Personalized approach to food in hospital: nutritional paradise or economic disaster? - Cater with Care

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

                                     Dietitian:
                            Adequate nutrition,
                            disease prevention,
Patient:                       easy inclusion of
Taste, freshness, easy        therapeutic diets,
ordering, flexibility,       better intake (less
eating with visitors,             malnutrition)
‘home’ feel

                           Facility Manager:
Kitchen staff:            Cost (neutral), patient
Preparation, time,                   satisfaction
presentation

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   Kitchen receives order   Tray is delivered
menu and calls         Tray is prepared         within 45 mins
Service Center

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
           Number of orders

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    At Your Request®
                                  service n=168           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

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)
                   60
                                    Mean intake in MUST groups
                   50                                        1.1 g/kg
                         0.9 g/kg           1.0 g/kg
Participants (%)

                   40
                                                                                 1.5 g/kg BW

                   10

                    0
                           MUST 0            MUST 1              MUST ≥2
                        (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
(   based on food lists, >1 days per patient possible)

                           26%                                                      30%

                                                             Protein intake (g/d)
    Protein intake (g/d)

                           meets                                                    meets
                           recommendation                                           recommendation

                              Protein recommendation (g/d)                             Protein recommendation (g/d)
                                (Recommendation based on ideal bodyweight at BMI 27 kg/m2)

Nutritional status is maintained, but
WHAT do patients eat when they have free
                 choice?

During AYR: patients make mostly prudent
food choices, but room for improvement
   Bread                                      In-between-meals
   1. Brown bread                             1. Fresh fruit salad
   2. Whole wheat                             2. Boiled egg
   3. Whole wheat husk                        3. Croissant
                                              4. “Kroket”
   Vegetables

        Fruits

Dairy products

                 0   100   200    300   400    500   600   700 g/d

                     Ordered     Recommended

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