Personalized approach to food in hospital: nutritional paradise or economic disaster? Nicole M. de Roos, PhD

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1 Personalized approach to food in hospital: nutritional paradise or economic disaster? Nicole M. de Roos, PhD

2 Malnutrition in hospitals is not surprising... but many cases can be prevented

3 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

4 Demands on new meal system hospital Gelderse Vallei Ede Patient: Taste, freshness, easy ordering, flexibility, eating with visitors, home feel Kitchen staff: Preparation, time, presentation Dietitian: Adequate nutrition, disease prevention, easy inclusion of therapeutic diets, better intake (less malnutrition) Facility Manager: Cost (neutral), patient satisfaction

5 Decision: At Your Request by Sodexo Patients choose: What they eat When they eat Where they eat With whom they eat

6 How food is ordered in AYR Patient chooses from menu and calls Service Center Kitchen receives order Tray is prepared Tray is delivered within 45 mins

7 Number of orders 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

8 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?

9 Study design Prospective study Two groups of patients, 2 years apart Completed participation Subgroup En+Pro+ diet competed food lists

10 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

11 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

12 Baseline characteristics in both periods Traditional meal service n=168 At Your Request n=169 % Men 52% 46% Age (y) Bedridden 24% 24% Weight (kg) BMI (kg/m 2 ) 28.0 ± ± 6.2 MUST score 1 22% 28% Length of stay (d)* Surgery* 42% 26% * Significant difference (p<0,05) between periods

13 Patient satisfaction using a nutritionrelated 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 Traditional Meal service score At Your Request More choice, better service, better presentation

14 Patient satisfaction in a score 7.5

15 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

16 Food intake Food ordering data Food lists for patients requiring energy & protein enriched diet

17 Participants (%) Provided amount of protein in g/kg bodyweight in MUST risk groups ( AYR) g/kg Mean intake in MUST groups 1.0 g/kg 1.1 g/kg <0.8 g/kg BW g/kg BW g/kg BW >1.5 g/kg BW 10 0 MUST 0 MUST 1 MUST 2 (No risk, n=122) (Risk, n=16) (Severe risk, n=31)

18 Protein intake (g/d) Protein intake (g/d) 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% meets recommendation 30% meets recommendation Protein recommendation (g/d) Protein recommendation (g/d) (Recommendation based on ideal bodyweight at BMI 27 kg/m 2 )

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

20 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 Vegetables Fruits Dairy products Ordered Recommended g/d

21 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

22 Costs comparable to traditional meal service For food costs in this hospital: 500 bed hospital, about 300 patients using AYR ~ 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)

23 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

24 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

25 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