DUBLIN INSTITUTE of TECHNOLOGY:GIVEN THE coverage Ireland's obesity epidemic receives and our standing as a still wealthy developed-world nation, it is difficult to believe that large numbers of Irish people suffer from malnutrition.
“There is a lot of focus on obesity but there is a problem at the other end of the scale with people suffering from malnutrition,” says HSE Dublin Mid-Leinster Region community dietician and PhD candidate Sharon Kennelly. “It affects people like the elderly or others who have recently been hospitalised. It has impacts on people’s immune systems and results in further hospitalisation and additional medical treatment. Apart from the effects on the people concerned the cost to the health service and economy is estimated at €1.4 billion a year. It could be a similar cost to obesity. My manager in the HSE, Mary Glennon, noticed the need for something to be done about this problem a number of years ago.”
There was evidence from research carried out in the Britain and locally in Ireland that the healthcare professionals mainly responsible for the nutritional management of patients at risk had a lack of knowledge and resources in relation to the management of malnutrition and the use of oral nutritional supplements (ONS) and that the majority of these wanted further support and education in this area.
This led Kennelly to seek funding from the HSE to carry out a research project into the area. The aim of the project was to implement a community dietetic intervention to improve the nutrition management of adult patients who are malnourished or at risk of malnutrition in the community with a focus on the use of oral nutritional supplements, and evaluate the benefits comparing results before and after the intervention.
“The project would have been very important research but it wouldn’t have been a PhD,” Kennelly points out. “We came to the conclusion that it would be better to make the project PhD standard so that it would be top quality and publishable. We approached DIT with a proposal and they came on board. Their inputs have been very beneficial.”
The DIT link came through the Environmental Health Services Institute (ESHI), a dedicated national translational research platform, based on collaboration between the Dublin Institute of Technology (DIT), the Health Service Executive (HSE) and Dublin City Council (DCC). ESHI integrates scientific and technical expertise with planning, policy and regulatory capability and relevant industry partners to bridge the science-policy-innovation gap. The overarching mission and vision is to achieve “healthier lives for children, the elderly and vulnerable populations”.
“The research ESHI does has to be useful, must be user-inspired, and must be of benefit to the population,” says Dr Mary McNamara, head of graduate research at Dublin Institute of Technology. “One way of doing a PhD is work-based like this one. But the research carried out must be of relevance to the day-to-day work of the individual and be capable of being put into practice. This project was jointly supervised by the EHIS and the HSE and has resulted in the design of interventions which can be used in the future to provide training to the healthcare professionals involved in this area.”
The community dietetics intervention had a two-pronged approach. The first part was a nutrition education programme for healthcare professionals about the best-practice management of malnutrition and use of ONS. The second was the establishment of a structured community dietetic referral service for patients at risk of malnutrition in the community.
In order to evaluate the intervention changes in knowledge of healthcare professionals, changes in nutrition care practices and changes in prescribing patterns of ONS before and after the intervention were measured.
The intervention was found to have a number of positive outcomes. There was an increase in the nutrition knowledge of healthcare professionals after the intervention compared to before. There was also an improvement in key nutrition care practices by healthcare professionals for patients at risk of malnutrition in line with best practice. Patients were weighed more often, they received basic dietary advice from healthcare professionals more often, nutrition screening for risk of malnutrition was carried out more often by healthcare professionals. They were referred via the structured referral pathway to the community dietetic service and all referrals were appropriate.
ONS prescribing practices changed also, there was a trend towards a decrease in the overall numbers of patients prescribed ONS (18 per cent reduction) and a trend towards a decrease in expenditure on ONS (3 per cent) by GPs who took part in the intervention compared to an increase of 25 per cent in expenditure by GPs nationally during the same period.
The project began six years ago with the research being carried out over the first three and a half years and the writing-up of the thesis taking up the last two and a half. “It would not have been possible without DIT,” Kennelly points out. “My supervisors there, Clare Corish and Sheila Sugrue, made sure that all the research was carried out in an evidence-based way. We also had meetings in DIT several times a year and these involved quite rigorous questioning which benefited the project as well.”
And her research is already having an impact across the wider health service with the findings being shared with all HSE community dieticians departments in Ireland. Other departments under the leadership of HSE community dietician managers have adopted the same approach and the model has been implemented by more than 120 GPs in Ireland to date.
