Food for thought

Patients benefit from proper nourishment throughout their illness, and medical students and doctors should be properly trained in nutrition. Keri-Michèle Lodge investigates why the standard of hospital food still has a long way to go, and why medical school curriculums are not covering nutrition effectively

mark thomas/spl

"When dad was in hospital, he would not eat the meals, and was surviving on biscuits. I did not understand how he could recover from his illness if he was not eating well,” Anne Lockwood says. She is correct in her concern. Poorly nourished patients take longer to recover from illness or surgery. Sumantra Ray, a clinical research fellow in nutrition, stroke, and cardiovascular disease and an honorary clinical teacher at Ninewells Hospital in Dundee, Scotland, and his colleagues explain, “Surgery and disease create a metabolic stress within the body, and requirements for protein, glucose, zinc, and selenium increase.”

“Good nutrition is key to good health and recovery,” according to Helen Andrews, chief dietician at St Luke’s Hospital in Bradford. Indeed, in France, the Comité de Liaison Alimentation Nutrition, which consists of doctors, nurses, catering staff, dieticians, and patients, has declared that food should be considered a medical treatment. Yet, a recent Council of Europe report highlighted an “unacceptable number of undernourished hospital patients in Europe.”¹ And 60% of patients admitted to UK hospitals are malnourished.² “The number of patients who become increasingly malnourished during their hospital stay is worrying,” Helen Andrews says.

Undernutrition is a state of nutrition in which deficiency of energy or protein or other nutrients causes measurable adverse effects on tissue or body form, composition, function, or clinical outcome.² The effects of undernutrition include impaired immune responses, delayed wound healing, decreased muscle strength, slower recovery from illness and surgery, extended hospital stays, diminished quality of life, and unnecessary costs to health care.¹

Any patient who is ill or undergoing surgery is at risk of undernutrition. But levels are particularly high in older people and in patients with gastrointestinal problems, dysphagia, anorexia nervosa, alcoholism, long term psychosocial problems, and cancer.

Identifying patients who are undernourished is vital. Hospitals in Coventry use a nutritional assessment screening tool to score a patient’s risk of undernutrition on the basis of parameters that include the ability to chew and swallow, recent weight loss, and the presence of nausea and vomiting. Patients at high risk are given written action plans for staff to follow to improve their nutritional status, and screening is repeated at regular intervals. This type of screening is now mandatory in Scottish hospitals, but in England, Wales, and many other countries, screening is not obligatory, making identification of undernourished patients haphazard. Box 1 shows four key questions that should be used to identify patients at risk of malnutrition. Patients at risk are those with unintentional weight loss of more than 10% or with a body mass index of 18.5 kg/m2 or less.²

The National Institute for Health and Clinical Excellence also recommends screening of patients in care homes to identify malnourished patients in the community.
 

Food glorious food?

“Hospital is a stressful place, people are unwell, so appetites are often poor,” says Helen Andrews. “The need to provide appetising and well balanced, nutritional meals and menu choices to meet all dietary needs is paramount.” But patients are not always complimentary about hospital food. “My husband tells me his hospital meals are always overcooked, cold, and tasteless,” Danielle Jameson says.

In 2001, leading UK chefs and dieticians collaborated to create meals for an NHS menu in a bid to improve the quality of hospital food, under the government’s better hospital food initiative.³ There are seven types of NHS menu, and UK hospitals are beginning to incorporate meals from these into their menus. As well as the main NHS menu, there is a therapeutic one for patients on cholesterol reducing or high fibre diets, and an easy chew menu for patients who have difficulties chewing and swallowing. Providing appetising meals for such patients is challenging. A typical meal is a thick brown soup resulting from liquidising a normal hospital meal. Dietitians at Harrogate District Hospital, working with speech and language therapists and hospital caterers, have created a more appealing option. Hospital meal components are pureed separately, then placed into specific moulds, so that the pureed food closely resembles its original form in terms of shape and colour.⁴

The NHS cultural menu caters for the food preferences of patients from various cultural backgrounds. Similarly, at the Royal Darwin Hospital in Australia, a bushtucker person has been employed, whose role is to gather and prepare food (“tucker”) from the Australian bush using traditional Aboriginal techniques, providing culturally appropriate food for Aboriginal patients.⁵

Other hospitals are improving meals in different ways. Four London hospitals are working with Sustain, a UK based alliance for better food and farming, to increase the proportion of local or organic food to 10% of the total catering provision of hospitals, supporting the UK government’s sustainable development agenda.⁶ The goal of this agenda is “to enable all people throughout the world to satisfy their basic needs and enjoy a better quality of life, without compromising the quality of life of future generations.”⁷

But UK doctors say that more action is needed to improve hospital food. In particular, Ray and colleagues say, “Healthier choices should be promoted.” And at the BMA’s junior doctors’ conference in 2005, doctors called on Jamie Oliver, a UK celebrity chef who has already helped overhaul school meals, to reform hospital meals.

Hospital meals compared

In the UK, £550m ($954m; €814m) is spent on providing 300 million NHS hospital meals each year, with less than £2 spent on hospital meals per patient per day.⁸ UK patients make their day’s meal choices each morning, whereas patients in the Netherlands choose meals one meal in advance. According to Andrew Isaac, marketing director at Sodexho Healthcare Services, €6-€7 are spent on food per patient per day in the Netherlands, compared with €4-€5 in German hospitals, and €3-€5 in French public hospitals. A typical day’s menu for patients in UK hospitals, French public hospitals, and the Sheri Maharaja Hari Singh Hospital in Kashmir, are compared in Box 2.

Nil by mouth?

Although the ingredients and choice of meals in UK hospitals are improving, Alison McCree, chairman of the UK Hospital Caterers’ Association, says, “Good quality food is no good to anyone unless it actually gets into the mouths and stomachs of patients.”⁹ Some patients require physical help, such as assistance with cutting food, or provision of modified cutlery. Others simply need encouragement. Helen Andrews says, “We are using a ‘red’ tray system in elderly care to highlight patients whose intakes are poor to make sure staff are aware of the need to encourage that patient to eat.” Monitoring food intake and body weight in such patients is important.

A calm, peaceful, and clean environment is conducive to eating, but patients often eat their meals in their hospital bed. Anne Lockwood suggests, “There should be ward dining rooms, where patients could sit and eat their meals together, which would improve the mealtime experience, and might make patients feel more like eating.” And how many times have you or your colleagues interrupted a patient in the middle of their meal? To tackle this kind of problem, UK hospitals have introduced protected mealtimes, where patients’ visitors are barred from the wards during mealtimes. At the Hull and East Yorkshire Eye Hospital, doctors are included in this ban, and are urged not to interrupt patients during mealtimes for non-urgent matters.

Sometimes, provision of food and drink is unsafe, inadequate, or impractical. Nutritional support using high protein drinks, enteral tube feeding, or parenteral nutrition might be needed instead. But knowledge of effective and safe routes for nutritional support in UK health professionals is poor. Consequently, the National Institute for Health and Clinical Excellence has published guidelines on nutrition support.¹⁰

Refeeding syndrome

Ray and colleagues say that caution is needed because suddenly loading starved patients with calories can result in refeeding syndrome. During starvation, reduced carbohydrate intake results in decreased insulin secretion, with fat and protein catabolism. The switch to carbohydrate metabolism upon refeeding causes a surge of insulin release, leading to stimulation of cell pumps and rapid uptake of electrolytes. Serum concentrations of phosphate, glucose, magnesium, and potassium plummet.¹¹ For as yet unexplained reasons, fluid balance disturbance can also occur, resulting in fluid retention and refeeding oedema. These changes can increase cardiac workload and precipitate cardiac failure. Other clinical features of refeeding syndrome include respiratory failure, arrhythmias, seizures, coma, and sudden death.¹¹. To prevent this, when starved patients begin to eat again, they must “Start low, go slow,” says Kerri Webb, a junior doctor from Ninewells Hospital. Doctors should monitor blood glucose and ­electro­lytes carefully, replacing electro­lytes and giving supplements of vitamins, such as thiamine, as ­necessary.

Education

Although Ray and colleagues say, “Education is the key to good practice,” little emphasis is placed on nutrition in UK undergraduate medicine courses. Medical students, doctors, nurses, healthcare assistants, dieticians, caterers, pharmacists, occupational therapists, and hospital managers need training on the importance of good patient nutrition and how to work together to achieve this. The UK’s National Nutrition Task Force has developed a core curriculum setting national standards on nutrition training for health professionals. Encouragingly, Ray and colleagues say, “All UK medical schools have now accepted this undergraduate curriculum.” By learning how to optimise patients’ nutritional status, we can help give every patient the best possible chance of recovery and good health.

We thank S Ray, P Rana, LK Raj, M Rajput, and MA Haleem at Ninewells Hospital; SM Kadri and W Quereshi for information on hospital meals in Kashmir; Hazel Green at the Hospital Caterers’ Association, and Helen Andrews.

Patients names have been changed.