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