Despite the clinical value of nutrition, hospital meals leave much to be desired, writes Haydn Shaughnessy.
Hospital food is very much like the children's school lunch. Most adults don't have to eat it. The Council of Europe though, of which Ireland is a part, has given considerable thought to the impact of hospital food on the health of patients.
Two and a half years ago, the Council reported:
"Studies of undernutrition in hospitals [ in Europe], of poor and inflexible provision of food and of conflicting clinical priorities continue to be published - and have been published for more than 100 years. . . The existence of disease-related undernutrition among patients in European hospitals is a fact."
Ireland is no exception.
According to a spokesperson at the Department of Health and Children: ". . . s a consequence of having a health problem, as many as 11 per cent of patients are malnourished on admission to acute hospitals. While in hospital this problem is often exacerbated because hospital procedures often necessitate fasting, conflict with meal times or the food served to patients is often not adequate to their needs."
Some 11 per cent is, in fact, very probably an underestimate. The European average is in the region of 20 to 30 per cent. That's the proportion of patients who enter hospital already undernourished. Worse is to come.
According to a number of studies, the problem of hospital undernourishment is not simply one of a few skipped meals or a little weight loss. There is a real and scientifically grounded understanding of the relationship between nourishment and disease. One indication of undernourishment is weight loss.
The safety margins, what patients can safely afford to lose, are surprisingly small, according to a number of analyses.
In sick patients, a 5 per cent loss of body weight is thought to be a critical threshold. Beyond it lies increased risk of complications, lowered resistance to infection, impaired physical and mental functioning, and delayed recovery, and it can be life threatening," says the Council of Europe.
How prevalent is that kind of weight loss?
In one English study of 112 patients with all kinds of diagnoses, hospitalised for more than one week, 64 per cent had lost weight (mean average weight loss was 5.4 per cent, slightly above the critical threshold) when discharged whereas only one could be reclassified as of normal weight. Comparable figures for Ireland are hard to come by.
Low food intake, in combination with disease, has a larger and more rapid impact on body weight and body function, and depletes what doctors call "body substrates". If that's a difficult term for us lay people to understand then its consequences are clear. It suppresses immune function and reduces blood clotting, wound healing and other recovery parameters.
The Department puts this in a tantalisingly positive context:
"The acute healthcare facility setting provides an excellent opportunity to attain and sustain healthful eating habits. In particular, for patients with chronic diet-related diseases learning to eat well can improve wellbeing and enhance quality of life."
With the help of the Irish Nutrition and Dietetics Institute, the Health Promotion Unit has drawn up minimal nutrition guidelines for hospitals. A report is due on those guidelines. A way of auditing the results is under development by the Health Promoting Hospitals network and is expected later this year.
The Irish Nutrition and Dietetics Institute represents the nutritionist profession in Ireland. While the US Department of Agriculture recommends nine helpings of fruit and vegetables a day, and the recommendation in Europe is only five a day, the Irish Nutrition and Dietetics Institute (IDNI) recommends a mere four, and urges people to consume six or more helpings of whole grains, a dubious recommendation at best. Spokeswoman Margot Brennan of the institute says the target was set low so that people would find it achievable. It's now being increased to five. The strategy of setting low targets belongs to the Department.
The "Health Promoting Hospitals" network will take responsibility for helping hospitals to implement the new guidelines, in conjunction with the National Hospitals Office at the Health Service Executive and help audit the results.
According to Anne O'Riordan of Health Promoting Hospitals, considerable work has already been done to improve hospital food, though initially the Department has focused on the staff and visitor canteen. "There's been a vast improvement in staff canteens over the past two years in a high percentage of hospitals," she reports. And this was done apparently to set a framework for improving patient nutrition from next year onwards.
In the UK, a scheme to improve hospital food was launched three years ago. A national menu provides 300 different recipes for catering staff to choose from. There is a policy of protecting meal times from disruption by consultants, diagnostic visits and treatments. And there is an annual audit of hospital meal quality.
Laudable though the British system appears to be, there are obvious flaws. The annual audit reveals, incredible though it may seem, that no hospital serves bad food. But then the audit is a patient survey and the question asked is whether or not hospitals meet patient expectations.
In France, in an experiment to assess the nutritional value of hospital food, a group of healthy hospital employees were given an exclusively hospital diet for a week. At the end of the week their nutritional intake was approximately 18 per cent less than it should have been and half of what was necessary. They were simply unable to ingest all the nutrients they'd, theoretically, been given. A 25 per cent drop in nutrition is again a threshold for patients beyond which complications lie.
How and why patients become undernourished is more complex than the quality of food they eat. Their medical condition on admission, anxieties about medical procedures, fasting, the interruption of meals, post-operative stress, and medications that make foods taste unpleasant are among the culprits. But so too is medical tradition.
Patients who undergo gastric surgery are routinely deprived of full nutritional meals for some days after surgery even though the evidence suggests that this delay increases their risk of infection.
Most surgical patients are obliged to fast the evening before an operation. Again the evidence shows that patients can safely drink a carbohydrate rich drink or water within two hours of an operation. Total fasting reduces nutritional profile and adds to patients' length of stay in hospital. And consultant visits or diagnostic appointments have always taken precedence over meals.
So improving nutrition is not just a catering issue, perhaps not even a catering issue. Nobody wants to blame undernourishment on hard pressed catering staff operating on limited budgets. The neglect is philosophical. The medical profession has long tilted at the nutrition windmill. O'Riordan agrees that clinical practitioners have been dismissive of nutritional issues. Investments in medical technology have taken precedence, and their impressive advances have tended to mean that nutritional issues have lost out.
In these days of multiplying antibiotic resistant bugs, little attention has been given to patients' nutritional status in the fight against, for example, MRSA, even though susceptibility to infection is a major consequence of being undernourished.
Just as MRSA policy is reduced to an issue of cleanliness, where Irish hospital food policy is strong is on food safety and food hygiene, and this is where the initial food guidelines work has focused.
The truth of the hospital dietary pudding though is about to be uncovered in the eating. "What's now brought into the hospital in the way of food has vastly improved," says O'Riordan of the situation since work began on improving staff food, though she admits, "what gets to patients has not necessarily improved".
To put right the substantial wrongs of the past century means the guidelines have to be adequate, though they have not yet been publicly debated and nor are they likely to be. But, as important, they need to be implemented uniformly if poor nutrition is not to become a seedbed for health disparities. Above all, the will to implement has to go well beyond the kitchen door.