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Hospital food as treatment
Clinical Nutrition (2003) 22(2): 113–114 r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1054/clnu.2002.0641
EDITORIAL
Hospital food as treatment Kondrup (9) has shown how, in a Copenhagen hospital, the energy requirements of the average hospital patient (1.3 resting metabolic rateFRMRFto maintain weight, or 1.5 RMR to gain weight) can be met by using high-quality food supplemented by energy-dense dishes, so that only a small minority of his patients lost weight in contrast to the majority who lost weight in the study by McWhirter and Pennington (1). The use of energy-dense food, smaller portions and snacks have also proved effective in meeting the energy needs of the elderly, although as Gall pointed out, we may need to increase protein density further in order to meet the appropriate target in this group (1–1.5 g protein/kg/ day). The food preferences and requirements of each patient group must be addressed if the hospital menu is to be made more appropriate to the needs of the sick. The term ‘food chain’, used not in its biological sense but to describe the whole process of catering for patients (10), has emphasised the need to address not only the quality and palatability of food but the whole process or chain, from patient assessment, through ordering meals, to the preparation, transport, serving, and presentation of hospital food in a way which invites its consumption. Factors such as portion size, food consistency and temperature, need for help with eating, special utensils for the disabled, and the eating environment, are all important. These issues, which have been highlighted in several national reports (11–13) as well as the recent COENUT report (14) from the Council of Europe, are the responsibility of all who care for patients and not just of catering departments who suffer from under-funding and isolation as the ‘poor relations’ of the hospital service. Catering deserves to be more highly valued and to have a more central role in therapeutics, as part of a quality of care policy in every hospital. If it is to be effective, this service may need some restructuring and a modest increase in investment, but this will almost certainly be offset by cost savings due to waste reduction and lower hospital care costs per patient (15). It is reassuring that the observations from the group in Geneva are leading to corrective measures in their hospital. Hopefully, the success of these measures will be the subject of a future paper in this journal.
More than 75% of hospital patients depend upon the catering menu for their sole source of nutrition. Those who spend less than 5 days in hospital, with mild illness, may suffer little from any shortfall in their nutritional intake, but those who are more severely ill, previously malnourished [up to 40% of admissions (1)] or spend longer in hospital (2, 3), may become sufficiently malnourished to cause weight loss, impaired function and recovery, increased complications, prolonged hospital stay and increased costsFthat is unless their nutritional needs are met in full, preferably by normal food from a menu designed for the sick and presented to them in a way that allows it to be consumed. Unfortunately, as Florence Nightingale (4) observed in 1859 Every careful observer of the sick will agree in this, that thousands of patients are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food [. . .] I would say to the nurse, have a rule of thought about your patient’s diet; consider, remember how much he has had, and how much he ought to have today. and Gall (5) in 1998: While, in theory, the standard hospital is designed to meet nutritional needs, it is not in a form which can be easily taken by people who are unwell or have appetite suppressed by the effects of disease or injury. Not much has changed, therefore, during the last 150 years. In this issue of Clinical Nutrition, the group from Geneva (6), in an admirably conducted study, provide further confirmation that, in Switzerland, as in the UK and France, hospital food waste is high and consumption falls short of nutritional requirements. This is not inevitable since in only 26% of those underfed did the major cause of this appear to be the disease or its treatment. As in the studies by Gall et al. (5) and Barton et al. (7), the shortfall was greater in protein than in energy. These observations give cause for concern in terms of both the quality of care and the economic consequences of malnutrition and food waste. The value of the hospital food wasted annually in England and Wales, for example, on the basis of the 40% plate waste observed (8) has been calculated at d155 million.
Simon P. Allison Clinical Nutrition Unit University Hospital Nottingham NG7 2UH, UK 113
114
EDITORIAL
References 1. McWhirter J P, Pennington C R. Incidence and recognition of malnutrition in Hospital. Br Med J 1994; 308: 945–948 2. Larsson J, Unosson M, Ek A-C, Nilsson L, Thorslund S, Bjurulf P. Effect of dietary supplement on nutritional status and clinical outcome on 501 geriatric patients: a randomised study. Clin Nutr 1990; 9: 179–184 3. Allison S P. Uses and limitations of nutritional support. Clin Nutr 1992; 11: 319–330 4. Nightingale F. Notes on Nursing, 1859 5. Gall M J, Grimble G K, Reeve N J, Thomas S J. Effect of providing fortified meals and between-meal snacks on energy and protein intake in hospital patients. Clin Nutr 1998; 17: 259–264 6. Dupertuis Y M, Kossovsky M P, Kyle U G, Raguso C A, Genton L, Pichard C. Food intake in 1707 hospitalised patients: a prospective comprehensive hospital survey. Clin Nutr 2003; 22: 115–123 7. Barton A D, Beigg C L, Macdonald I A, Allison S P. High food wastage and low nutritional intakes in hospital patients. Clin Nutr 2000; 19: 445–449
8. Barton A D, Beigg C L, Macdonald I A, Allison S P. A recipe for improving food intakes in elderly hospitalized patients. Clin Nutr 2000; 19: 445–449 9. Kondrup J, Hansen B S, Ipsen B, Ronneby H. Requirements of the general hospital population: experience with 977 consecutive patients. Proc Nutr Soc 1997; 56: 214A 10. Wilson R. Service Standards. Nutritional Guidelines: the Food Chain. SE Thames Regional Health Authority, 1993 11. Lennard-Jones J E (ed.) King’s Fund Report. A Positive Approach to Nutrition as Treatment. King’s Fund Centre, 126 Albert Street, London NW1 7NF, 1992 12. BAPEN Report. In: Allison S P (ed.) British Association for Parenteral and Enteral Nutrition, PO Box 822, Maidenhead, Berks, SL6 4SH, 1999 ISBN 1 899467 10 6 13. Nuffield Trust. Managing Nutrition in HospitalFA Recipe for Quality, 1999 14. Council of Europe Partial agreement in the social and public health field. Committee of Experts on Nutrition, Food Safety and Consumer Health. ‘‘Food and Nutritional Care in Hospitals: How to Prevent Undernutrition’’, 2002. www.coe.fr/soc-sp 15. Tucker H. Cost containment through nutrition intervention. Nutr Rev 1996; 54: 111–121
EDITORIAL
Hospital food as treatment Kondrup (9) has shown how, in a Copenhagen hospital, the energy requirements of the average hospital patient (1.3 resting metabolic rateFRMRFto maintain weight, or 1.5 RMR to gain weight) can be met by using high-quality food supplemented by energy-dense dishes, so that only a small minority of his patients lost weight in contrast to the majority who lost weight in the study by McWhirter and Pennington (1). The use of energy-dense food, smaller portions and snacks have also proved effective in meeting the energy needs of the elderly, although as Gall pointed out, we may need to increase protein density further in order to meet the appropriate target in this group (1–1.5 g protein/kg/ day). The food preferences and requirements of each patient group must be addressed if the hospital menu is to be made more appropriate to the needs of the sick. The term ‘food chain’, used not in its biological sense but to describe the whole process of catering for patients (10), has emphasised the need to address not only the quality and palatability of food but the whole process or chain, from patient assessment, through ordering meals, to the preparation, transport, serving, and presentation of hospital food in a way which invites its consumption. Factors such as portion size, food consistency and temperature, need for help with eating, special utensils for the disabled, and the eating environment, are all important. These issues, which have been highlighted in several national reports (11–13) as well as the recent COENUT report (14) from the Council of Europe, are the responsibility of all who care for patients and not just of catering departments who suffer from under-funding and isolation as the ‘poor relations’ of the hospital service. Catering deserves to be more highly valued and to have a more central role in therapeutics, as part of a quality of care policy in every hospital. If it is to be effective, this service may need some restructuring and a modest increase in investment, but this will almost certainly be offset by cost savings due to waste reduction and lower hospital care costs per patient (15). It is reassuring that the observations from the group in Geneva are leading to corrective measures in their hospital. Hopefully, the success of these measures will be the subject of a future paper in this journal.
More than 75% of hospital patients depend upon the catering menu for their sole source of nutrition. Those who spend less than 5 days in hospital, with mild illness, may suffer little from any shortfall in their nutritional intake, but those who are more severely ill, previously malnourished [up to 40% of admissions (1)] or spend longer in hospital (2, 3), may become sufficiently malnourished to cause weight loss, impaired function and recovery, increased complications, prolonged hospital stay and increased costsFthat is unless their nutritional needs are met in full, preferably by normal food from a menu designed for the sick and presented to them in a way that allows it to be consumed. Unfortunately, as Florence Nightingale (4) observed in 1859 Every careful observer of the sick will agree in this, that thousands of patients are annually starved in the midst of plenty, from want of attention to the ways which alone make it possible for them to take food [. . .] I would say to the nurse, have a rule of thought about your patient’s diet; consider, remember how much he has had, and how much he ought to have today. and Gall (5) in 1998: While, in theory, the standard hospital is designed to meet nutritional needs, it is not in a form which can be easily taken by people who are unwell or have appetite suppressed by the effects of disease or injury. Not much has changed, therefore, during the last 150 years. In this issue of Clinical Nutrition, the group from Geneva (6), in an admirably conducted study, provide further confirmation that, in Switzerland, as in the UK and France, hospital food waste is high and consumption falls short of nutritional requirements. This is not inevitable since in only 26% of those underfed did the major cause of this appear to be the disease or its treatment. As in the studies by Gall et al. (5) and Barton et al. (7), the shortfall was greater in protein than in energy. These observations give cause for concern in terms of both the quality of care and the economic consequences of malnutrition and food waste. The value of the hospital food wasted annually in England and Wales, for example, on the basis of the 40% plate waste observed (8) has been calculated at d155 million.
Simon P. Allison Clinical Nutrition Unit University Hospital Nottingham NG7 2UH, UK 113
114
EDITORIAL
References 1. McWhirter J P, Pennington C R. Incidence and recognition of malnutrition in Hospital. Br Med J 1994; 308: 945–948 2. Larsson J, Unosson M, Ek A-C, Nilsson L, Thorslund S, Bjurulf P. Effect of dietary supplement on nutritional status and clinical outcome on 501 geriatric patients: a randomised study. Clin Nutr 1990; 9: 179–184 3. Allison S P. Uses and limitations of nutritional support. Clin Nutr 1992; 11: 319–330 4. Nightingale F. Notes on Nursing, 1859 5. Gall M J, Grimble G K, Reeve N J, Thomas S J. Effect of providing fortified meals and between-meal snacks on energy and protein intake in hospital patients. Clin Nutr 1998; 17: 259–264 6. Dupertuis Y M, Kossovsky M P, Kyle U G, Raguso C A, Genton L, Pichard C. Food intake in 1707 hospitalised patients: a prospective comprehensive hospital survey. Clin Nutr 2003; 22: 115–123 7. Barton A D, Beigg C L, Macdonald I A, Allison S P. High food wastage and low nutritional intakes in hospital patients. Clin Nutr 2000; 19: 445–449
8. Barton A D, Beigg C L, Macdonald I A, Allison S P. A recipe for improving food intakes in elderly hospitalized patients. Clin Nutr 2000; 19: 445–449 9. Kondrup J, Hansen B S, Ipsen B, Ronneby H. Requirements of the general hospital population: experience with 977 consecutive patients. Proc Nutr Soc 1997; 56: 214A 10. Wilson R. Service Standards. Nutritional Guidelines: the Food Chain. SE Thames Regional Health Authority, 1993 11. Lennard-Jones J E (ed.) King’s Fund Report. A Positive Approach to Nutrition as Treatment. King’s Fund Centre, 126 Albert Street, London NW1 7NF, 1992 12. BAPEN Report. In: Allison S P (ed.) British Association for Parenteral and Enteral Nutrition, PO Box 822, Maidenhead, Berks, SL6 4SH, 1999 ISBN 1 899467 10 6 13. Nuffield Trust. Managing Nutrition in HospitalFA Recipe for Quality, 1999 14. Council of Europe Partial agreement in the social and public health field. Committee of Experts on Nutrition, Food Safety and Consumer Health. ‘‘Food and Nutritional Care in Hospitals: How to Prevent Undernutrition’’, 2002. www.coe.fr/soc-sp 15. Tucker H. Cost containment through nutrition intervention. Nutr Rev 1996; 54: 111–121