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.

Indirect Nutrition and Mobility Risks during Hospitalization: An Architectural Perspective on the nutritionDay Study Findings

Nutrition and mobility risks include complex and interrelated physiological, medical, and social factors. A growing body of evidence demonstrates that the built environment can affect patients' well-being and recovery. Nevertheless, the relationship between the built environment, nutrition, and mobility in general hospitals is largely unexplored. This study examines the implications of the nutritionDay study's results for the architectural design of hospital wards and nutrition environments. This one-day annual cross-sectional study uses online questionnaires in 31 different languages to collect ward-specific and patient-specific variables. The main findings relevant to the design of hospital wards were: (1) 61.5% of patients (n = 48,700) could walk before hospitalization and (2) this number dropped to 56.8% on nutritionDay (p < 0.0001), while the number of bedridden patients increased from 6.5% to 11.5% (p < 0.0001), (3) patients who needed more assistance had a much longer mean LOS than mobile patients, (4) mobility was associated with changes in eating, and (5) 72% of units (n = 2793) offered additional meals or snacks, but only 30% promoted a positive eating environment. The built environment may indirectly affect hospitalized patients' mobility, independence, and nutritional intake. Possible future study directions are suggested to further investigate this relationship.

Patient Evaluation of Food Waste in Three Hospitals in Southern Italy

In recent years, food waste has received great attention and is now considered the cause of many negative effects, including health, economic, social and environmental issues. A cross-sectional study was conducted among a sample of 762 inpatients at three hospitals of Campania region in Italy. The purpose of this study was to evaluate the amount of food waste occurring in these hospitals using a structured questionnaire and asking inpatients about the average percentage of food they had disposed of in the previous three days. The overall food wasted amounted to 41.6%. The main plates, first (pasta or rice), second plate (meat or fish), resulted in similar amounts of waste (38.5% and 39.7%, respectively). The side plate (vegetable or potatoes), however, generated the greatest amount of waste (55.0%); 40.7% of patients totally discarded this part of their meals. The type of food wastage among the three hospitals reflected similar patient behaviours, with the amount of food wasted never falling below 30%. Females tended to waste more food than males (59.1% vs. 38.2%; p = 0.000). Other variables were correlated with less food waste, such as having a good opinion of the food's quality (RR = 1.91; 95% C.I. = 1.68-2.17) and satisfaction with the foodservice in general (RR = 1.86; 95% C.I. = 1.64-2.10). Poor quality, different eating habits and the feeling of satiety were the main reasons patients gave for food waste. Our study suggests that the most promising way to reduce food waste in hospitals is to improve the quality of meals and to establish an individual, simplified and flexible meal reservation process based on specific needs and preferences.

The Currently Available Literature on Inpatient Foodservices: Systematic Review and Critical Appraisal

BACKGROUND

An adequate hospital foodservice is important to optimize protein and energy intake and to maintain or improve a patient's nutritional status. Key elements that define an optimal foodservice have yet to be identified.

OBJECTIVES

To systematically describe the effects of published foodservice interventions on nutrition and clinical outcomes and determine which elements should be considered essential. Secondly, to describe the outcome measures used in these studies and evaluate their relevance and validity to guide future research.

METHODS

PubMed, Embase, the Cochrane Library, and the Web of Science databases were searched. Studies that included assessment of nutrition and/or clinical outcomes of hospital foodservice up to December 2017 were eligible. The details of the subject population, the type of intervention, and the effects on reported outcomes were extracted from each study.

RESULTS

In total, 33 studies that met inclusion criteria were identified, but only nine (27%) were rated as having sufficient methodologic quality. These nine studies concluded that various elements of a foodservice can be considered essential, including using volunteers to provide mealtime assistance, encouraging patients to choose protein-rich foods, adding protein-enriched items to the menu, replacing existing items with protein-enriched items, giving patients the ability to order food by telephone from a printed menu (room service concept), or a combination of these interventions. The interstudy heterogeneity was high for both outcome measures and methods.

CONCLUSIONS

Various foodservice interventions have the potential to improve outcome measures. Recommendations are made to facilitate future research.

Hospital food waste and environmental and economic indicators--A Portuguese case study

This study presents a comprehensive characterization of plate waste (food served but not eaten) at an acute care hospital in Portugal and elaborates on possible waste reduction measures. Even though waste prevention is a priority in Europe, large amounts of food are still being wasted every day, with hospitals giving rise to two to three times more food waste than other foodservice sectors. For this work the plate waste arising at the ward level was audited during 8 weeks, covering almost 8000 meals, using a general hospital as case study. Weighing the food served to patients and that returned after the meal allowed calculating plate waste for the average meal, as well as for individual meal items. Comparison of food waste arising showed that differences exist among wards, with some generating more waste than others. On average each patient throws away 953 g of food each day, representing 35% of the food served. This equates to 8.7 thousand tonnes of food waste being thrown away each year at hospitals across Portugal. These tonnes of food transformed into waste represent economic losses and environmental impacts, being estimated that 16.4 thousand tonnes of CO2 (equivalent) and 35.3 million euros are the annual national indicators in Portugal. This means that 0.5% of the Portuguese National Health budget gets thrown away as food waste. Given the magnitude of the food problem five measures were suggested to reduce food waste, and their potential impact and ease of implementation were discussed. Even though food waste is unavoidable the results obtained in this work highlight the potential financial and environmental savings for Portuguese hospitals, providing a basis to establish future strategies to tackle food waste.

Dietary, food service, and mealtime interventions to promote food intake in acute care adult patients

Malnutrition is common in acute care hospitals. During hospitalization, poor appetite, medical interventions, and food access issues can impair food intake leading to iatrogenic malnutrition. Nutritional support is a common intervention with demonstrated effectiveness. "Food first" approaches have also been developed and evaluated. This scoping review identified and summarized 35 studies (41 citations) that described and/or evaluated dietary, foodservice, or mealtime interventions with a food first focus. There were few randomized control trials. Individualized dietary treatment leads to improved food intake and other positive outcomes. Foodservices that promote point-of-care food selection are promising, but further research with food intake and nutritional outcomes is needed. Protected mealtimes have had insufficient implementation, leading to mixed results, while mealtime assistance, particularly provided by volunteers or dietary staff, appears to promote food intake. A few innovative strategies were identified but further research to develop and evaluate food first approaches is needed.

Aceitação de dietas em ambiente hospitalar

OBJETIVO: O objetivo do estudo foi avaliar a aceitação de dietas de pacientes internados em um hospital público do município de Florianópolis, Santa Catarina. MÉTODOS: Realizou-se análise dos restos alimentares de pacientes internados em unidades de internação médica durante 15 dias, por meio do índice resto-ingestão. O índice foi determinado por tipos de dieta, classificadas em normal, especial com sal e especial sem sal. Enquetes de satisfação com pacientes avaliaram os fatores que influenciam a aceitação das refeições. RESULTADOS: O peso total distribuído correspondente a 1.877 refeições foi de 868kg e o peso dos restos totalizou 313kg. Foi encontrado um índice resto-ingestão de 36,09% e um retorno de 53,68%, 33,99% e 33,84% de dietas especiais com sal, normais e especiais sem sal respectivamente. A variedade, a quantidade e a apresentação das refeições foram avaliadas de forma positiva. A temperatura e o uso de temperos foram os aspectos de menor satisfação, representando 43,00% e 34,30%, respectivamente, para os critérios de regular a ruim. O índice resto-ingestão encontrado (36,09%) estava acima do aceitável para uma população enferma (20,00%), demonstrando uma perda considerável de alimentos. CONCLUSÃO: A partir dos resultados, observou-se a necessidade de avaliar os processos envolvidos na produção dessas refeições e de elaborar estratégias que estimulem a ingestão alimentar do paciente.

Patients' satisfaction with the bulk trolley system in a government hospital in Malaysia

Purpose

The purpose of this paper is to determine patients' satisfaction with the bulk trolley food service system and the effect of the system on energy and protein intakes.

Design/methodology/approach

An interview‐based questionnaire was used to measure patients' satisfaction (n=70) with the hospital food services. Dietary intake of hospital food was determined through one‐day weighed food intake survey and a food record for non‐hospital food.

Findings

The majority of the patients (98.6 per cent) were satisfied and 1.4 per cent was very satisfied with the food service. Energy (kcal) and protein (g) intakes from hospital food were higher than that of outside food (p<0.05). However, most patients did not obtain their full energy and protein requirements from the hospital food provided. Four food service dimensions were found to be significantly correlated with patients' overall satisfaction (p<0.05).

Research limitations/implications

The questionnaire was adapted from the study by Capra et al. and modified to suit the local food service system, thus the application may be context‐specific. The instrument did not measure factors that influence hospital food consumption, nor did it differentiate between the acceptability of different kinds of food. Also a comparison of patients' acceptance between the plated and bulk trolley system was not conducted in this study.

Practical implications

The results of the study can be used as a basis for decision making and for future planning of the food service system. The findings prompt analytical comparison, between the bulk trolley, and plated systems, in determining patients' preference, and to increase food intake.

Originality/value

Patient satisfaction surveys are regularly conducted in the country but none had ever studied the effectiveness of the bulk trolley system in relation to patients' satisfaction. The findings are noteworthy and, compared with the past literature review, the difference in the way the system is carried out in the country may be the contributing factor regarding patients' satisfaction system.

Antibiotic-resistant gram negative bacilli in meals delivered at a general hospital, Italy

This study aimed at detecting the presence of antibiotic-resistant Gram-negatives in samples of meals delivered at the University General Hospital of Palermo, Italy. Antibiotic resistant Gram negatives were isolated in July—September 2007 ffrom cold dishes and food contact surfaces and utensils. Bacterial strains were submitted to susceptibility test and subtyped by random amplification of polymorphic DNA (RAPD). Forty-six of 55 (83.6%) food samples and 14 of 17 (82.3%) environmental swabs were culture positive for Gram negative bacilli resistant to at least one group of antibacterial drugs. A total of 134 antibiotic resistant strains, 51 fermenters and 83 non-fermenters, were recovered. Fermenters and non-fermenters showed frequencies as high as 97.8% of resistance to two or more groups of antibiotics and non fermenters were 28.9% resistant to more than three groups. Molecular typing detected 34 different profiles among the fermenters and 68 among the non-fermenters. Antibiotic resistance was very common among both fermenters and non-fermenters. However, the wide heterogeneity of RAPD patterns seems to support a prominent role of cross-contamination rather than a clonal expansion of a few resistant isolates. A contribution of commensal Gram negatives colonizing foods to a common bacterial resistance pool should not been overlooked.

Hospital inpatients' experiences of access to food: a qualitative interview and observational study

BACKGROUND

Hospital surveys indicate that overall patients are satisfied with hospital food. However undernutrition is common and associated with a number of negative clinical outcomes. There is little information regarding food access from the patients' perspective.

PURPOSE

To examine in-patients' experiences of access to food in hospitals.

METHODS

Qualitative semi-structured interviews with 48 patients from eight acute wards in two London teaching hospitals. Responses were coded and analysed thematically using NVivo.

RESULTS

Most patients were satisfied with the quality of the meals, which met their expectations. Almost half of the patients reported feeling hungry during their stay and identified a variety of difficulties in accessing food. These were categorized as: organizational barriers (e.g. unsuitable serving times, menus not enabling informed decision about what food met their needs, inflexible ordering systems); physical barriers (not in a comfortable position to eat, food out of reach, utensils or packaging presenting difficulties for eating); and environmental factors (e.g. staff interrupting during mealtimes, disruptive and noisy behaviour of other patients, repetitive sounds or unpleasant smells). Surgical and elderly patients and those with physical disabilities experienced greatest difficulty accessing food, whereas younger patients were more concerned about choice, timing and the delivery of food.

CONCLUSIONS

Hospital in-patients often experienced feeling hungry and having difficulty accessing food. These problems generally remain hidden because staff fail to notice and because patients are reluctant to request assistance.

Does a new steam meal catering system meet patient requirements in hospital?

BACKGROUND

It has been consistently observed that a significant proportion of hospital inpatients are malnourished and many actually develop malnutrition in hospital. The NHS provides over 300 million meals each year at a cost of pound 500 million, yet there is relatively little research evaluating how well different catering systems provide for the needs of hospital inpatients.

AIM

The aim of the study was to: (i) evaluate whether a new steam meal catering system (Steamplicity) enables patients in theory to meet their energy requirements in hospital and (ii) compare energy and protein intake using Steamplicity with a traditional bulk cook-chill system.

METHODS

Patients not at nutritional risk had their food intake at one lunchtime assessed. Energy intake was compared with the patients' energy requirements and energy and protein intake were compared with previous data from a bulk system.

RESULTS

Fifty-seven patients had a median daily energy requirement of 7648 kJ (1821 kcal) [inter-quartile range (IQR): 6854-9164 kJ]. Assuming 30% [2293 kJ (546 kcal)] should be supplied by the lunch meal the average intake of 1369 kJ (326 kcal) fell short by 40%. Patients served meals from Steamplicity ate less energy [1369 kJ versus 1562 kJ (326 kcal versus 372 kcal) P = 0.04] but similar protein (18 g versus 19 g P = 0.34) to the bulk system. The largest difference was the energy provided by the dessert since the bulk system served more hot high-calorie desserts.

CONCLUSIONS

Patient intakes did not meet their estimated requirements. The patients in this study were eating well and not at nutritional risk, thus patients with a poor appetite will be even less likely to meet their nutritional requirements. Steamplicity meals result in a lower energy intake than meals from a bulk cook-chill system, but similar protein intakes.

Changes in type of foodservice and dining room environment preferentially benefit institutionalized seniors with low body mass indexes

OBJECTIVE

To compare energy intakes in seniors with cognitive impairment residing in long-term care and receiving meals by bulk (cafeteria style with waitress service) vs traditional tray delivery systems and determine subject characteristics that identify responsiveness to type of foodservice provided. DESIGN AND SUBJECTS/SETTING: Usual energy intakes were compared in subjects residing in cognitive impairment units in either the old (tray delivery, n=23) or new (bulk delivery, n=26) nursing home at Baycrest, a teaching facility associated with University of Toronto Medical School.

INTERVENTION

Changes to foodservice and physical environment (from institutional to more home-like environment).

MAIN OUTCOME MEASURES

Twenty-one consecutive day investigator-weighed energy and macronutrient intakes and behavioral function (London Psychogeriatric Rating Scale).

STATISTICAL ANALYSES PERFORMED

Analysis of variance determined mean differences in intake and regression analyses identified predictors of sensitivity to type of food delivery systems.

RESULTS

Higher 24-hour total (P<0.001) and dinner (P<0.001) energy intakes in subjects receiving bulk compared to tray delivery were predominantly associated with greater carbohydrate intakes (P<0.001). Higher energy, carbohydrate, and protein, but not fat intakes, with bulk delivery were more apparent in individuals with lower body mass indexes (BMIs) (food delivery by BMI interaction, all P values <0.05).

CONCLUSIONS

High-risk, cognitively impaired individuals with low BMI benefited the most from the changed foodservice and physical environment, whereas individuals with higher BMIs did not show substantive changes in intake. Bulk foodservice and a home-like dining environment optimize energy intake in individuals at high risk for malnutrition, particularly those with low BMIs and cognitive impairment.

Plate versus bulk trolley food service in a hospital: comparison of patients’ satisfaction

OBJECTIVE

The aim of this research was to compare plate with bulk trolley food service in hospitals in terms of patient satisfaction. Key factors distinguishing satisfaction with each system would also be identified.

METHODS

A consumer opinion card (n = 180), concentrating on the quality indicators of core foods, was used to measure patient satisfaction and compare two systems of delivery, plate and trolley. Binary logistic regression analysis was used to build a model that would predict food service style on the basis of the food attributes measured. Further investigation used multinomial logistic regression to predict opinion for the assessment of each food attribute within food service style.

RESULTS

Results showed that the bulk trolley method of food distribution enables all foods to have a more acceptable texture, and for some foods (potato, P = 0.007; poached fish, P = 0.001; and minced beef, P < or = 0.0005) temperature, and for other foods (broccoli, P < or = 0.0005; carrots, P < or = 0.0005; and poached fish, P = 0.001) flavor, than the plate system of delivery, where flavor is associated with bad opinion or dissatisfaction. A model was built indicating patient satisfaction with the two service systems.

CONCLUSION

This research confirms that patient satisfaction is enhanced by choice at the point of consumption (trolley system); however, portion size was not the controlling dimension. Temperature and texture were the most important attributes that measure patient satisfaction with food, thus defining the focus for hospital food service managers. To date, a model predicting patient satisfaction with the quality of food as served has not been proposed, and as such this work adds to the body of knowledge in this field. This report brings new information about the service style of dishes for improving the quality of food and thus enhancing patient satisfaction.

Visual Plate Waste in Hospitalized Patients: Length of Stay and Diet Order

The purpose of this pilot research was to investigate the effect of diet order, sex, diagnosis, and length of stay on visual lunch plate waste in hospitalized patients. Information on 346 patients was collected using the computer program CBORD Diet Office. Visual plate waste during lunch was measured and analyzed for 4 consecutive days. Neither sex nor diagnosis at admittance was associated with visual plate waste. However, the odds of visual plate waste increased by 14.1% for every day a patient was admitted. In patients receiving a diabetic diet order, odds of visual plate waste decreased by 61.2%, indicating there was reduction in plate waste. Conversely, in patients receiving altered consistency diet orders, odds of visual plate waste increased by 344%, signifying a rise in plate waste. Due to an increase of visual plate waste associated with long length of stay and altered consistency diet orders, registered dietitians working in acute-care facilities need to develop strategies to create cost-effective, nutritionally balanced, altered consistency diets that would enhance patient acceptance and consumption of food.

An evaluation of renal inpatient meals against Renal Nutrition Group standards

BACKGROUND

The Renal Nutrition Group (RNG) of the British Dietetic Association has developed standards for the nutritional composition of meals provided to renal patients in hospital. However, no data are available as to whether these are achievable. The purpose of this study was to determine whether renal inpatient meals can meet the standards set by the RNG.

METHOD

A prospective 10-day weighed food analysis of hospital meals provided to renal patients was undertaken. Two sample meals were analysed at each mealtime to include (1) the most energy dense choice and (2) the most frequent patient choice (FPC).

RESULTS

Energy dense choice meals achieved the standard for protein provision on 90% of days, but provided too little energy on 100% of days (for men) and on 30% of days (for women). Although daily standards for potassium were met on 70% of days, those for sodium and phosphate were exceeded. FPC meals met the daily standards for potassium, sodium and phosphate on at least 80% of days, but provided too little protein on 40% of days and too little energy on 100% of days (for men and women).

CONCLUSION

The majority of hospital meals fail to meet the RNG standards. Problems exist in providing sufficient energy and protein whilst restricting sodium, potassium and phosphate.

Factors Affecting Satisfaction Level with the Food Services in a Military Hospital

OBJECTIVE

To determine the factors affecting general satisfaction level of patients with the food services in a military hospital in Turkey.

STUDY DESIGN

The study was carried out in a military hospital providing tertiary health care services with the capacity of 1000 hospital bed. A questionnaire was used as data collection tool on measuring satisfaction of the patients with the food services.

RESULTS

The results showed that of 374 patients 51.3% evaluated food service quality adequate, 32.4% said that the food quality was inadequate, and 16.3% stated that they were uncertain. A logistic regression model was estimated in determining the most important and statistically significant factors affecting patient satisfaction with hospital foods and food services. The results showed that patient-specific demographic characteristics were insignificant in explaining satisfaction level with food services, but the variables of taste (OR = 9.853, p = 0.000) and appearance (OR = 2.687, p = 0.014) of the food were statistically significant and important determinants of patient satisfaction with the foods served at the hospital.

CONCLUSIONS

The results of this study would be helpful in making decision on increasing the level of satisfaction of patients with the food services for hospital managers and the food (nutrition) departments. On the other hand, the results can also be used in benchmarking the hospital's food services quality with other hospitals, and in monitoring improvements in food services quality in the future.