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And 3 When discharged from hospital, it will be the duty of the hospital to prescribe a treatment plan to be followed, and also in some cases the hospital will be responsible for follow-up after discharge.

Immune-modulating oral or enteral nutritional support Certain key nutrients L-arginine and L-glutamine, ribonucleic acid RNA and the n-3 essential fatty acids EFA seem to be able to modulate a variety of inflammatory, metabolic, and immunological processes when ingested in excess of the normal daily requirements.

Meta-analysis of recent trials suggests reduced risk of infections, fewer days on a ventilator, and reduced length of intensive care and hospital stay, and reduced hospitalisation costs, but mortality does not appear to be affected Beale et al.

Thus, a level A recommendation i. Besides, consensus recommendations regarding its use were made U. Summit Consensus Panel Another question is whether benefits of immunemodulating nutritional support in patients suffering from shock, sepsis and organ failure are equal to those in moderately traumatised surgical patients.

In this context it should be noted that meta-analyses did not show any improvements in the former group of patients, rather demonstrated a tendency towards a poorer outcome Beale et al.

These results might be a serious warning to the unrestricted use of immune-modulating formulas in the most seriously ill patients Heyland et al.

Finally, no studies have examined the clinical benefit of immune-modulating nutritional support among the majority of patients - those who are not critically ill or suffering from surgical stress.

In a study from Denmark the use of appropriately designed and targeted energy and protein dense hospital menus prevented the weight loss normally observed during hospital stay Kondrup et al.

Others have been quite successful in improving the intake of ordinary hospital food with simple means. These sip feedings can be a valuable addition to the hospital food for some patients with low intake.

Hospital food, including sip feedings, can often bring intake to desired levels, and only if these measures fail or are inappropriate artificial nutritional support becomes necessary Lennard-Jones The majority of the early published studies of nutritional support, used parenteral nutrition.

However, since then studies reporting the effect of enteral or oral supplements sip feedings has been steadily increasing table 2.

Conclusions from a systematic review Potter et al. The benefits of routine nutritional supplementation are not restricted to particular subgroups or trials.

More old people than young adults have been studied, and for each outcome the old people seem to benefit as much as the young.

Considerable uncertainties remain; thus large pragmatic randomised controlled trials of routine oral or enteral nutritional supplementation are justified.

In general better hospital food provision may diminish the necessity to use sip feeding and artificial nutrition, and allow earlier weaning from these treatments.

This may cause worthwhile reductions in costs and offset any increased expenditure on food service. Sip feedings should not be used as a substitute for the adequate provision of normal food, and should only be used if there are clear clinical indications Allison The caring professions have an ethical duty to recognise and treat undernutrition, as part of optimal care for patients - usually by attention to drinking and eating but also by means of artificial nutritional support.

Only when such care prolongs the period of dying or maintains an unacceptable quality of life should artificial nutritional support be reconsidered Lennard-Jones All professionals are influenced by own personal experiences.

There are specific instances, however, where force is legal and even ethical, e. Withholding or withdrawal of artificial nutrition and fluids often implies ethical considerations, and it is a decision that is always difficult and often controversial.

Unlike other medical treatments, food and feeding has an emotional and symbolic significance for many people playing a significant role in religious, cultural and ethnic traditions, and has evolved as a symbol of caring and comfort ASPEN As a consequence, some physicians, hospitals and judges have held that withdrawal of artificial nutrition and fluids from a patient in a persistent vegetative state would be similar to murder.

However, professional medical groups and courts of final jurisdiction have consistently concluded that artificial nutritional support is legal medical treatment and not basic care.

Furthermore, where there is evidence that the patient would not want such treatment, its withdrawal is an acceptable medical practice Lennard-Jones , Paris Today a wealth of techniques to deliver artificial nutrition exists.

As evidence accumulates that undernutrition impairs and nutritional support improves outcome, the more it becomes apparent that failure to consider these techniques, is not only a failure of the duty to do good and avoid doing harm, but may well be construed as negligence and lead to court.

Artificial nutritional support will often be initiated in patients with e. An expensive but ineffective nutritional treatment provided to one patient might reduce the resources in money, staff and equipment available to treat another patient who might benefit.

It is not easy to recognise when the patient is close to the end of life, and when artificial nutritional support is futile or indeed harmful or uncomfortable.

Even though such 40 cases could be settled by court, it is important to bear in mind that relatives are acutely aware of the smallest details of care as their loved one dies and recall incidents long afterwards.

It is essential that their memories should be free from anger or resentment against the physicians and other health care professionals at this critical time LennardJones The European Association for Palliative Care has made guidelines, which deal with some of the raised topics Bozetti b.

Also the 4 principles of beneficence, nonmalfeasance, autonomy and justice may be used to assist the physician in the decision as to whether to feed or not to feed MacFie The decision to terminate artificial nutritional support does not mean that oral intake should be terminated.

Ordinary hospital food and fluids should be offered to all patients capable of oral intake. Providing food and drink is an important expression of concern and caring Gastmans Hence, all attempts to maximise the actual or illusory sense of nurturing, caring and comfort provided by ordinary food should be encouraged ASPEN Children 2.

Besides, children cannot survive starvation as long as adults because of their lesser stores of energy substrates relative to their higher rate of energy expenditure Cunningham Assessing and treating undernutrition Screening paediatric patients at risk of undernutrition is relatively easy to perform by evaluating the growth charts weight-for-age, height-for-age and weight-for-height.

There is general agreement that all children admitted to hospital should have a growth chart that is updated weekly, but often the reality is that this is not done.

The use of growth charts is also important in children after discharge, especially in those with chronic disease Fjeld et al.

Assuring that all children admitted and followed as outpatients have an updated growth chart is pivotal in improving nutrition in hospitals.

There are 2 main types of undernutrition in children: wasting low weight-for-height and stunting low height-for-age.

The anthropometric indicator most often used is weight-for-age, but this is inferior to weight-for-height and height-for-age, as a low weight-for-age does not distinguish between wasting and stunting.

The 3 anthropometric measures can be expressed as percentiles, standard deviation scores SDS or percent of median Fjeld et al.

As in adults, nutritional risk assessment should involve both nutritional status and severity of disease. Such simple screening methods have been developed and found useful among paediatric patients Reilly et al.

A simple strategy for improving the intake of ordinary food by undernourished hospitalised children is given in table 2.

Increase energy density and frequency of meals. Favourite dishes should be available round the clock. No reasons to focus on protein The protein requirement is almost covered when the intake energy requirement is covered.

Give a multi vitamin-mineral This will cover for some of the possible deficits due to tablet the disease or an unvaried menu.

As in adults, ordinary food should always be the first choice of nutritional support. If that is not sufficient the energy density of the ordinary food should be optimised.

Sip feedings could also be used, but children often do not like these. If energy intake is still not sufficient enteral feeding should be started without unnecessary delay.

Parenteral nutrition should only be started if nutrition via the enteral route is not sufficient Michaelsen Enteral nutrition seems as effective as parenteral nutrition in maintaining nutritional status Papadopoulou et al.

In the first 3 years of life a traumatic incident could lead to total refusal of food. Enteral feeding should be used in this case.

If the child is over 3 years, psychological treatment should be considered Wilson Children under 4 years need nutritional support within 24 hrs after surgery due to their low energy reserves.

Children above this age should meet their nutritional requirements within 3 days after surgery. Early start of nutritional support is also recommended in children with cancer den Broeder et al.

Few children start to regain weight and height during hospitalisation. However, the use of long-term artificial nutritional support after discharge has been found to result in improvements Kist et al.

The magnitude of the problem Relatively few studies have assessed the prevalence of undernutrition among children in hospitals.

However, a common finding is that a significant proportion of the children are underweight-for-age, stunted or wasted Hendrikse et al.

As in adults, the prevalence of undernutrition increases during treatment and after discharge Lenssen et al. The data about the causes of undernutrition are sparse, except with regard to the disease related causes, e.

There is no clear assigned responsibility with regard to nutritional care and support, and food service.

There is a lack of nutritional practices, which suggests that improved education with regard to clinical nutrition is needed for all health care professionals involved in the nutritional care and support of the patients.

More specifically the staffs need appropriate training and suitable protocols and aid by nutritional support teams for the early identification and treatment of nutritional risk patients.

Beside this there is a need for improved communication and co-operation between different staff categories. In spite of the apparent gloomy situation several initiatives are going on to improve the situation including the initiation of nutritional education programmes.

Table 3. The impact on parenteral nutrition when a nutrition support team NST authorises the supply Newton et al.

Therefore, it is important that physicians, nurses, dieticians and food service staff, and hospital management work together, as for example in an NSC.

It is, however, important to look at the provision of meals in hospital food service systems as a management issue. Hospital food service is a complex process where food becomes meals and where meals become nutrition, and where many different actors are involved.

Therefore, management must give priority to create the organisational framework in which food service and nutritional issues can be discussed.

Responsibilities for the NSC could be to negotiate and manage the food service system and nutritional support, and to ensure that the hospital purchasing authorities include contract specifications regarding food service and nutritional supports, to establish NSTs, to set standards for the nutritional risk screening, so that risk patients are recognised, to develop protocols for the action to be taken, when a risk patient is identified and to implement an agreed process of audit in this context see Silk , for suggestions for further responsibilities.

Some of the suggested responsibilities for the NST could be to implement the standards of nutrition support agreed by the NSC, monitor patients receiving nutritional support and audit its clinical activities see Howard and Jonkers et al.

The recommendations are very similar. Still, responsibilities seem to be unclear in many wards table 3.

A study from Denmark has shown that there is a lack of agreement between nurses and physicians when asked who they think are responsible for the nutritional care of the patient Rasmussen et al.

In practice, however, this seldom functions. In a survey of the hospitals in the Nordic region the specific requirements for communication were outlined based on meal ordering, time frame, information, flexibility and co-operation Nordic Council of Ministers, One characteristic of these hospitals was that the food service and ward personnel had co-operated in the design of meal order forms.

Other characteristics were a varied food delivery system, menu choices, and existence of contact persons and NSCs.

There were some discrepancies in the answers from, respectively, ward and food service staff. As an example, the management of 12 hospital food services stated that the patients had a choice of menu, however, in only 5 of the hospitals the ward staff were aware of this.

In England a new role of ward housekeeper is being developed. The ward housekeeper will be part of the ward team and will be responsible for making sure that patients receive a food service, which meets the needs of the patients.

They will play an important role in communication. None of the official recommendations from, respectively, Denmark, Sweden, Norway and Finland deal with the communication and co-operation between hospitals and 47 primary health care sector.

Today this kind of communication is virtually non-existent, however, due to the very short length of stay for many patients, communication between hospitals and primary health care sector should be improved.

Also the nutritional treatment plan should include suggestions for monitoring, e. In practice however, routine nutritional risk screening and assessment is generally not performed at admission or during hospitalisation table 3.

When it is performed body weight, recent weight loss and BMI are used most frequently as screening tools.

Neither is nutritional counselling commonly practised. Finally, the use of nutritional support for undernourished patients and nutritionally at-risk patients is sparse and inconsistent.

The most common explanations why nutrition-related practices are not done are lack of time, staff, nutritional education and interest, while none of the European countries put the blame on the quality of the food Appendix 2.

The reported lack of nutritional practices are documented in many studies Almdal et al. The prevalence of nutritional assessment, recording of food intake and body weight measurement according to a Danish survey Rasmussen et al.

Examples of these were misapplication of nutritional support, misuse of parenteral nutrition, too short treatment periods and high rates of complications Braga et al.

There does not seem to be consistency across Europe with respect to nutritional support practices Howard et al. Hence, European hospitals face two major common problems: 1 Lack of clearly defined responsibilities in planning and managing nutritional care.

And 2 Lack of cooperation between different staff groups see also Appendix 4. The gloomy situation may not apply to intensive care patients Preiser et al.

However, recent data show that nutrition support provided is inappropriate Montejo et al. It must be recognised that there are several initiatives going on in the European countries to improve the situation with respect to the nutritional practices see Appendix 2.

In the United States sufficient nutrition is part of the general requirements for approval of hospitals. These requirements have formed the basis of similar standards in the Danish Copenhagen hospital corporation, now undergoing accreditation by the Joint Commission International.

All patients identified, as nutritionally at risk by the patient screening mechanism shall undergo a formal nutritional assessment.

The formal nutritional assessment shall be performed by or under the supervision of a clinical dietician or a physician and be documented and available to the patient care providers.

A NST shall function to assess and manage patients to be nutritionally at risk. The patients shall be monitored for therapeutic and adverse effects and clinical changes that may influence nutritional support.

Reassessment and the resulting changes in the nutritional support plan shall be documented. The same is the case with regard to the nurses and most other health care professionals Appendix 2.

Apparently only clinical dieticians acquire some knowledge and skills in nutrition during pre-registration training. This assumption is certified in a survey where different staff members completed a questionnaire regarding undernutrition.

The results showed that the clinical dieticians had most correct answers followed by the medical students. Hence one major common problem exists in Europe - the lack of sufficient educational level with regard to nutrition among all staff groups.

Teaching has lagged behind nutritional research, which has forged ahead, increasing the gap between knowledge and practice.

This means that it might be difficult for individual physicians, who use nutritional support techniques only occasionally see e. PayneJames et al.

According to a European survey performed by the education committee of the European Society of Parenteral and Enteral Nutrition ESPEN in there were no organised post-graduate courses identified for either physicians or nurses in any of the participating countries Howard et al.

The same interest in nutrition was found in a Danish survey, however, with exception of the ICUs, there was a large discrepancy between attitudes and practices Rasmussen et al.

Based on the survey performed by the education committee of ESPEN some general educational themes that could benefit from a more focused approach were identified table 3.

Educational themes that should require high priority Howard et al. The content of training programmes for clinical staff.

Nutritional assessment methodology. Nutritional assessment. Estimation of nutritional requirements. Nutrient metabolism.

Regulation of metabolic pathways. The impact of nutritional disorders on clinical status. Nutritional support and outcomes.

Nutrition in specific diseases. Specific nutrient-related diseases. Physicians A study conducted by a working party of the British Association of Parenteral and Enteral Nutrition BAPEN found that almost half of the physicians, who did not know whether their patients had been weighed, regarded measurement of body weight as unimportant.

This reason was also given by approximately two thirds of the physicians who did not ask simple questions about recent weight loss and altered food intake Lennard-Jones et al.

Lately some important initiatives in this context have been started see also Appendix 2. Also, national nutrition societies were requested to inform health and educational authorities as well as the medical schools FENS Until now only the IUNS has received the recommendations, and further work has apparently been suspended B.

Miranda-daCruz, personal communication. It is now the official programme in the field. Chambers of physicians in the various federal states, as well as other organisations are offering the curriculum.

Participation in this hour course is certified by the chambers, but some legal aspects still need clarification.

In medical schools comprehensive nutrition education is not yet available Schauder et al. The United States has already introduced nutrition education in the majority of medical schools Schulman This has happened by means of free distribution of computerassisted instructions see e.

Also, the above-mentioned courses in nutritional support, which are held each year by ESPEN, are helping to meet some of the identified specific needs.

Finally, relevant contacts in relation to improvement of education could be the Standing Committee of European Doctors www.

Nurses Compared to physicians the nurses seem to show a greater interest in the nutritional care and support of the patient Lennard-Jones et al.

Nurses generally find it difficult to identify risk patients, to set up nutrition plans and monitor the effect of the nutritional 1 WFME has its own journal: Medical Education 53 support Rasmussen et al.

The results indicate that the nutrition related training given to all nurses should be reevaluated and restructured to be more relevant to clinical practice.

This might be accomplished by means of e. Besides knowledge about optimal practice with regard to nutritional care and support could be improved by means of societies for nurses involved in clinical nutrition, as is seen in e.

Clinical and general dieticians Clinical and general dieticians seem to receive the most up-to-date training Appendix 2. However, their educational level and responsibility are in practice very varied.

The Finnish clinical dieticians obtain a master degree, and work with specialised care, while the German general dieticians only have limited access to patient data, and are mainly occupied in the kitchens producing diets on a medical indication.

The role played by the clinical and general dieticians in hospital nutrition management varies widely throughout Europe, probably caused by several factors, including education, clinical awareness of the benefits of nutritional support and access to adequate financial resources.

Minimum educational standards for the practice of nutritional support of clinical dieticians Howard et al.

There should be a common standard at first-degree level for all nutritional support clinical dieticians.

There should be an identified programme of post-graduate studies for clinical dieticians both clinical and academic leading to specialisation in nutritional support.

There should be an innovative approach to providing clinical support by clinical dieticians for emerging specialists.

ESPEN should investigate the potential for developing an accredited and integrated European standard in nutritional support.

Food service staff may not be aware of the importance of providing highly nutritious food to ill patients. One result of this is the lack of a powerful voice for food service systems, unlike clinical services, when it comes to financial control and the allocation of budgets.

Nutrition is not taught on all courses and what is taught may be insufficient. Also, there is an educational lack with regard to management.

As can be seen from Appendix 2. In some countries, e. United Kingdom the role of the dietician is not split into the 2 areas of clinical and administrative.

When dieticians do not manage food service, it is important that they have some input into monitoring food service contracts, particularly in relation to nutritional quality and patient satisfaction.

Among other things this means that they might need additional help and support from new grades of staff.

This help could be provided by part-time care assistants employed by the hour or by ward housekeepers usually of domestic orderly grade. Common to these staff members is their lack of nutritional knowledge.

In practice this means that the staffmembers who have the closest contact with the patient in relation to food, are the ones who know least of all about nutrition.

Carefully designed and detailed job description and specification of their area of responsibility, as well as a proper nutritional in-house training programme, is crucial to obtain a benefit of their aid Allison Other occupational groups, which could play a role, are pharmacists in relation to the composition of enteral and parenteral nutrition, drug-nutrient interactions etc.

Patients The majority of patients are not aware of the importance of a good nutritional status to secure a proper treatment see section 5.

Therefore the topic of education and information of the patient should receive high priority in the educational themes at all levels.

The teaching should cover preventive as well as therapeutic aspects of nutritional care and support. Still, as in adults undernutrition often goes unrecognised Hendrikse et al.

There are only few paediatric NSTs in Europe, which reflects a lack of focus on nutritional problems in children.

The lack of knowledge about the nutritional needs of children has been suggested as one of the major causes of neglecting this group of hospitalised patients Howard et al.

However, food service is not merely a hotel function and the food served is part of the clinical treatment.

Out-sourcing of food service is increasing. Major efforts are needed from the management in order to secure that all significant terms and conditions in relation to food service are described in the contract.

Arrangements for food preparation, distribution and serving should deliver hospital food of defined standards in terms of nutritional quality, balances, palatability and temperature.

Each method of food preparation and distribution has its advantages and disadvantages in terms of nutrient losses, menu flexibility, food wastage, food hygiene requirements, staff skills in the kitchen, staff skills in the wards, and other factors.

The choice of method should therefore depend on the patients in question. It involves decisions on a range of issues including food service technology, food service management, and organisation of food service and serving systems, food purchasing management, human resource management and distribution systems.

Many of these decisions are political issues, and adoption and implementation of a meal, or a food or a nutrition policy at hospital or regional level can be a way to address these issues.

Improving nutrition requires a change of both attitudes and routines. In many cases the food service is regarded as a subject matter that can be addressed separately, and as a simple task any food service operator could handle.

Compared to the attention consumers pay to food the low status of food service and nutrition in hospitals at management level is surprising.

But also the attitudes of the physicians and nurses are important. Food cannot solely be regarded as something that is prescribed by a physician and as a result eaten by the patient.

The meal is a complex cultural and social phenomenon for the patient. A successful meal includes eating in a proper environment, having choices, friendly staff, good information about meal options, and the possibility to eat with relatives or other patients.

Improving hospital nutrition is far from just being a question of changing attitudes of the physicians and nurses.

A changed attitude of the hospital management is necessary giving priority to such matters as food policy and management of food service and nutritional aspects table 4.

Setting up an NSC and taking active part in this. Taking into account the potential cost of complications and prolonged hospital stay due to undernutrition when assessing the cost of ordinary food and nutritional support.

Taking into account the different patient needs when deciding on serving systems. Taking into account the social context of eating when number of staffs on duty, serving hours, dining environment etc.

Apparently, most countries use in-house food service Appendix 3. In most countries the public has taken the responsibility for the management of hospitals, including the provision of meals.

If the food service is out-sourced local authorities still have the responsibility for the food service, but an external operator carries out management.

In other cases local authorities co-operate and establish independent joint venture companies to carry out food service. This means that the hospital managers negotiate a contract with the food service operator.

All significant terms and conditions in relation to the food service should be described in the contract. Accordingly, the process of establishing the contracts and tenders becomes an extremely important tool when trying to improve 58 hospital nutrition.

Contracting out also creates difficulties in making food service part of the clinical delivery. Such experience should be gathered in order to develop common guidelines for out-sourcing hospital food service.

High quality meals are not only a question of skilled food service operators. It also requires very competent purchasers at hospital management level.

If the management is unable in well-defined terms to describe what the food service should include the performance of the out-source service is going to be poor.

An important task of the NSC in this context could be to secure that the hospital purchasing authorities include contract specifications for hospital food service and nutritional support.

Another could be to ensure that the standards for these two items, agreed by the authorities are adhered to Silk Small hospital food service systems serve less than patients per day.

Medium sized systems serve between and patients per day and large hospital food service systems more than patients. Most hospital food service systems include one central food service production unit servicing a number of wards distributed throughout the hospital site.

However, in some cases a central production unit services different hospital locations. The type and size of the hospital is important because it influences the way food service can be organised, the usable technology and distribution system, and the organisational framework in which food service and nutrition can be discussed.

In the centrally plated system, food is plated at an assembly line in the central food service production unit and then distributed to the wards.

In de-centrally plated systems the food is plated either by the nurse the non-buffet or trolley type or by the patient the buffet type.

The centrally plated system seems to be predominant in the European hospitals Appendix 3. There are advantages and disadvantages by both serving systems table 4.

Centralised serving is suitable for use in for example geriatric wards, but not in children's and psychiatric wards. The system involves extensive transport between the wards and the central kitchen before and after every mealtime.

It also means that work on the wards must be organised to coincide with mealtimes. Food will have to be served at specific hours, and if patients happen not to be on the ward at those hours, then other ways of providing food must be found.

As an alternative, kitchen staff will send or employ personnel to assist the ward staff during the serving of meals.

The buffet type of de-central plating makes it easy for the patient to design individual meals. However, the buffet serving systems require kitchen facilities locally at the wards depending on the type of production technology.

Both central and de-central plating require tight logistics and a range of hygienic considerations. Table 4. The portion control is effective.

No extra food is available at the The nutrient content of the food can wards to cover unexpected needs. There is a need for extra personnel The kitchen staff can influence the in the kitchen.

The food is easy to serve for the staff at the ward. There is a possibility for a daily discussion of the food between patient and ward and kitchen staff.

Problems with loss of appetite are easily overlooked. There is a need for extra personnel in the ward with knowledge and time to handle the meals.

Food production Traditional food service systems are based on preparation of the food followed by immediate consumption, also called cook-serve.

However, in most hospital environments immediate serving is not possible due to the spread-all-over nature of most hospital wards.

Therefore, a warm-holding process is required while the food is distributed. All meals are prepared in the central kitchen prior to serving, and therefore induce serious peak hour problems in the food service system.

To overcome this problem some hospitals have introduced cook-chill technology. In cookchill food is prepared and subsequently chilled. After the chilling the food can be held for several days before it is reheated and served.

This technology creates limitations in the types of meals that can be handled. The advantage is that meal shelf life can be increased, and that a buffer of meals can be kept locally in a chilled stock.

However as for cook-serve, cook-chill operations require strict quality management and control of the microbiological risks is essential.

Other production technologies that increase the shelf life and are used in food service systems include cook-freeze, sous-vide and modified atmosphere technologies.

There is a need for a closer co-operation between researchers, authorities and other partners with expertise in food production to track trends in the use of new food production technologies and new ways of operating food service systems.

This trend tracking should enable the authorities and planners of hospital food service systems to view the trends and changes from a hospital undernutrition point of view at an early stage.

This often requires different serving systems. One study examined the temperature profile of the food from time of distribution from the kitchen until the last patient was served on the ward Kelly Food borne illnesses are reported from time to time and can be fatal to hospitalised patients.

Hygiene can be planned and managed, and, therefore, hygiene in food service systems must be an integrated part of the management issue.

The legislation is most commonly based on a selfcontrol concept. Self-control means that the food service management establishes a control scheme based on written instructions, which is approved and audited by food control authorities.

Self-control can, according to the EU directive be based on a guideline for good hygienic practice, for example covering the hospital food service sector.

It is up to the hospital itself to agree on guidelines for good hygienic practice. In some countries the authorities must approve the guidelines.

Since hygiene already is an important management subject matter hygiene can be used to place nutrition on the management agenda.

In order for activities in relation to nutritional issues to become implemented in the hospital organisation management must be involved.

Food service systems can be divided into systems where meals are eaten at the bedside or in bed and systems where meals are eaten in a dining room.

Eating at bedside or in bed seems to be the more common in the European hospitals Appendix 3. Eating in bed can be difficult. If available, the dining rooms in hospitals are often characterised by sparse and standardised decorations.

Studies from long-term care and nursing homes have found that improving the eating environment i. Results obtained among hospitalised children suggest that these findings are probably transferable to hospital settings Kok et al.

However, it should be realised that eating in the company of others in a dining room is not always good for food intake.

One of the questions raised has been whether patients with severe eating problems took small portions to avoid too many failures in the presence of others Sidenvall et al.

The debate led to a change in the production system to centralise portioning, giving the kitchens a larger responsibility for providing food to the patients.

However, centrally plated serving systems have not solved the undernutrition problem. Simply changing a serving system can of course not remove a problem, which might primarily be found in motivation of the patient to eat and in access to food.

Also it is a misperception that the responsibility of the nurses ends with the serving of the food in a centralised portioning system.

Of course the nurses should still observe, note and report the food intake of the patients, and their reactions to the food offered and eaten, and as in de-central plating take necessary actions to combat undernutrition among their patients.

Finally, centralised plated systems make it difficult to provide purpose-cooked meals or frequent snacks, and the disappearance of the ward kitchen has not helped either Silk Today food service is supplied on a tightly budgeted contract, and extra meals require referral to the clinical dietician.

Further, implementation of high hygienic standards has precluded nurses from preparing food in the ward kitchens.

This inflexibility could impede food intake for the fasting patient Garrow In some hospitals in-between meals are available in the wards or from the kitchens, however sometimes they are not offered to the patient Frost et al.

In another study it was found that the hospital food provided only 4. Compared with several nineteenth century hospital menus , and the amount of energy served was about the half.

Despite the low energy content plate wastage was high, and hence the low amount of food served could be seen as an attempt to minimise this waste.

This was probably also a reason why patients postoperatively ordered meals of half a portion size, which would not cover their nutritional needs but would reduce the amount of food they had to leave untouched on the plate Arveby The patients were all routinely offered the general hospital menu with a low fat content and a high volume, with no squint at their problems with loss of appetite and nausea.

Lack of feeding aid To feed an eating-dependent patient properly requires 30 to 45 minutes and time for the labour-intensive task is not available in many hospitals, so often more than one patient is fed at the same time Kerstetter et al.

One study found that the need of more than 25 minutes to consume an adequate meal was highly associated with the presence of undernutrition among institutionalised old people Keller Further, there is a gap between the observations made by the nursing staff and the experiences of the patients.

Hence it is mandatory to obtain information about the dependency of patients regarding feeding and other physical and mental abilities from patients, relatives and primary health care sector.

Besides, relatives are often able to assist the patients at meals. However, some countries have introduced measures to improve the practices in an attempt to prevent undernutrition Appendix 2.

The experienced obtained could be of great value to other countries, and should be made public. Also the majority of European countries have national clinical nutrition societies.

Since a common aim is to improve the nutritional care and support of the patients, the international co-operation between these societies should be expanded.

Children The contents of the above sections are relevant for children as well as for adults. The role of the relatives has proved to be of major importance since most hospitals they are allow them to nurse the child during the hospital stay and this includes the intake of food.

Also, the type of food service has to be taken into consideration since it has a considerable impact on both the nutritional intake and the enjoyment of meals Holm et al.

Topics to consider are listed in table 4. Topics to consider when food service is offered to sick children adapted from Holm et al.

Good social and physical environments for meals e. Possibility of children and relatives to participate in the preparation of meals.

Presence of clinical dieticians or other health care professionals with a specific knowledge about nutrition in children.

Screening of patients to identify those at nutritional risk, monitoring dietary intake, modifying the hospital menus continuously according to patient preferences, and assuring that serving and ambience of serving are focused on the patient with reduced appetite.

However, hospital food has a poor image. A limited food choice, the way it is served, and the lack of help for those unable to feed themselves properly are significant problems with regard to the nutritional care and support of the undernourished vulnerable patients.

The provision of nutritious and appetising food must be recognised at all levels of staff as a key component of an effective high quality hospital treatment.

Hospital menus should provide sufficient choice to offer adequate nutrition for all patients. Focus should be moved away from the production and serving of specific diets on medical indications.

Instead, more attention should be given to the frequent provision of appropriate energy and protein dense meals for the undernourished patients.

The use of ordinary food to prevent or treat undernutrition is cheap and has no complications. Besides, the recipes developed in England to the NHS-menu have a high fat-content.

Both a German 1 In practice this is managed by an increase in the use of butter, cream, fatty meat products and so one, resulting in a high content of saturated fatty acids.

In contrast the protein content has been found to be lower than recommended. In most countries a menu rich in energy and protein is available, but according to studies from Sweden Arveby and Germany Hermann et al.

Why an energy dense menu? Different macronutrients do not affect satiety to the same degree. Per unit of energy protein and carbohydrates suppress appetite, and, hence, energy intake to a greater extent than fat.

The argument for a higher fat content in the general menu has been that meals with high energy density would be easier to eat for patients with reduced appetite.

A low dietary fat content decreases energy intake Frost et al. Focus is consequently directed towards the intake of energy instead of the intake of protein.

This does not mean that the intake of protein is unimportant. In the up till now randomised controlled trials of the effect of nutritional support, the patients have received a mixture of nutrients, and hence it is impossible to know whether it is energy, protein or specific micronutrients which have resulted in the beneficial effects observed.

Specifically, in a study of old people suffering from a hip fracture, protein was found to be of importance for the recovery Tkatch et al.

Different opinions exist with regard to the satiety of different macronutrients Stubbs et al. Cultural and personal factors also have a role to play.

Hence, the main point should not be the fat content of the served meals, but rather that the patient can find something attractive on the menu to eat.

An example of this is the NHS-menu, in which the planners deliberately have avoided providing nutritional specifications since their main purpose have been to get dishes, which look good, taste good and smell good and since a nutritional specification is immaterial if a dish is not eaten R.

Wilson, personal communication. Many of the non-scientific diets have also been discarded in the Danish and Swedish recommendations1.

From publications reviewing the relevance of these, the conclusion is that many of them lack scientific documentation. If dietary restrictions are instituted for medical reasons, the indications should be well grounded Coulston et al.

The abolition of these needless restrictive diets is important, because their long-term use can cause undernutrition Buckler et al.

These alternative diets often restrict the use of certain foods, e. No scientific data supports the benefit of such diets e.

In contrast to both Germany and Denmark most of the remaining diets on medical indications in the Swedish recommendations take their origin from and are similar to the food recommended to the healthy population ESS A comparison of the types of diets recommended in these 3 countries is shown in table 5.

Comparison of types of diets on medical indications recommended in, respectively, Denmark, Sweden and Germany selected Kluthe et al.

Guidelines for diets on medical indications should be reassessed regularly. In general, very few patients need specific diets on medical indications during hospitalisation, and much time and money are spent on producing a variety of different diets to these patients.

Micronutrient content Vitamin losses can be substantial, depending on the handling practices and processing techniques of hospital food.

It is of nutritional interest to get a high retention of vitamins during processing. Still, the measured values were higher than the recommended values, despite a relatively high fat content Lassen , Schauder et al.

It should therefore be considered, whether some patients e. Besides, specific micronutrients may play a role in e. On the other hand supplementation with specific micronutrients might also have adverse effects Braunschweig et al.

Taste of food Sensory sensations are primary enforcers of eating. It has not been firmly established if undernutrition in itself affects taste and smell.

However, several diseases are known to be associated with disturbances of taste and smell, such as cancer, renal failure and liver 71 disease.

Also, drugs and other treatments can alter taste and smell, e. It is important to be aware of sensory disturbances in sick people and modify menus accordingly.

Perception of foods is highly individual. To maintain a quality level that most people find satisfactory requires the establishment and operation of a quality management system.

This system should include methods for: 1 Routine intra-kitchen quality supervision. The methods are described in the literature on quality management systems.

There can be long gaps between some meals, e. Also, there is often interference with meal times by ward rounds and diagnostic procedures Allison No data of the use of fortified meals, energy and protein dense snacks and drinks are available from the European countries.

Food brought from outside the hospital can increase the total amount eaten by patients Frost et al. However, e. This dilemma should be dealt with.

In-between meals Availability of in-between meals seems to increase total food consumption. In one study it was found that offering patients a choice of cake or one quarter cheese sandwich at mid-afternoon and bedtime increased total energy intake Gall et al.

Many of the nutritional support studies performed up till now have examined the effect of sip feedings on nutritional state and clinical outcome Potter et al.

The overall solid food intake does not seem to be altered by sip feedings, and even an increase in main meal intake was reported after gastro-intestinal surgery Rana et al.

Also, the compliance is usually high with these supplements Hessov , Green Even low levels of intake from sip feedings can significantly increase the total energy intake Lawson et al.

These findings together with the observed positive effect on energy intake of in-between meals support the recommendations of a more frequent meal pattern than is available at present.

The influences of sip feedings on the overall energy intake Reference Patients Delmi et al. Energy intake before start of the nutritional support with, respectively, energy dense and standard concentration sip feedings.

Two large surveys from the United Kingdom found that the data about the nutritional status of the patients receiving sip feedings was limited and so was the documentation as to why they received the oral supplements Brosnan et al.

In general it is important that the use of sip feedings is targeted and supervised properly Allison It is therefore essential to observe the food 74 intake of the patients.

In this respect the semi-quantitative system, i. This method can also be used to assess nutritional risk see table 2.

When a patient is diagnosed to be at risk nutritional support should be initiated and the food intake should be supervised more closely.

It is also important to learn, largely by trial and error, which types of food different patient categories can tolerate in order to determine appropriate, target group specific menus Kondrup Training in how to monitor food intake seems to be a key element in improving dietary intake Kondrup et al.

In practice food intake is infrequently recorded in the European hospitals see Appendix 2. Why not their food intake?

Before even tasting it patients often expect poor quality Holmes , and after tasting it their expectation is many times confirmed.

Yet few patients are aware of the fact that a weight loss in relation to disease will increase their risk of complications. In Denmark much emphasis has been put on information regarding the discrepancy between optimal foods in relation to, respectively health i.

It is known that in-between meals is infrequently offered by the staff or asked for by the patients, even when available Frost et al.

Some patients might even opt for sip feedings, which they apparently find more convenient Schwenk et al. Also, the influence of the individual factors such as age, nutritional status, mood, appetite or oral health are able to inflict on satisfaction with the quality of food service, and thus to modify food intake and nutritional status Rigaud et al.

One major common problem among the European hospitals is the lack of influence of the patients see also Appendix 4. This is in spite of the evidence that food consumption can be improved without a change of menu, if patients are involved in planning their meals, have some control over food selection and feel responsible for following given advice Holmes Menu choice In most hospitals the patients have a choice between menus, and in some hospitals questionnaires to gauge satisfaction are used Appendix 3.

A choice of menus is not necessarily beneficial if, for example, undernourished patients choose food from the low nutrient density healthy eating option.

As can be seen from Appendix 3. Assistance with menu choice is imperative to prevent patients from choosing foods, which are inadvisable with respect to their clinical condition McGlone et al.

Also, there is seldom a good description of the offered menus. Finally, a menu often has to be ordered the day in advance, and a change in the medical condition of the patient may make foods chosen 24 hours before unsuitable McGlone et al.

Yet another barrier could be the attitude of the patients, highlighted in a Swedish study of geriatric patients, who did not want to participate in the decision-making regarding their own menu, rather it was up to those who worked in the kitchen to decide Sidenvall et al.

The information given may not be understood, and also particular methods of food preparation and eating practices may be extremely important Holmes , McGlone et al.

Meal ambience To have a meal differs essentially from the mere intake of food. People do not eat only to stay alive since meals also have a social, psychological and religious meaning.

The satisfaction people feel at mealtime depends not only on the quality and quantity of the food, but also on the social context in which the meal is eaten, and the extent to which a meal is attuned to personal eating habits and to the prevailing circumstances Gastmans However, most importantly, is the food culture among staff members of the hospital.

Since lack of appetite due to the disease is probably the main reason for hospital undernutrition the ambience, with its element of informing the patient, preparing the patient, motivating the patient, urging or feeding the patient, and other aspects of doing and showing care are essential in relation to the food chain Kondrup A patient served with respect, feels respectable.

In many cases attentive mealtime-care can postpone the use of artificial nutritional support Gastmans However, in the majority of the European countries the ward staff today lacks interest in this field see Appendix 2.

Children Most hospitals have special menus for children. However, since it often has to be ordered in advance it is probably seldom used.

Instead the relatives often cook for the children at home and bring the food to the hospital Holm et al.

Only in some paediatric wards kitchens are available for relatives to prepare the food the child likes best.

The provision of meals has to be more frequent and more flexible than at adult wards, since children eat more frequent and will often not eat at scheduled times Michaelsen Snacks with a high energy density, including items that are often regarded as unhealthy, e.

The reasons for hospitalisation of children can be different from adults and often metabolic disorders or allergic reactions to food bring children to hospitals.

Therefore there should be a provision of diets on medical indications, which could fit the strict requirements of such diseases.

Evidence shows that nutritional support of undernourished patients improves recovery rates, decreases complications, and reduces length of stay and cost per day and in total.

Hence improved or expanded nutrition services can actually help cut hospital costs or increase revenue.

Studies of hospital food wastage show high level of waste. There are many factors involved in determining how much food is wasted.

In general waste represents a major clinical problem because it reflects inadequate food intake. It is also a major economic problem.

Disease-related undernutrition is associated with increased prevalence of complications and a prolonged length of stay, and, therefore, higher costs Shulkin et al.

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