Malnutrition in Acute Care Patients: What is the Role for Food Service?

While we often think of malnutrition as being a problem more associated with the developing world, it has become increasingly apparent that malnutrition is an issue that is also prevalent much closer to home. In Canada, approximately 69% of patients are at least moderately malnourished upon admission to hospital [1). Moreover, few are appropriately screened and diagnosed, and as guidelines for treating malnourished patients are not well-defined, many patients are not adequately treated. Recently, this issue has garnered interest within the research community, with groups such as the Canadian Malnutrition Task Force advocating for clearer guidelines and an interdisciplinary approach to identification and treatment [2].

The high prevalence of malnutrition observed in Canadian hospitals is due to a variety of factors, including inadequate dietary intake, increased nutrient needs due to illness, and nutrient malabsorption and losses. This leads to exceedingly high costs, both for the patient, and the Canadian health care system. Of detriment to the patient, malnutrition prevents healing, increases risk of infection and pressure sores, causes a loss of fat and muscle, reduces cardiovascular and respiratory functioning, and is associated with increased risk of depression. Combined, these issues can lead to increased length of hospital stay, complications, and increased mortality rates [3].

For the acute care facility, malnutrition also has major implications. Increased complexity of patients leads to greater time spent on nursing care. Complications such as pressure ulcers, infections, and poor wound healing require greater time and resources, as do patients who are weaker and less independent than their well-nourished counterparts. Length of stay amongst patients with malnutrition may be up to five days longer than those with adequate nutritional status, again, using extra time and financial resources [3]. It is therefore beneficial from both a patient care and organizational standpoint to effectively identify and manage malnutrition. This starts with identifying what barriers patients must overcome to achieve adequate food intake.

Acute care patients encounter many barriers to consuming enough food while in hospital. While many of these barriers are related to illness and fatigue, other factors related to organizational food systems and the food itself can also play a role in insufficient intake. In a 2015 survey completed by Keller and colleagues, patients identified being absent from their room over mealtime, and not being given food upon their return (69.2%) as the primary barrier to food intake [4]. Other commonly cited barriers applicable to food service include:

  • Not wanting to eat the food that was ordered (58.0%)
  • Feeling that there was not enough information about choices on the menu to make a selection (36.9%)
  • Difficulties with opening packets on tray or unwrapping food (30.1%)
  • Unappealing taste of food (28.8%)
  • Not receiving the food that was ordered (27.6%)
  • Becoming hungry between meals (24.4%)
  • Not being able to choose foods they prefer (23.3)
  • Undesirable temperature of food (21.0%)

So what can food service do to overcome these barriers and help combat malnutrition in acute care facilities? To put it simply, we need to take a more patient-centered approach to how we prepare, serve, and deliver meals. Below are examples of patient-centered practices that can improve dietary intake, outlined by the Canadian Malnutrition Task Force [5].

  • Becoming more quick and efficient at implementing diet order changes.
  • Ensuring a variety of food options are available on the menu, representing different diets and cultures.
  • Having meals available, at the correct temperature, when patients are ready to consume them. Hot food should be hot, and cold food should be cold.
  • Food should be accessible between meals and in the evenings. This could involve implementation of a snack and beverage cart.
  • Trays themselves should be attractive in appearance, with food plated in an appealing manner.
  • Monitoring intake during tray collection.
  • Creation of a volunteer program, where volunteers can sit with patients during meals.

The issue of malnutrition in acute care is not easily solved, and it takes an interdisciplinary team, including dietitians, nurses, and speech pathologists, to work together on ensuring that at-risk patients are properly identified and treated. As the source of patient meals, it is also up to food service to work as part of that team, and work towards promoting the best possible health outcomes for patients.