espen congress lisbon 2015 malnutrition in … · personalized approach to food in hospital:...
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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
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Personalized approach to food
in hospital:
nutritional paradise or economic disaster?
Nicole M. de Roos, PhD
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Malnutrition in hospitals is not surprising
... but many cases can be
prevented
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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
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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)
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Decision: At Your Request by Sodexo
Patients choose:
What they eat
When they eat
Where they eat
With whom they eat
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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
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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
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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?
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Study design
Prospective study
Two groups of patients,
2 years apart Completed
participation
Subgroup
En+Pro+ diet
competed
food lists
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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
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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
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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
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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
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Patient satisfaction in a score
7.5
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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
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Food intake
Food ordering data
Food lists for
patients requiring
energy & protein
enriched diet
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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)
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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)
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Nutritional status is maintained, but
WHAT do patients eat when they have free
choice?
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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”
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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 |
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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)
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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
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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
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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