Meals as defined by hospital patients

Transcription

1 Meals as defined by hospital patients Janice Sorensen, PhD Clinical Nutrition / Dietitian janice.m.sorensen@gmail.com Principal supervisor: Prof. Jens Kondrup, Dept. Human Nutrition/ Clinical Nutrition Co-supervisors: Assoc. Prof. Michael Bom Frøst, Dept. Food Science/ Sensory Prof. Lotte Holm, Dept. Human Nutrition/ Sociology of Food Faculty of Life Sciences, University of Copenhagen, Denmark Slide 1 of 19

2 Introduction About 1/3 of hospital patients are at nutritional risk. Complications, longer hospital stays, higher healthcare costs. Worsened quality of life (physical and mental function). Low food intake in patients is a problem in many hospitals. Insufficient intake despite nutritionally sufficient provisions. Lack off appetite and unsuitability of the hospital food. Food sensory quality associated with food intake in patients. 1 How can food quality and the sensory properties of meals be optimised to promote food intake in hospital patients? How do hospital patients define food quality? User-driven innovation. Support: UC-LIFE, Arla Foods, the Danish Dairy Research Foundation & Innovationsloven. Slide 2 of 19 1 Paquet C et al. J Gerontol A Biol Sci Med 2003;58:153-8.

3 Aims and outline Aim: establish a framework for developing functional foods, i.e., appetising energy and protein rich foods, for patients at nutritional risk. 1) Explore food sensory quality as experienced and perceived by patients at nutritional risk. Qualitative study 2) Prevalence/associations between factors identified in the qualitative study in a larger heterogeneous group of patients at nutritional risk. Questionnaire study 3) Develop and trial newly developed functional foods and meals. Food sensory studies 4) Investigate the effect (food intake, physiological function & quality of life) of individualised food-sensory-quality-based nutritional care in hospital patients at nutritional risk. Randomised controlled trial (RCT) Slide 3 of 19

4 Qualitative study Patients: nutritional risk (NRS-2002) and decreased intake (<75%). Interviews (N=65) in 22 patients (50% ; 51 ± 16 mean ± SD years) Age < >69 Hepatology Hepatologi Oncology Oncologi 5% 27% (n=1) (n=6) Cardiology Kardiologi 5% (n=1) InfekMed 27% (n=6) Gastro GastroKir surgery 36% (n=8) Mellemmåltid Snacks 3% (n=2) Post Efter Discharge udskr. 18% (n=12) Aftensmad Supper 29% (n=19) Interviews (N=65) Breakfast Morgenmad 22% (n=14) Lunch Frokost 28% (n=18) Slide 4 of 19

5 Appearance Preferred familiar foods, but often disappointed. Complex vs. Simple reflection of caring Garnished, colourful, etc. Peaceful Aroma Appetising e.g., fresh bread, toast, rice, pancakes, soup. Nauseating e.g., commercial nutritional supplements. bliver mæt helt af duften ( 30 Inf. Med.) Slide 5 of 19

6 Taste A fine balance: tasty, but not provocative. Fresh/local as opposed to mass-produced off-site. Taste of the raw ingredients as opposed to artificial flavours. Wanted to recognise what they were eating familiar. Åltså back to basic, hvis man kan sige det sådan. ( 30 Inf. Med.) Taste changes Expectations -> disappointment. Some patients with taste changes preferred neutral/mild flavours. Temperature Maintaining optimal serving temperature a challenge for patients that eat/drink slowly. Compromised food quality -> decreased desire to eat. Slide 6 of 19

7 Texture & Consistency Easy to eat minimal effort to chew & swallow. Det er varmt og det glider bare ned igennem ( 57 Onk) Fluid, soft, moist, tender. E.g., fish, egg, chicken, sausage as opposed to red meat, lamb, turkey. Should not stick / expand in one s mouth. Depending upon the patient s symptoms. Some prefer a variety / contrast in texture & consistency. Light as opposed to heavy food. Some patients have the impression that solid foods were better/healthier albeit more difficult/unpleasant to eat. Post-ingestive response E.g., stomach settling, refreshing. Slide 7 of 19

8 Variety 1. Within a dish / a meal. Is sensory specific satiety more pronounced in patients? 2. From day to day. 3. Find something that works and stick to that. Great confusion about what one can mange to eat. Min appetit, min mund og min krop er fuldstændig i mod hinanden. ( 33 ) Food preferences changing in accordance with eating-related symptoms. Some patients appreciate specific menu suggestions. The food is fine, but there is something wrong with me. Slide 8 of 19

9 Motivation 1. Hunger 2. Enjoyment (pleasant vs. less unpleasant) 3. Social / cultural 4. Comfort (deal with symptoms right here right now) Thirst quenching and refreshing. Stomach settling / pleasantly satiating. (post-ingestive response) Help to swallow pills. Mask unpleasant tastes. 5. Nutrition and health 6. Follow recommendations 7. Survival Motivation changes from healthy ill and throughout the course of illness and is effected by one s opinions, expectations and understanding regarding food, nutrition and health. Slide 9 of 19

10 Model of food sensory quality to promote intake in patients at nutritional risk Slide 10 of 19

11 Patient food choice questionnaire Symptoms (15): Low appetite Early satiety Nausea / Vomiting Dry mouth Pain or discomfort in mouth/throat/stomach Problems with chewing/swallowing Diarrhea / Constipation Assistance with eating Food allergy or intolerance Taste changes Meal experiences and preferences (46): Appearance (6) Aroma (2) Taste (12) Texture / consistency (10) Post-ingestive response (2) Temperature (1) Variation (6) Motivation (7) Slide 11 of 19

12 Questionnaire study (N=200) Top five most common eating-related symptoms Symptom Not at all Somewhat Very much Energy balance Protein balance Low appetite 30 (15%) 63 (32%) 107 (54%) Lower, p < Lower, p < Early satiety 42 (21%) 56 (28%) 102 (51%) Lower, p < 0.05 Lower, p < 0.05 Dry mouth 67 (34%) 62 (31%) 71 (36%) NS NS Taste changes b 83 (42%) 65 (33%) 50 (25%) Lower, p < 0.05 NS Nausea 104 (52%) 73 (37%) 23 (12%) Lower, p < 0.05 Lower, p < 0.01 Slide 12 of 19

13 Questionnaire study (N=200) Food sensory statements related to energy/protein balance Section Questionnaire statement Agree Energy balance Protein balance Appearance Q1: prefer familiar foods 72% Lower, p < 0.05 Lower, p < 0.05 Aroma Q8: nauseating aroma problems 56% Lower, p < 0.01 Lower, p < 0.01 Taste Q11: prefer sour foods 53% NS Higher, p < 0.05 Q12: prefer sour side dishes 69% Higher, p < 0.05 NS Q13: prefer savoury foods 74% Higher, p < 0.01 Higher, p < 0.05 Q16: prefer different tastes 77% Higher, p < 0.01 Higher, p < 0.05 Q20: preferred taste important 86% Lower, p < 0.05 Lower, p < 0.05 Texture Q24: difficulty forming a bolus 58% Lower, p < 0.05 Lower, p < 0.01 Q26: prefer light foods 61% Lower, p < 0.01 Lower, p < 0.05 Slide 13 of 19

14 Questionnaire study (N=200) Motivation to eat statements & association with energy/protein balance Section PLEASURE Illustrative quotes (Study I) When I eat something I like, then my appetite also comes. Questionnaire statements (Study II) Agree Energy balance Q41: I enjoy my food. 65% Higher, Q42: It is important for me to enjoy my food to eat. Protein balance Higher, p < p < % NS NS COMFORT SURVIVAL It s to rinse it down I like apple. It has a fresh taste. The comfort and enjoyment of eating now is based on its satiating effect. I eat because I want to survive this. I know if I don t get anything to eat then it's my own grave that I m digging. Q30: I prefer food that is 82% NS NS refreshing and thirst quenching. Q31: I prefer food that is pleasantly satiating. 75% NS Higher, p < 0.05 Q45: I often force myself to eat. 60% NS Lower, p < 0.05 Q46: I eat to overcome my illness. 78% NS NS Slide 14 of 19

15 Questionnaire study: patient characteristics by PC1 Group a Nutrition Symptoms Food sensory experiences Food sensory preferences Motivation PC1 ( + ) Forced eating (n=102) NRS intake score Low appetite Early satiety Nausea Vomiting Mouth pain Stomach pain Problems chewing Problems swallowing Diarrhea Taste changes Q8: nauseating aroma Q24: difficulty form bolus Q25: film left in mouth Q33: temperature problems Q32: consistency important Q35: sensory specific satiety Q37: don t know what to eat Q38: difficulty tolerating food Q39: redundant food choices Q1: familiar foods Q5: small portions Q18: mild flavours Q19: not spicy Q21: easy to eat Q22: soft/fluid Q23: moisture giving sauces Q45: forced eating Q46: eat to overcome illness PC1 ( ) Enjoy eating (n=98) Energy balance Protein balance NS Q7: aroma increases appetite Q13: savoury Q27: crispy/crunchy Q16: varied tastes Q34: varied dishes Q28: varied textures Q41: enjoy food Mann-Whitney U test of positive vs. negative side of PC1-axis PC1 (+) vs. PC1 (-). Variables were included in the table based on p<0.01. NS = Not significant. Slide 15 of 19

16 Conclusions A Model of food sensory quality to promote intake in patients at nutrition risk was developed. Motivation to eat provided an important context for defining food sensory quality: Pleasure Comfort Survival Motivation to eat: pleasure vs. survival Food sensory needs: awaken appetite vs. facilitate intake Patients that forced themselves to eat were associated with lower energy and protein balance than in patients that enjoyed eating. Slide 16 of 19

17 Application and perspectives Application of the model in developing user-driven, innovative food, beverages and meals for patients. Targeted menu development in hospitals (e.g., wording, selection). Investigate effect on food intake. Application of the model in clinical practice: (RCT) Individualised, food-sensory-quality-based nutritional care improved energy and protein intake in hospital patients at nutritional risk compared to usual nutritional care and advice. Improvement in physiological function within a few days in hospital. Positively associated with energy and protein intake. Longer longitudinal studies investigating the experiences & perceptions of foods sensory quality in patients at nutritional risk during the course of illness. Assessment of international generalisability of the qualitative and questionnaire study results. i.e., influence of food culture. Slide 17 of 19

18 Gourmandiet - developing organic, gourmet food for patients with low food intake Arla Foods Rigshospitalet - Central Kitchen Slide 18 of 19

19 Thank you! Jens Kondrup, Michael Bom Frøst, and Lotte Holm (supervisors) Lene Holm Jakobsen, Lise Munk Plum, Berit Ipsen, Vibeke Sode, & Lene Troensgaard (qualitative study - focus group) Birgitte Sonne Rasmussen, Linda Lund Tietz, Janus Cronquist Mlynek, Marie-Louise Suk Olsen, Rikke Lunau, & Pia Groulef (students) Gözde Gürdeniz & Thomas Hjort Skov (PCA analysis) Anne-Lis Olsen, Randi Hansen, & Marianne Willumsen (Central kitchen, Rigshospitalet) Erik Adamsen (Arla Foods) Signe Braband Jensen, Matilde Jo Allingstrup, Negar Esmailzadeh, Pia Groulef, Marie Qvist, Stine O. Petersen, Catharina Engelhardt, Mette Krøger, Rikke Lunau, Birgitte Sonne Rasmussen, Karen Lindegaard Lauterlein, and Camilla Storm Slumstrup (RCT) Birthe Stenbæk Hansen & Peter Steen (Gourmandiet) Departments at Rigshospitalet and study patients Slide 19 of 19