Protein and energy intake improved by breakfast intervention in hospital

Individualised nutritional treatment increases the positive effects of a novel á la carte hospital food service concept: Results of a quasi-experimental study

BACKGROUND & AIMS

One-third of hospitalised patients are at nutritional risk, and limited choice regarding meals and meal times, and inadequate nutritional support may contribute to inadequate nutritional intake during hospitalisation. The aim was to test the effect of a novel á la carte hospital food service concept as a stand-alone intervention and combined with individualised nutritional treatment.

METHODS

Medical inpatients at nutritional risk were recruited for this three-arm quasi-experimental study. The control group received meals from the traditional bulk trolley food service system. Intervention group 1 (IG1) received meals from a novel á la carte food service concept with an electronic ordering system, whereas intervention group 2 (IG2) in addition to this received individualised nutritional treatment by a clinical dietitian. Nutritional intake and length of stay was measured, and patient satisfaction was assessed with purpose-designed questionnaires.

RESULTS

206 patients were included: 67 in the control group, 68 in IG1, and 71 in IG2. The proportion of participants reaching ≥75 % of both their energy and protein requirement was higher in IG1 compared to the control group (34 % vs. 12 %, p = 0.002) and higher in IG2 compared to IG1 (53 % vs. 34 %, p = 0.035). Length of stay was shorter in IG2 compared to the control group (6.0 vs. 8.7 days, p = 0.005). It was important to participants to be able to choose when and what to eat, and this preference was met to a larger extent in the intervention groups.

CONCLUSION

The novel á la carte concept increases energy and protein intake in hospitalised patients, and the positive effects are increased, when the concept is used in combination with individualised nutritional treatment.

Dietary assessment methods for measurement of oral intake in acute care and critically ill hospitalised patients: a scoping review

Quantification of oral intake within the hospital setting is required to guide nutrition care. Multiple dietary assessment methods are available, yet details regarding their application in the acute care setting are scarce. This scoping review, conducted in accordance with JBI methodology, describes dietary assessment methods used to measure oral intake in acute and critical care hospital patients. The search was run across four databases to identify primary research conducted in adult acute or critical care settings from 1st of January 2000-15th March 2023 which quantified oral diet with any dietary assessment method. In total, 155 articles were included, predominantly from the acute care setting (n = 153, 99%). Studies were mainly single-centre (n = 138, 88%) and of observational design (n = 135, 87%). Estimated plate waste (n = 59, 38%) and food records (n = 43, 28%) were the most frequent assessment methods with energy and protein the main nutrients quantified (n = 81, 52%). Validation was completed in 23 (15%) studies, with the majority of these using a reference method reliant on estimation (n = 17, 74%). A quarter of studies (n = 39) quantified completion (either as complete versus incomplete or degree of completeness) and four studies (2.5%) explored factors influencing completion. Findings indicate a lack of high-quality evidence to guide selection and application of existing dietary assessment methods to quantify oral intake with a particular absence of evidence in the critical care setting. Further validation of existing tools and identification of factors influencing completion is needed to guide the optimal approach to quantification of oral intake in both research and clinical contexts.

Impact of food-based fortification on nutritional outcomes and acceptability in older adults: systematic literature review

Background

"Do it yourself" (DIY) food-based fortification involves adding fortificants into everyday foods. It is a flexible solution that allows older people with reduced appetite to meet their nutritional needs.

Objectives

The aims of the systematic review are (a) to describe DIY fortified recipes, (b) to evaluate their acceptability, and (c) to evaluate whether they are effective levers to improve nutritional outcomes in older people.

Methods

A systematic search of 3 databases (Web of Science, PubMed, Scopus, last searched on January 2022) was undertaken. Main eligibility criteria include older adults aged ≥60 years living at home, in an institution or in hospital. Studies carried out for a specific medical condition or targeting only micronutrient fortification were excluded. After reviewing all titles/abstracts then full-text papers, key data were extracted and synthesized narratively. The quality of included studies was assessed using Kmet et al.

Results

Of 21,493 papers extracted, 44 original studies were included (3,384 participants), with 31 reporting nutritional outcomes, 3 reporting acceptability outcomes and 10 reporting both nutritional and acceptability outcomes. The review highlighted a wide variety of DIY fortified recipes, with additional energy ranging from 23 to 850 kcal/d (M = 403; SE = 62) and/or protein ranging from 4 to 40 g/d (M = 19; SE = 2). Compared to a standard diet, DIY fortification seems to be a valuable strategy for increasing energy and protein intake in older people. However, no strong evidence was observed on the nutritional status.

Implication for future

Further acceptability studies are crucial to ensure that DIY fortified foods are palatable and thus have a significant impact on the nutritional status. In addition, it would be useful for studies to better describe DIY recipes. This information would result in a better understanding of the factors that maximize the impact of DIY fortification on nutritional outcomes. Study registration: PROSPERO no. CRD42021244689.Systematic review registration: PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021244689.

The Acute Effects of Breakfast Drinks with Varying Protein and Energy Contents on Appetite and Free-Living Energy Intake in UK Older Adults

Proposed strategies for preventing protein deficiencies in older patients include increasing protein intake at breakfast. However, protein is highly satiating and the effects of very high protein intakes at breakfast on subsequent appetite and free-living energy intake (EI) in older adults are unclear. This study compared the acute effects of two breakfast drinks varying in protein and energy contents on appetite and free-living EI in healthy older adults using a randomized 2 × 2 crossover design. Participants (n = 48 (20 men, 28 women); mean ± SD age: 69 ± 3 years; BMI: 22.2 ± 2.0 kg·m⁻²; fat-free mass: 45.5 ± 8.0 kg) consumed two drinks for breakfast (high-protein (30.4 ± 5.3 g), low-energy (211.2 ± 37.1 kcal) content (HPLE) and very high-protein (61.8 ± 9.9 g), fed to energy requirements (428.0 ± 68.9 kcal) (VHPER)) one week apart. Appetite perceptions were assessed for 3 h post-drink and free-living EI was measured for the remainder of the day. Appetite was lower in VHPER than HPLE from 30 min onwards (p < 0.01). Free-living energy and protein intake did not differ between conditions (p = 0.814). However, 24 h EI (breakfast drink intake + free-living intake) was greater in VHPER than HPLE (1937 ± 568 kcal vs. 1705 ± 490 kcal; p = 0.001), as was 24 h protein intake (123.0 ± 26.0 g vs. 88.6 ± 20.9 g; p < 0.001). Consuming a very high-protein breakfast drink acutely suppressed appetite more than a low-energy, high-protein drink in older adults, though free-living EI was unaffected. The long-term effects of adopting such a breakfast strategy in older adults at high risk of energy and protein malnutrition warrants exploration.

Eat what you want and when you want. Effect of a free choice menu on the energy and protein intake of geriatric medical patients

BACKGROUND

Geriatric medical patients are often at nutritional risk when admitted to hospital. More flexible meal service concepts may prove successful in improving nutritional intake.

AIM

To evaluate whether the Free Choice Menu (FCM), a new room service resembling meal service concept, improves energy and protein intake in a population of geriatric medical patients compared with the traditional concept of serving meals from a trolley with a fixed menu (trolley).

METHODS

Data were collected consecutive in a geriatric ward at Slagelse Hospital (Denmark) before (autumn 2018; n = 98) and after (autumn 2020; n = 52) implementing the Free Choice Menu. Weighed dietary intake was recorded for three full days for each patient.

RESULTS

Energy and protein intake did not differ significantly when comparing the two meal service concepts (trolley: 6124 kJ; 52.6 g and FCM: 5923 kJ; 47.1 g) over three days. The FCM concept showed however a significantly higher energy and protein intake for the dinner (relative to the other meals), whereas a higher percentage of protein and energy intake was covered by oral nutritional supplements in the trolley concept. The majority of the participants met the recommendations for energy intake, while only a minority met the recommendations for protein intake. Plate waste was significantly lower (p = 0.0005) at the lunch meal for the FCM concept (15.6%) compared with the trolley concept (26.1%).

CONCLUSION

When implementing a FCM, energy and protein intake was maintained and patients received more energy and protein from the dinner and less from oral nutritional supplements. However, the introduction of a free choice of meals concept did not in itself ensure nutritional intake in geriatric medical patients.

Hospital Food Service Strategies to Improve Food Intakes among Inpatients: A Systematic Review

This review aims to identify hospital food service strategies to improve food consumption among hospitalized patients. A systematic search that met the inclusion and exclusion criteria was manually conducted through Web of Science and Scopus by an author, and the ambiguities were clarified by two senior authors. The quality assessment was separately conducted by two authors, and the ambiguities were clarified with all the involved authors. Qualitative synthesis was used to analyze and summarized the findings. A total of 2432 articles were identified by searching the databases, and 36 studies were included. The majority of the studies applied menu modifications and meal composition interventions (n = 12, 33.3%), or included the implementation of the new food service system (n = 8, 22.2%), protected mealtimes, mealtime assistance and environmental intervention (n = 7, 19.4%), and attractive meal presentation (n = 3, 8.3%). Previous studies that used multidisciplinary approaches reported a significant improvement in food intake, nutritional status, patient satisfaction and quality of life (n = 6, 16.7%). In conclusion, it is suggested that healthcare institutions consider applying one or more of the listed intervention strategies to enhance their foodservice operation in the future.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

Protein and energy intake improved by in-between meals: An intervention study in hospitalized patients

BACKGROUND/AIM

Disease related malnutrition is a major problem in hospitals. Malnutrition in hospitalized patients is caused by many factors. Among these factors are decreased appetite and early satiety, and reaching nutritional requirements in nutritional risk patients is a challenge when using ordinary energy and protein dense food. The aim of this study was to examine if total protein and energy intake in medical and surgical patients at nutritional risk could be improved by protein fortified and energy rich in-between meals.

METHODS

An assortment of fortified in-between meals including 10 g of protein was developed based on patient preferences and served in the Departments of Lung Medicine and Abdominal Surgery for a period of three months. Nutrition intake was recorded before and after intervention.

RESULTS

Food intake records were collected from a total of 92 patients, (46 before and 46 after intervention). The total amount of protein intake per in-between meal was increased from 2,6 g to 10,3 g. Total daily protein intake increased from 49% to 88% (p < 0.00) and total energy intake from 74% to 109% (p < 0.00) of requirements.

CONCLUSION

Protein and energy intake for surgical and medical patients at in-between meals as well as total daily intake increased significantly. Recommended average level for individually measured requirements was reached.

The Psychology of Nutrition with Advancing Age: Focus on Food Neophobia

Many factors impact on eating behaviour and nutritional status in older adults. Strategies can be suggested to combat the impact of these factors, including the development of novel food products, but food neophobia ("the reluctance to eat and/or avoidance of novel foods") may be a barrier to the acceptance of these foods/products. This work aimed to investigate associations between food neophobia, physical disadvantage, and demographic characteristics in adults over 55 years old. Cross-sectional data from 377 older adults was analysed for relationships between food neophobia scores and physical disadvantage (denture wearing, help with food shopping and/or preparing, and risk of sarcopenia), controlling for age group, gender, living status, education, and employment level. Initial analyses demonstrated higher food neophobia scores in association with denture wearing (Beta = 0.186, p = 0.001). However, when demographic characteristics were also considered, food neophobia scores were no longer related to denture wearing (Beta = 0.069, p = 0.226) but instead were related to a higher age, living alone, and a shorter education (smallest Beta = -0.104, p = 0.048). Food neophobia may thus act as a barrier to the consumption of novel foods/products in those who are of higher age, are living alone, and have a shorter education.