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ESPEN Congress Lisbon 2015
Personalized approach to food in hospital:
nutritional paradise or economic disaster? N. de Roos (NL)
MALNUTRITION IN HOSPITAL PATIENTS
WITH INSIGHTS FROM ND RESULTS
Personalized approach to food
in hospital:
nutritional paradise or economic disaster?
Nicole M. de Roos, PhD
Malnutrition in hospitals is not surprising
... but many cases can be
prevented
Strategies to reduce malnutrition
in hospitals
Awareness, Screening
Quality and temperature of the food
Assortment
● Familiar foods
● Portion size options
Logistics
● Availability of food
● Help with eating
Demands on new meal system hospital
Gelderse Vallei Ede
Kitchen staff: Preparation, time, presentation
Patient: Taste, freshness, easy ordering, flexibility, eating with visitors, ‘home’ feel
Facility Manager: Cost (neutral), patient
satisfaction
Dietitian: Adequate nutrition, disease prevention,
easy inclusion of therapeutic diets,
better intake (less malnutrition)
Decision: At Your Request by Sodexo
Patients choose:
What they eat
When they eat
Where they eat
With whom they eat
How food is ordered in AYR
Patient chooses from
menu and calls
Service Center
Kitchen receives order Tray is delivered
within 45 mins
Tray is prepared
Flexibility in meal times shows
Patients order throughout the day, with 3 peaks
Patients order >3 times per day
Hot and cold (sandwiches) meals both at lunch time and
evening
Num
ber
of ord
ers
Effect evaluation: involvement of nutrition
researchers Wageningen UR
Research question:
What is the effect of implementing AYR on
patient satisfaction, nutritional status, and
food choice?
Practical questions:
Is food waste reduced?
What are the costs?
Study design
Prospective study
Two groups of patients,
2 years apart Completed
participation
Subgroup
En+Pro+ diet
competed
food lists
Outcomes Patient satisfaction
• Questionnaire
• Score
Nutritional status
• MUST (based on BMI, weight↓, intake↓) • ∆ Bodyweight • ∆ Hand grip strength
• Intake: Food records for patients on En+P+ diet; Food orders for AYR
Food choice
• Food orders (AYR) on day 4
Methods: wards and selection of patients
Wards:
• Cardiology
• Geriatrics
• Oncology
• Surgery
• Neurology
• Acute admission
Criteria:
• No tube feeding
• Dutch language
• Expected admission time ≥ 4 d
• Age ≥ 18 years
Baseline characteristics in both periods
Traditional meal
service n=168
At Your Request®
n=169
% Men 52% 46%
Age (y) 63 66
Bedridden 24% 24%
Weight (kg) 84 78
BMI (kg/m2) 28.0 ± 6.1 26.9 ± 6.2
MUST score ≥1 22% 28%
Length of stay (d)* 8.9 7.3
Surgery* 42% 26%
* Significant difference (p<0,05) between periods
Patient satisfaction using a nutrition-
related quality of life questionnaire
Developed by students of Wageningen UR
27 questions, 6 points per question (max score 162)
Example: “I find the choice in vegetable options adequate” with six answers ranging from “Totally disagree” to “Totally agree”
Results: score 124.5 Traditional Meal service
score 132.9 At Your Request
More choice, better service, better presentation
Patient satisfaction in a score
7.5
Nutritional status:
MUST, weight, hand grip strength
MUST score improved during stay
Body weight -0.2±2.7 kg (ns)
Hand grip strength starts at 30.2 kg, drops at day 4 (2.7 kg vs 0.7 kg) but returns to baseline values in both groups
Food intake
Food ordering data
Food lists for
patients requiring
energy & protein
enriched diet
Provided amount of protein in g/kg
bodyweight in MUST risk groups ( AYR)
0
10
20
30
40
50
60
MUST 0 MUST 1 MUST ≥2
Parti
cip
an
ts (
%)
<0.8 g/kg BW
0.8-1.2 g/kg BW
1.2-1.5 g/kg BW
>1.5 g/kg BW
Amount of protein
0.9 g/kg 1.0 g/kg
1.1 g/kg
(No risk, n=122) (Risk, n=16) (Severe risk, n=31)
AYR slightly better in helping patients with En+Pro+
diet to meet 1,2 g/kg/d protein recommendation
( food lists, subgroup)
30% meets recommendation
26% meets recommendation
Protein recommendation (g/d) Protein recommendation (g/d)
Pro
tein
inta
ke
(g
/d)
Pro
tein
inta
ke
(g
/d)
Nutritional status is maintained, but
WHAT do patients eat when they have free
choice?
0 100 200 300 400 500 600 700
Dairy products
Fruits
Vegetables
Ordered Recommended
g/d
During AYR: patients make mostly prudent
food choices, but room for improvement
Bread
1. Brown bread
2. Whole wheat
3. Whole wheat husk
In-between-meals
1. Fresh fruit salad
2. Boiled egg
3. Croissant
4. “Kroket”
How about food waste?
Data from 7 consecutive days
Total food waste from 134 kg to 98 kg per day
54% less food returned to kitchen
Result: increase in the amount of served food
Food Hospitality | Aug 2013 |
Costs comparable to
traditional meal service
For food costs in this hospital:
● 500 bed hospital, about 300 patients using AYR ~ € 800.000 per year
● Costs per patient per day ~ € 7,50
Introduction costs may be higher depending on kitchen infrastructure, training of personnel, etc
AYR can be tailored (service times, assortment)
Conclusions about At Your Request
• Patients are more satisfied
• No measurable effect on nutritional status during (brief)
hospital stay
• Protein intake may be further improved, especially in
patients not at risk for malnutrition
Further possibilities of this meal concept
‘Nudging’ by call center staff towards healthy choices
Monitoring of intake (records of food returned, tube feeding, foods from outside)
Signal function: intake throughout the day
Research:
● Effect of changes in assortment: e.g. more protein-rich foods and drinks on menu card
Acknowledgements
Yvonne van Gameren, ZGV
Emmelyne Vasse, ZGV
Astrid Doorduijn, MSc WUR
Angelique Honderdors, ZGV
Dietitians Hospital Gelderse Vallei
Willem van Zeben, Sodexo
Students
Participating patients