician, especially when allocation of health-care resources is limited Ethicists would argue that refusal to place a percutaneous endoscopic gastrostomy in this situation violates the ethical principles of futility and justice. With regard to futility, refusal to place a percutaneous endoscopic gastrostomy generates a clash of values between the family and the caregiver.

With regard to justice, patients should never become aware that their low socio-economic status, lack of insurance, or low points on a survival scoring system has ultimately led to the denial of the procedure by health-care providers The most important ethical principle that drives management is patient autonomy, as the patient is the final arbiter of their own destiny Decisions on gastrostomy placement and provision of nutrition therapy at end-of-life often have little to do with scientific data or medical evidence derived from RCTs Decision making in end-of-life situations is often influenced by both the health-care literacy and the spiritual literacy of the patient and their families If at any time in this process, the clinician becomes uncomfortable or conflicted with the management decisions, he or she may excuse themselves from the care of a particular patient.

This can only be done if they are able to transfer the care to an equally qualified and willing practitioner. At no time should a patient or their families feel abandoned by the health-care process.

This guideline was produced in collaboration with the Practice Parameters Committee of the American College of Gastroenterology. The Committee gives special thanks to Brian P. Bosworth, who served as guideline monitor for this document.

McClave is a speaker and an advisor for Nestle, Abbott, Covidien, and Kimberly Clark, a speaker for Nutricia, and has received research support from Nestle. Martindale is a advisor for Nestle, Covidien, and Fresenius Kabi. DiBaise has received research support from GI Dynamics. Mullin has no potential competing interests. Significance of the four levels of evidence 25 High We are very confident that the true effect lies close to that of the estimate of effect Moderate We are moderately confident in the effect estimate: Indications for nutritional therapy Question: Specialized nutrition therapy in the form of EN should be initiated promptly in the hospitalized patient who is at high nutritional risk and is unable to maintain volitional oral intake conditional recommendation, low level of evidence.

EN should be used preferentially over PN in hospitalized patients who require non-volitional specialized nutrition therapy and do not have a contraindication to the delivery of luminal nutrients conditional recommendation, low level of evidence. Specialized nutrition therapy EN or PN is not required for hospitalized patients who are at low nutritional risk, appear well nourished, and are expected to resume volitional intake within 5 to 7 days following admission conditional recommendation, very low level of evidence.

PN should be reserved for the hospitalized patient under specific circumstances, when EN is not feasible or sufficient enough to provide energy and protein goals conditional recommendation, very low level of evidence. Prior to initiation of specialized nutrition therapy either EN or PN , a determination of nutritional risk should be performed using a validated scoring system such as the Nutritional Risk Score NRS or the NUTRIC Score on all patients admitted to the hospital for whom volitional intake is anticipated to be insufficient conditional recommendation, very low level of evidence.

An additional assessment should be performed prior to initiation of nutrition therapy of factors that may impact the design and delivery of the nutrition regimen conditional recommendation, very low level of evidence.

Surrogate markers of infection or inflammation should not be used for nutritional assessment conditional recommendation, very low level of evidence. Caloric requirements should be determined and then be used to set the goal for delivery of nutrition therapy conditional recommendation, very low level of evidence. One of the three strategies should be used to determine caloric requirements: Protein requirements should be determined independently of caloric needs, and an ongoing assessment of protein provision should be performed conditional recommendation, very low level of evidence.

Nutrition assessment scoring systems used to determine nutrition risk NRS A nasogastric or orogastric feeding tube should be used as the initial access device for starting EN in a hospitalized patient conditional recommendation, very low level of evidence. Radiologic confirmation of placement in the stomach should be carried out prior to feeding except with the use of electromagnetic transmitter-guided feeding tubes.

Conversion to a post-pyloric feeding tube should be carried out only when gastric feeding has been shown to be poorly tolerated or the patient is at high risk for aspiration strong recommendation, moderate-to-high level of evidence.

When long-term enteral access is needed in a patient with gastroparesis or chronic pancreatitis, a jejunostomy tube should be placed conditional recommendation, very low level of evidence. A percutaneous gastrostomy should be placed preferentially in the gastric antrum in order to facilitate conversion to a GJ tube in the event that the patient is intolerant to gastric feeding conditional recommendation, very low level of evidence. For the patient at high risk for tube displacement, steps should be taken proactively to secure the access device at the time of placement conditional recommendation, very low level of evidence.

Initiating Enteral Nutrition Question: In the patient at high nutritional risk unable to maintain volitional intake, EN should be initiated within 24—48 h of admission to the hospital conditional recommendation, low level of evidence. Although early EN should be initiated within 24—48 h of admission, the timing by which to advance to goal is unclear. When tolerated, feeding should be advanced to goal within 48—72 h conditional recommendation, very low level of evidence.

With reduced tolerance, feeding should be advanced with caution to goal by 5 to 7 days conditional recommendation, very low level of evidence. A standard polymeric formula or a high-protein standard formula should be used routinely in the hospitalized patient requiring EN conditional recommendation, very low level of evidence. An immune-modulating formula containing arginine and omega-3 fish oil should be used for patients who have had major surgery and are in a surgical ICU setting conditional recommendation, very low level of evidence.

An immune-modulating formula containing arginine and omega-3 fish oil should not be used routinely in patients in a medical ICU conditional recommendation, very low level of evidence.

Monitoring tolerance and adequacy of EN Question: Hospitalized patients on EN should be monitored daily by physical exam conditional recommendation, very low level of evidence.

Patients on EN should be monitored for adequacy of provision of EN as a percent of target goal calories, cumulative caloric deficit, and inappropriate cessation of EN conditional recommendation, very low level of evidence. In the patient at high risk for refeeding syndrome, feeding should be ramped up slowly to goal over 3 to 4 days, while carefully monitoring electrolytes and volume status conditional recommendation, very low level of evidence.

Enteral feeding protocols should be used in hospitalized patients in need of nutrition therapy strong recommendation, moderate-to-high level of evidence. A validated protocol should be used, such as a volume-based feeding protocol or a multi-strategy bundled top-down protocol conditional recommendation, very low level of evidence.

Gastric residual volume GRV should not be used routinely as a monitor in hospitalized patients on EN conditional recommendation, very low level of evidence. Patients on EN should be assessed for risk of aspiration conditional recommendation, very low level of evidence. For patients determined to be at high risk, the following steps should be taken to proactively reduce that risk: For the patient receiving EN who develops diarrhea, an evaluation should be initiated to identify an etiology and direct management conditional recommendation, very low level of evidence.

The patient receiving EN who develops diarrhea should be managed by one of the three strategies: Complications of enteral access Question: The percutaneous enteral access site should be monitored by cleaning daily with mild soap and water and maintaining correct positioning of the external bolster conditional recommendation, very low level of evidence. Prevention of tube clogging is important to successful EN and may be achieved by frequent water flushes delivered every shift and each time medications are given conditional recommendation, very low level of evidence.

When a clogged tube is encountered and the use of water flushes is unsuccessful at clearing, a de-clogging solution comprising a nonenteric-coated pancreatic enzyme tablet dissolved in a sodium bicarbonate solution should be used conditional recommendation, very low level of evidence. If still unsuccessful, a mechanical de-clogging device should be considered prior to exchanging the tube for a new one conditional recommendation, very low level of evidence. In this latter circumstance, radiologic confirmation should be carried out prior to feeding if there is any question of inappropriate location of the tube conditional recommendation, very low level of evidence.

Placement of a larger tube should not be used to manage leakage caused by an enlarging stoma around the percutaneous access device conditional recommendation, very low level of evidence.

A percutaneous enteral access device that shows signs of fungal colonization with material deterioration and compromised structural integrity should be replaced in a non-urgent but timely manner conditional recommendation, very low level of evidence.

If early EN is not feasible and the patient is at low nutritional risk upon admission, no specialized nutrition therapy should be provided and PN should be withheld for the first week of hospitalization conditional recommendation, very low level of evidence. If a patient is at high nutritional risk on admission to the hospital and EN is not feasible, PN should be initiated as soon as possible strong recommendation, moderate level of evidence.

Initiating supplemental PN prior to this 7—day period in those patients already receiving EN does not improve outcomes and may be detrimental to the patient strong recommendation, moderate level of evidence. Following this first week if long-term PN is required , energy provision should be increased to meet energy goals conditional recommendation, low level of evidence. Peripheral PN PPN should not be used, as it leads to inappropriate use of PN, has a high risk of phlebitis and loss of venous access sites, and generally provides inadequate nutrition therapy conditional recommendation, very low level of evidence.

Careful transition feeding should be used in the patient on PN, for whom EN is now being initiated. As tolerance to EN improves and volume of delivery increases, PN should be tapered to avoid overfeeding conditional recommendation, very low level of evidence.

Nutritional Therapy at End-of-Life Question: The decision to place a gastrostomy tube in an end-of-life situation should be determined by patient autonomy and the wishes of that patient and their family, even though the nutrition therapy may do little to change traditional clinical outcomes conditional recommendation, very low level of evidence.

Percutaneous gastrostomy placement should be considered even if the only benefit is to provide improvement in the quality of life for the family, increased ease of providing nutrition, hydration, and medications, or to facilitate transfer out of the hospital setting to a facility closer to home conditional recommendation, very low level of evidence.

The clinician is not obligated to provide hydration and nutrition therapy in end-of-life situations. The decision to initiate nutrition therapy is no different than the decision to stop therapy once it has started thus, clinicians are not obligated to provide therapy that is unwarranted conditional recommendation, very low level of evidence.

If requested, nutrition therapy in end-stage malignancy should be provided by the enteral route conditional recommendation, very low level of evidence. Use of PN in this setting may cause net harm and should be highly or aggressively discouraged conditional recommendation, very low level of evidence.

The clinician who has ethical concerns of his own in a difficult end-of-life situation should excuse himself from the case, as long as he can transfer care to an equally qualified and willing health-care provider conditional recommendation, very low level of evidence. Indicators can be categorized schematically in the following way according to the level at which they are produced or made available:.

They include both indicators regarding the implementation of services as well as indicators regarding the situation or the impact of actions under way. It is generally easy to obtain them from the departments concerned, which usually have time series that are very useful in distinguishing medium- and long-term trends. Even so, it is not always possible to cross-tabulate these indicators, since they do not necessarily come from the same databases and are accessible only in a relatively aggregated form.

It is also difficult to verify the quality of the original data. Lastly, even if the data are collected on a frequent basis monthly reports, for example , recovery and analysis may take too long. Such data tend not to be immediately accessible except in summary form, although it is easy to organize new analyses with the departments in charge of them. These data allow statistical cross-tabulation to be made between the many variables collected simultaneously on the sample.

Although carried out at best at very long intervals, they can be updated with reasonable projections, especially if information on trends in the fields of interest, based on routinely collected data, are also available.

These data are often kept together in national statistical offices. They consist of a regular collection of information based on a small number of selected indicators. The system varies by country, those that perform best are based on an explicit conceptual framework and are linked to a clear decision-making mechanism. They can represent a sound basis for central monitoring.

A particular category is derived from surveys conducted by international bodies for various purposes: These cross-sectional surveys are conducted directly at household level on samples which are representative at national level but of variable size; they include a wide variety of indicators in number, goals and qualities and are now frequently repeated.

Although conducted peripherally, they are generally available and used centrally. These sources, which are in principle fairly reliable, benefit from an advanced level of analysis allowing causal inference to be derived of relationships among various household indicators, and with individual indicators, such as nutritional status.

They represent a precious source when establishing a baseline and when analysing causes prior to launching an intervention. These are constructed primarily on the basis of routinely collected data from local government offices, community-based authorities.

They are usually passed on as indicators or raw data to the central level, and then sent back to the decentralized levels, with varying degree of regularity, after analysis. They are often disaggregated by district or locality, but are not always representative, since they often refer only to users of the services under consideration.

They are generally grouped together at the central administrations of regions or administrative centres. The indicators relate primarily to activities that lend themselves to regular observation, either because they record activities indicators of operation or delivery of services or because they are necessary for decision-making crop forecasts, unemployment rates or for monitoring purposes market prices of staples, number of cases of diseases, etc.

They do not necessarily include indicators of the causes of the phenomena recorded and are not in principle qualitative indicators. Indicators collected at decentralized levels should meet both the needs of users on these levels and also those of users on the central level for the implementation and monitoring of programmes.

If these regularly compiled indicators do not have any real use at the local level and are intended only for the national central level, there is a danger that their quality will drop over time, for lack of sufficient motivation of those responsible for collection and transmission - and gaps are therefore often found in available data sets.

Nevertheless, they are invaluable in giving a clear picture of the situation on the regional or district level, together with medium-term trends. Generally speaking, their limitation is the low level of integration of data from different sectors. A certain number of indicators, particularly those concerning the life of communities or households and not touching on the activities of the various government departments, are not routinely collected by such departments and are in any case not handed on to the regional or central offices.

They are sometimes collected at irregular intervals by local authorities, but most often by non-governmental organizations for specific purposes connected with their spheres of activity - health, hygiene, welfare, agricultural extension, etc. Analytical capabilities are often lacking at this level, and the available raw data may not have led to the production of useful indicators.

Action therefore should be taken to enhance analytical capacities or else sample surveys will have to be carried out periodically on these data in order to produce indicators. A sound knowledge of local records and their quality is needed to avoid wasting time. New collection procedures often have to be introduced for use by local units, while being careful not to overload them or divert them from their own work.

Otherwise a specific collection has to be carried out by surveying village communities targeted for analysis or intervention. These surveys are vital for a knowledge of the situation and behaviours of individuals and households and an evaluation of their relationship with the policies introduced.

In general, they offer an integrated view of the issues concerned. They may have the aim of supplying elements concerning the local situation and local analysis, in order to confirm the consensus of the population and of those in charge as to the situation and interventions to be carried out, and also to allow an evaluation of the impact of such interventions.

The participatory aspect should be emphasized rather than the precision or sophistication of data. An FAO work on participatory projects illustrates issues of evaluation, and especially the choice of indicators in the context of such projects FAO If data already collected are used or if a new survey is carried out for use on a higher level, the size and representativeness of the sample must be checked, and it must be ensured that the data can be linked to a more general set on the basis of common indicators collected under the same conditions method, period, etc.

Verification of the quality of the data is crucial. Before undertaking a specific data collection, a list of indicators and of corresponding raw data should be developed which can be used by services at all levels; it is not unusual to find that surveys could have been avoided by a better knowledge of the data available from different sources.

To track down these useful sources and judge the quality of the data available and their level of aggregation, a good understanding is needed of the goals and procedures of the underlying information system.

The country had set up a monthly national information system on production estimates for 35 crops, covering information on crop intentions, areas actually planted, crop yields and quantities harvested in each state. The information was obtained during monthly meetings of experts at various levels - local, regional and national. The information was then put together at the state level, and then at the national level, reviewed by a national committee of experts, and sent on to the central statistics office.

The different levels thus had some rich information at their disposal, coming from a range of local-level sources. Although it was certainly fairly reliable, being confirmed by a large number of stakeholders and experts, its precision could not be defined, in view of its diversity.

The usefulness of such data varies depending on information needs and thus on the quality of the data required. Data concentrated at the central level are probably useful primarily for analysing trends.

On the other hand, apart from the figures, more general information on production systems exists at local level, and this can be useful for identifying relevant indicators of causes, or for simplifying monitoring of the situation.

We have seen that there is a great number of indicators which differ widely in quality; the availability of corresponding data is variable, and any active collection will be subject to constraints. Therefore the choice of indicators must be restricted to the real needs of decision makers or programme planners. This implies that a method is needed for guiding the choice. The main elements that will guide choice are: Any intervention is based on an analysis of the situation, an understanding of the factors that determine this situation, and the formulation of hypotheses regarding programmes able to improve the situation.

A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners. However, the convenient classification that it implies, for instance into levels of immediate, underlying or basic causes needs to be operationalized through further elaboration in context.

The benefit of constructing such a framework, over and above the complete review of the chain of events which determine the nutritional situation, is to allow the expression, in measurable terms, of general concepts which, because of their complexity, are not always well defined. For example, it is not enough to refer to "food security"; one should state which of the existing definitions is to be used, on which dimensions of food security the focus is placed and the corresponding indicators.

The use of conceptual frameworks when implementing programmes or planning food and nutrition is not new. Many examples have been developed, focusing on different aspects. The concept of food security is generally perceived as that of sufficient availability of food for all.

However, several dozen different definitions have been proposed over these last 15 years! This concept may, for example, comprise different aspects depending on the level being related to: In the first case, analysis will focus on agricultural production, and in the second the emphasis will be on improving the resources of those who lack access to a correct diet.

This preliminary brainstorming exercise will allow a better definition of the perceived chain of causes production shortfall, excessive market prices, defective marketing infrastructures, low minimum wage, low level of education, etc. It will then be easier to consider potential indicators of the situation and its causes, or potential indicators of programme impact.

Obviously it is not so much the final diagram which is of importance as the process through which it was developed. Insofar as the relations between all the links of the chain of events or flow data, depending on the type of representation have been discussed step by step and argued with supporting facts, the framework will be adapted to the local situation and will become operational.

Methodologies have been developed for making this process effective in the context of planning, for example with the method of "planning by objectives" see ZOPP , which comprises several phases: During this planning process, all programme activities, corresponding partners, necessary inputs and resulting outputs as well as indicators for both monitoring implementation and evaluating impact of the programme will be successively identified.

The method acts as a guide for team work, encouraging intersectoral analysis and offering a simplified picture of the situation, so that the results of discussions are clear to all in the team. Let us again take the example of a problem of food security. It can be broken down into three determining sectors: A series of structural elements can be defined for each sector: These elements affect both production levels and operation of markets. A certain number of macro-economic or specific policies will affect one or all the elements in this block.

Each block can be considered in a similar way, and this will provide the groundwork for a theoretical model of how the system works see C. The final steps in order to operationalize the model are i that of defining indicators that will, in the specific context of the country, reflect the key elements of the system, and ii , once policies and programmes have been chosen, that of identifying which of these indicators are useful for monitoring trends and evaluating programme impact.

This will be the basis for an information system reflecting the overall framework of the programme and how it should work. Another method has been proposed by researchers from the Institute of Tropical Medicine in Antwerp based on their field experience in collaboration with different partners Lefèvre et al.

Basically, it stresses the participatory aspect, with the aim of obtaining a true consensus on the local situation, the rationality of interventions in view of the situation, and the choice of indicators. It includes first a phase in which a causal framework is developed with the aim of providing an understanding of the mechanisms leading to undernutrition in the context under consideration.

The framework is constructed in the form of a schematic, hierarchized diagram of causal hypotheses formulated after discussions among all stakeholders. The way it is built tends to favour a clear, "vertical" visualization of series of causal relationships, eliminating the lateral links or loops that are often the source of confusion in other representations.

In a second phase, a framework is developed linking the human or material resources available at the onset inputs , the procedures envisaged activities , the corresponding results of implementation outputs , and the anticipated intermediate outcomes or final impact of each activity or of the programme. This tool is very useful for defining all the necessary indicators.

This represents the formalisation of a real conceptual scheme. While many representations of conceptual models comprise comparable elements, it is essential that a model should never be considered as directly transposable, since it must absolutely apply to the local context.

A direct transposition would therefore be totally counter-productive. While it is obvious that the conceptual analysis must ideally be carried out before the programmes are launched, it can be done or updated at any time, leading to greater coherence and a consensus on current and anticipated actions; this applies even more in a long-term perspective of sustainability. In operational terms, establishment of a conceptual framework allows to define in a coherent way the various types of indicators to be used at each level.

After defining the activities to be undertaken, status indicators referring to the target group will be identified, as well as indicators of causes that will or will not be modified by these activities, and indicators that will reflect the level or quality of the activities performed. Lastly, indicators will be chosen to reflect the changes obtained, whether or not these are a result of the programme.

Identification of precise objectives makes it possible to monitor changes in impact indicators not only vis-à-vis the original situation but also in terms of fulfilment of the objectives adopted. During this initial phase, existing indicators are assessed, as well as those that will be taken from records or collected through specific surveys.

It should be specified who needs this information, as well as who collects the data. In fact, it is important that this choice should be demand-driven, in order to be sure that the information selected is then actually used. One might be dealing with several groups of users who do not exactly have the same needs: In this way, foundations can be laid for an information system essential for monitoring and evaluation. A proximate, often indirect, indicator will have to be sought and limitations to its validity in the context considered will have to be verified carefully which will depend on the precise objective.

For example, can a measurement of food stocks at a given moment be validly replaced in the context under consideration with a measurement of food consumption in order to assess the food insecurity situation of a target group? Is a measurement of food diversity a good proximate indicator for micronutrient intake? Does it at least consistently classify consumers into strong and weak consumers? Does it allow defining an acceptable level of consumption vis-à-vis recommendations?

Will it allow children to be classified correctly vis-à-vis a goal of improved growth? Validity studies are sometimes available locally, otherwise specific studies can be carried out; hence the usefulness of collaborating with research groups - for example from universities - who will be able to carry out this type of validation study under good conditions. The relationship between two variables, making them interchangeable for defining an indicator, may vary over time as a result of implementation of a programme, and this must be taken into account.

For example, if there is a clear link between family size and food insecurity in a given context, the criterion of family size can simply be taken as a basis for identifying families at risk. However, if a specific programme has been successfully carried out among these families, this indicator could lose its validity.

The ideal would be to use the same indicators in all places and at all times in order to have the benefit of common experience regarding collection and analysis, so that direct comparisons can be made. In practice, however, concepts on indicators evolve steadily with the progress of knowledge, leading to the dilemma of being unable to carry out comparisons either with older series of indicators or with what is being done elsewhere.

Comparability within time is obviously a priority in the case of monitoring. Preference will thus be given to indicators that, although not necessarily identical, are comparable, in other words give a similar type of information. The issue of the comparability of data from different sources has been the subject of studies especially in the field of health indicators. Whenever traditional indicators seem inadequate or insufficient in capturing the phenomenon or situation under consideration, the value of "innovative" and potentially promising indicators with excellent basic characteristics should not be neglected - although it is important to make sure that they have been validated for circumstances similar to those under study.

Since such innovative indicators usually have to be collected "actively", especially at the community level, the decision often depends on their technical feasibility as a guarantee of the sustainability of collection. In a context of dietary transition, an indicator expressing the structure of food consumption for example the percent of energy from fat is more subject to major changes than the average consumption level expressed in calories, while also providing important information on the future health of the population considered.

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