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LEADING ARTICLE

Proper hospital nutrition as a human right

Jens Kondrupa,b

aNutrition Unit 5711, Rigshospitalet, 2100 Copenhagen, DenmarkbDepartment of Human Nutrition, Royal Veterinary and Agricultural University, Frederiksbery, Denmark

ESPEN is strongly encouraging the national societiesto implement the resolution on Food and Nutri-tional Care in Hospitals, as adopted by theCommittee of Ministers of the Council of Europein November 2003.1 The Committee of Ministers isthe decision-making body of the Council, consistingof the foreign ministers of the member countries,or their ambassadors. The main aims of the Councilare to reinforce democracy, human rights and therule of law and to develop common responses topolitical, social, cultural and legal challenges,based on the Declaration of Human Rights from1948. The Council of Europe also hosts theEuropean Court of Human Rights in which casesconcerning human rights can be raised against astate by individuals, associations or other contract-ing states.

This particular resolution was accepted by the 18member states of the Partial Agreement in theSocial and Public Health Field, i.e. Australia,Belgium, Cyprus, Denmark, Finland, France, Ger-many, Ireland, Italy, Luxembourg, the Netherlands,Norway, Portugal, Slovenia, Spain, Sweden, Swit-zerland and the United Kingdom.

The introduction to the resolution outlines thebackground for the initiative: (a) access to a safeand healthy variety of food is a fundamental humanright, (b) proper food service and nutritional care inhospitals has beneficial effects on the recovery ofpatients and their quality of life, (c) the number ofundernourished hospital patients in Europe isunacceptable and (d) undernutrition among hospi-tal patients leads to extended hospital stays,prolonged rehabilitation, diminished quality of lifeand unnecessary costs to health care.

Therefore this resolution recommends to thegovernments of the member states to (a) draw up

and implement national recommendations on foodand nutritional care in hospitals based on theprinciples and measures set out in the appendix tothis resolution (see below), (b) promote theimplementation and take steps towards the appli-cation of the principles and measures contained inthe appendix, in fields where these are not thedirect responsibility of governments but wherepublic authorities have a certain power and (c)ensure the widest possible dissemination of thisresolution among all parties concerned, particu-larly public authorities, hospital staff, primaryhealth care sector, patients, researchers and non-governmental organisations active in this field.

The appendix to the resolution consists of some100 specific recommendations in a number ofcategories: nutritional assessment and treatment,responsibility and education of staff, hospital foodand food service practices and health economics. Ineach category, the role of the level of government/health authority versus the level of hospital/department/patient is specified. The recommenda-tions were proposed by a large European expertgroup, based upon the information gathered fromhealth authorities of all member states in a reportwhich preceded the resolution.2

Some of the key recommendations at the level ofgovernment/health authority are: (1) Standards ofpractice for assessing and monitoring nutritionalrisk should be developed. (2) The definition ofdisease-related undernutrition should be univer-sally accepted and used as a clinical diagnosis andhence treated as such. (3) Good practice to ensurethe intake of ordinary food by the patients shouldbe documented. (4) Standards of practice forinitiation, monitoring and termination of all artifi-cial nutritional support should be developed. (5)

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Clinical Nutrition (2004) 23, 135–137

The authorities’ responsibility with regard tonutritional care and support, and food servicesystems, should be acknowledged. (6) Nutritionalrisk screening, assessment and monitoring shouldbe included in the accreditation standards forhospitals. (7) A continuous postgraduate educationprogramme for all staff should be implemented.Clinical nutrition should be recognised as a specia-lised discipline by medical schools. Clinical nutri-tion should be included or improved in theeducation of physicians and nurses. The educationof dieticians should be set at the highest under-graduate level. (8) National guidelines and stan-dards for food provision in hospitals should beestablished. Food service contracts should besufficiently detailed and they should cover specialdiets on medical and personal indications, energyand protein dense menus and provision of snacksand/or meals at ward or near-ward level. TheClinical Nutrition Service should be given theresponsibility for ensuring that the contract reflectsnutritional standards.

These key recommendations will help the level ofgovernment/health authority to evaluate the ade-quacy of nutrition activities in individual hospitalsand also help the authorities to evaluate unfortu-nate individual cases. It is quite obvious that futurestudents of medicine, nursing or dietetics need tobe educated in this area but since universities andnursing schools are moving very slowly in thisdirection, it is a clear responsibility for theauthorities to draw the attention to the fact thatthese are required competencies of the medicalstaff in the future.

Key recommendations at the level of hospital/department/patient are: (1) The nutritional risk ofall patients should be routinely assessed eitherprior to or at admission. This assessment should berepeated regularly during hospital stay. (2) Identi-fication of a patient at nutritional risk should befollowed by a treatment plan including dietarygoals, monitoring of food intake and body weight,and adjustment of treatment plan. (3) The foodintake of patients at nutritional risk and receivingnutritional support should be registered by meansof dietary records. (4) ‘‘Nil-by-mouth’’ regimes,overnight fasting and bowel-cleansing protocolswith dietary restrictions should not be usedroutinely; the literature should be reviewed inorder to assess which procedures may require suchregimes. (5) Medical and nursing patient recordsshould contain information about each patient’snutritional status. (6) Physicians, pharmacists,nurses, dieticians and food service staff shouldwork together in providing nutritional care, whilethe hospital management should give due attention

to such co-operation. The responsibility of differ-ent staff categories with respect to nutritional careand support, and food service should be clearlyassigned. (7) Immediate feedback from the pa-tients to the kitchen and ward staff in relation toliking or disliking of the food served should beencouraged. (8) Snacks and nourishing drinksbetween meals should be available and be offeredon every ward. (9) Hospital managers should takeinto account the potential cost of complicationsand prolonged hospital stay due to undernutritionwhen assessing the cost of nutritional care andsupport. Steps should be taken to reduce docu-mented wastage of food and artificial nutritionproducts.

These key recommendations will assist thehospitals and departments in establishing the mainsteps of providing nutrition support. Their success-ful implementation has the potential of improvingthe efficiency of the hospital service by reducinglength of stay and rate of complications, orseverity/cost of complications. In addition, it willmake the patient comfortable to see that basicneeds are taken care off and thereby reduce thelikelihood of complaints over unfortunate nutri-tional events. To some doctors, the specificrecommendations may be seen as overlapping withthe traditional right of ‘‘Doctor’s order’’ but itshould be remembered that the resolution is basedon a Human Rights concept. Also within nutritionshould the Doctor’s order be compatible with this.

ESPEN has given a high priority to this area.Screening methods to be used in the community, inhospitals and among the elderly were recentlyendorsed by ESPEN.3 In recent years, ClinicalNutrition has published a number of papersproviding insight to these problems and theirpossible solution. A study describing all patientspresent in the hospital found that 70% of thepatients did not reach a reasonable recommendedintake. In most cases, this was not related to thedisease or treatment but rather to inadequate mealservice e.g. lack of choices and/or inadequatetaste.4 A study reported that about 25% of a randomsample of hospital patients from various units atenothing or very little in the hospital, and that alarge part of those who had no appetite alsoconsidered food in hospital to be only moderatelyimportant, pointing to the role of patient educa-tion.5 Other studies have shown that a patient-oriented improvement in hospital food increasedintake and decreased wastage6,7 while a broad non-obligatory staff training did not.8 A study ofnutritionally at-risk patients during their entirehospital stay suggested that the main causes forinadequate nutritional care were the lack of

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136 J. Kondrup

management’s instructions to deal with the pro-blems, the lack of elementary knowledge withrespect to dietary requirements and ignoranceabout practical aspects of the hospital’s foodservice, while patient-related aspects and thesystem of food service itself only contributed to asmall degree.9 It seems obvious that the problemsto be dealt with, and their solution, will vary fromone patient category to the other. Therefore, therecommendations given in the appendix to theresolution is useful as a check-list when improve-ments are being prepared.

Finally, recommendations for future research anddevelopment is recognised as a third level in theappendix. The resolution is based on today’sknowledge which is seen as sufficient to act, butit is also realised that much more work is requiredto optimise the effort. Key areas of future researchare: (1) Studies should be undertaken to developand validate simple screening methods, aimed foruse in hospitals and primary health care sector. (2)Randomised trials and systematic reviews should beperformed to evaluate the effect of nutritionalsupport on clinical outcome, including physical andmental condition. In particular, randomised trialsevaluating the effect of ordinary food on clinicaloutcome should be given high priority. (3) Studiesshould be undertaken to evaluate the effect ofenergy and protein dense menus on food intake andpatient outcome. These topics also relate to theprimary cause of undernutrition in hospitals: thedisease processes leading to increased, or changed,

nutritional requirements and at the same timeleading to a decrease in appetite. These recom-mendations could serve as suggestions for publicand private funding organisations that may considersupporting the development of this truly multi-disciplinary field in the years to come.

References

1. Committee of Ministers. Resolution ResAP(2003)3 on Food andNutritional Care in Hospitals. Strasbourg: Council of Europe;2003.

2. Beck AM, Balknas UN, Camilo ME, et al. Practices in relationto nutritional care and supportFreport from the Council ofEurope. Clin Nutr 2002;21:351–4.

3. Kondrup J, Allison SP, Elia M, et al. ESPEN guidelines fornutrition screening 2002. Clin Nutr 2003;22:415–21.

4. Dupertuis YM, Kossovsky MP, Kyle UG, et al. Food intake in1707 hospitalised patients: a prospective comprehensivehospital survey. Clin Nutr 2003;22:115–23.

5. Stanga Z, Zurfluh Y, Roselli M, et al. Hospital food: a survey ofpatients’ perceptions. Clin Nutr 2003;22:241–6.

6. Barton AD, Beigg CL, Macdonald IA, et al. A recipe forimproving food intakes in elderly hospitalized patients. ClinNutr 2000;19:451–4.

7. Odlund Olin A, Armyr I, Soop M, et al. Energy-dense mealsimprove energy intake in elderly residents in a nursing home.Clin Nutr 2003;22:125–31.

8. Almdal T, Viggers L, Beck AM, et al. Food production andwastage in relation to nutritional intake in a general districthospitalFwastage is not reduced by training the staff. ClinNutr 2003;22:47–51.

9. Kondrup J, Johansen N, Plum LM, et al. Incidence ofnutritional risk and causes of inadequate nutritional care inhospitals. Clin Nutr 2002;21:461–8.

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