Nutrition and patients--whose responsibility? (Editorial).

A recent Australian study reported that on average over one third of hospital patients consumed only 50% of the total energy provided by hospital meals, suggesting a large proportion of the hospital patient population may not be meeting their nutritional requirements (1). Many studies in Australian hospitals and elsewhere have reported high rates of malnutrition in patient populations both on admission and at discharge (2-6).

In Britain, the Royal College of Physicians has recently released a report called Nutrition and patients -- a doctor's responsibility (7). It notes that undernutrition and overnutrition are important clinical problems for patients that are often overlooked or ignored. It calls for nutritional screening of patients to be an integral part of clinical practice, the establishment of multidisciplinary steering groups to develop policies for nutritional care, and highlights that those responsible for hospital governance should identify nutrition as an important aspect of clinical care that involves catering and many health care disciplines.

Such calls are not new (8), but changing attitudes and practice will be a long process. Medical and nursing students still have limited knowledge of nutritional matters, and dietitians are often increasingly removed from responsibilities around the management of food services. At the same time there are many changes in what food is being provided to patients in hospital and how it is delivered, that could directly impact the nutritional care of inpatients. We have seen a dramatic increase in the use of cook-chill food services in New South Wales, from 5% of hospitals in 1986 to 42% in 2001, despite the fact that managers of such systems report lower levels of satisfaction than those with cook-fresh systems (9). There has been a considerable amount of research on the impact of cook-chill food service on the nutritional quality of hospital food, however there has been little attention given to the more subtle impacts the system may have on the choices of food provided on the menu. Some data suggest that menus f rom cook-chill hospitals are providing more hot menu options and healthier choices that are lower in fat and salt, but that they are less likely to offer optional serving sizes or a choice of whether to have sauces or gravy served with meats (unpublished observations).

An increasing proportion of hospitals is now offering a continental breakfast only. This trend remains a concern when there is evidence that patients may have poorer nutrient intakes when a hot breakfast is not available (10). Other changes that are being trialled in a number of centres are moves away from selective patient menus and centralised meal plating to bulk food delivery and bedside spoken meal orders, that allow last minute meal selections. Such systems may result in less waste and greater patient satisfaction but it is unclear how they affect nutritional intake (11-14).

The provision of food suitable for the sick is not just a hotel function: it is treatment (15) and the first step to ensuring hospital patients are meeting their nutritional needs is to provide a menu that is of high nutritional quality and which promotes healthy, well balanced eating. There are useful resources to assist dietitians in providing professional food service advice (16-18), but there is remarkably little solid research to base many of our current recommendations and there is a need to evaluate more innovative ways to provide more cost effective oral nutrition support to patients.

Dietitians have always recognised food service as a key area of professional practice. Dietetic involvement in menu formulation was required as part of earlier hospital accreditation standards and remains one of the key competencies for entry-level dietitians. There have been several studies that reported success by dietitians in improving the nutritional quality of general patient menus (19,20), and in a number of settings dietitians are exploring better ways to provide between meal supplements that will increase the overall energy intake of at-risk patients.

The issue of hospital malnutrition will become even more relevant as our population ages and we have more elderly people in institutional care for extended periods. If dietitians are going to make a difference we need to make this a priority for more research, both into the impact of alternative menu and food service systems, and the cost-effectiveness of more targeted nutrition support strategies. Certainly doctors should be more interested in the nutritional status of their patients, but it is dietitians who are in the best position to regularly monitor this and to advocate for and manage changes to improve the food provided in hospital. Good nutrition for patients is a doctor's responsibility, but it is our responsibility too.

Peter Williams

President, DAA 

References

(1.) Kowanko E, Simon S, Wood J. Energy and nutrient intake of patients in acute care. J Clin Nurs 2001;10:51-7.

(2.) Zador D, Truswell A. Nutritional status on admission to a general surgical ward in a Sydney hospital. Aust N Z J Med 1987;17:234-40.

(3.) McWhirter J, Pennington C. Incidence and recognition of malnutrition in hospital. BMJ 1994;308:945-8.

(4.) Gallagher-Allred C, Voss A. Finn S, McCamish M. Malnutrition and clinical outcomes: the case for medical nutrition therapy. J Am Diet Assoc 1996;96:361-9.

(5.) Beck E, Patch C, Milosavljevic M, Mason S, White C, Carrie M, et al. Implementation of malnutrition screening and assessment of dietitians: malnutrition exists in acute and rehabilitation settings. Aust J Nutr Diet 2001;58:92-7.

(6.) Thomas D, Zdrowski C, Wilson M, Conright K, Lewis C, Tariq S, et al. Malnutrition in subacute care. Am J Clin Nutr 2002;75:308-13.

(7.) Royal College of Physicians. Nutrition and patients. A doctor's responsibility. London: Royal College of Physicians; 2002.

(8.) Garrow J. Starvation in hospitals. BMJ 1994;308:934.

(9.) Mibey R, Williams P. Food services trends in New South Wales hospitals, 1993-2001. Food Serv Technol 2002;2:95-103.

(10.) Coote D, Williams P. The nutritional implications of introducing a continental breakfast in a public hospital: a pilot study. Aust J Nutr Diet 1993;50:99-103.

(11.) Kelly L. Audit of food wastage: differences between a plated and bulk system of meal provision. J Hum Nutr Diet 1999;12:415-24.

(12.) Clusky M, Dunton N. Serving meals of reduced portion size did not improve appetite among elderly in a personal-care section of a long-term-care facility. J Am Diet Assoc 1999;99:733-5.

(13.) Wilson A, Evans S, Frost G, Dore C. The effect of changes in meal service systems on macronutrient intake in acute hospitalized patients. Food Serv Technol 2001;l:121-2.

(14.) Shatenstein B, Ferland G Absence of nutritional or clinical consequences of decentralized bulk food portioning in elderly nursing home residents with dementia in Montreal. J Am Diet Assoc 2000;100:1354-60.

(15.) British Association for Parenteral and Enteral Nutrition. Hospital food as treatment. Maidenhead: BAPEN; 1999.

(16.) Wilson R. Food service in hospitals and institutions. In: Thomas B, editor. Manual of Dietetic Practice. 3rd ed. Oxford: Blackwell Science; 2001. p.108-15.

(17.) NSW Department of Health. Hospital Menu Assessment Tool: manual version. State Health Publication No HP 990109. Sydney: NSW Department of Health; 1999.

(18.) Institute of Hospital Catering (NSW). Food Service Guidelines for Healthcare. Sydney: Institute of Hospital Catering; 1997.

(19.) Anderson P, Cook G Debenham K, Myatt G, Wykes K. Introducing a healthier diet in a small community hospital. Comm Med 1986;8:47-53.

(20.) Morris H, Davies M, Byrnes T, Orr P, Goodwin S, Dyson L. An approach to increasing the frequency of better food choices in a South Australian public hospital. Aust J Nutr Diet 1994;51:9-13.