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Evidence‐based approaches

Rationale

An essential part of providing diet for a patient is to ensure that they are able to consume the food and fluid in a safe and pleasant environment. Some patients may require assistance with feeding or drinking and a system should be in place to ensure that these patients receive the required attention at each mealtime and beverage service, as well as adapted cutlery or crockery if appropriate. Clear guidance on menu design and content is available via The Nutrition and Hydration Digest (BDA [21]). Menus are the ideal way to ensure a patient has choice. Either a cyclical or an à la carte menu can be used. It is important to remember when planning the menu that patients who have long stays may develop menu fatigue, so variety is key. In the UK, The Eatwell Guide (PHE [140]) is used to design menus. The standard menu should meet the needs of everybody, from those who are nutritionally well to those who are vulnerable. Coding should be used to assist patients to select suitable options; in the UK this should follow the following format:

Healthier Eating (H or heart symbol)
High Energy (E)
Softer or Easier to Chew (S)
Vegetarian (V).

Meals should also be available for patients requiring diets based on religious, cultural and lifestyle considerations; those who have allergies; and those who for therapeutic reasons need a modified diet. The International Dysphagia Diet Standardisation Initiative (IDDSI [69]) (Figure 8.18) provides a standardized approach to the assessment and care of patients experiencing dysphagias. This initiative offers toolkits to enable the guidance to be implemented.

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Figure 8.18 The IDDSI framework.

It is essential that meals are appetizing and strictly comply with any dietary restriction relevant to the patient. For example, those with food allergies, texture modifications, or religious or cultural dietary requirements need to be clearly identified with the senior ward nurse before assistance with feeding commences. Eating and drinking are pleasurable experiences and the psychosocial aspect of this cannot be overestimated. The inability to participate in mealtimes can be socially isolating (Nund et al. [130]). Research has highlighted that dysphagia also affects carers due to its impact on eating and social activity, and it can lead to permanent changes in lifestyle for both patient and carer (Nund et al. [131]).

Supporting the patient with feeding requires a patient‐centred approach and involving the patient throughout the process (DH [46]).

Provision of food and nutrition in a hospital setting

Good nutritional care, adequate hydration and enjoyable mealtimes can dramatically improve the general health and wellbeing of patients who are unable to feed themselves, and can be particularly relevant to older people (Young et al. [190]). Unfortunately, it is evident that assistance with meals for those who require it does not always occur. In the summary of the results of the 2011 National Inpatients Survey, 15% described the hospital food as ‘poor’, an increase from 13% in 2010. Of those needing help to eat their meals, 14% did not receive this (NICE [124]).

There are many factors, including being in hospital, that need to be taken into consideration when planning nutritional support. For those in the UK, the Hospital Food Standards Panel published a report (DH [46]) that identified five food standards with which all hospitals should comply, in order to provide the highest quality and nutritional value of food for NHS patients, staff and visitors. The standards are:

10 Key Characteristics of ‘Good Nutrition and Hydration Care’ (NHS England [113])
The Nutrition and Hydration Digest (BDA [21])
The MUST Toolkit (or equivalent) (BAPEN [15])
Healthier and More Sustainable Catering: Nutrition Principles (for staff and visitor catering) (PHE [141])
Sustainable Procurement: The Government Buying Standards for Food and Catering Services (DEFRA [45]).

Ten factors affecting intake and benchmarks of best practice have been identified to support optimal provision and monitoring of food and drink. These are shown in Box 8.3. The Department of Health and the Nutrition Summit Stakeholder Group have worked together to produce an action plan based on the 10 key characteristics of good nutritional care in hospitals. These are outlined in Box 8.4.

Box 8.3

Food and nutrition benchmark (‘food’ includes drinks)

Agreed patient‐focused outcome

Patients are enabled to consume food (orally) that meets their individual needs.

Indicators/information that highlights concerns that may trigger the need for benchmarking activity

Patient satisfaction surveys
Complaints figures and analysis
Audit results, including catering audit, nutritional risk assessments, documentation audit and environmental audit (including dining facilities)
Contract monitoring, for example wastage of food, food handling and/or food hygiene training records
Ordering of dietary supplements and special diets
Audit of available equipment and utensils
Educational audits and student placement feedback
Litigation and the Clinical Negligence Scheme for Trusts
Professional concern
Media reports

Source: Adapted from Council of Europe Committee of Ministers ([41]) with permission of the Council of Europe.

Box 8.4

10 key characteristics of ‘good nutrition and hydration care’

All patients are screened on admission to identify the patients who are malnourished or at risk of becoming malnourished. All patients are re‐screened weekly.
All patients have a care plan which identifies their nutritional care needs and how they are to be met.
The hospital includes specific guidance on food services and nutritional care in its clinical governance arrangements.
Patients are involved in the planning and monitoring for food service provision.
The ward implements protected mealtimes to provide an environment conducive to patients enjoying and being able to eat their food.
All staff have the appropriate skills and competencies needed to ensure that patients’ nutritional needs are met. All staff receive regular training on nutritional care and management.
Hospital facilities are designed to be flexible and patient centred with the aim of providing and delivering an excellent experience of food service and nutritional care 24 hours a day, every day.
The hospital has a policy for food service and nutritional care which is patient centred and performance managed in line with governance frameworks.
Food service and nutritional care are delivered to the patient safely.
The hospital supports a multidisciplinary approach to nutritional care and values the contribution of all staff groups working in partnership with patients and users.

Source: Adapted from NHS England ([113]) with permission of the NHS.

Modification of diet

Various publications provide initial advice for people requiring modification of diet, such as Have You Got a Small Appetite? (NDRUK [111]). See also Table 8.10.

Table 8.10 Suggestions for modification of diet

Eating difficulty	Dietary modification
Anorexia	Serve small meals and snacks, for example twice‐daily snack options Make food look attractive with garnish Fortify foods with butter, cream or cheese to increase the energy content of meals Encourage food that patient prefers Offer nourishing drinks between meals; in hospital, consider a ‘cocktail’ drinks round
Sore mouth	Offer foods that are soft and easy to eat Avoid dry foods that require chewing; choose moist, soft foods Avoid citrus fruits and drinks Avoid salty and spicy foods Allow hot food to cool before the patient eats
Dysphagia	Refer to or liaise with the speech and language therapy team regarding safe swallowing and modified diet/fluid recommendations (IDDSI [69])
Nausea and vomiting	Offer cold foods in preference to hot as these emit less odour Keep patient away from cooking smells Encourage patient to sip fizzy, glucose‐containing drinks Offer small, frequent meals and snacks that are high in carbohydrate (e.g. biscuits and toast) Offer ginger drinks and ginger biscuits or peppermint sweets or tea
Early satiety	Offer small, frequent meals; in hospital, access an out‐of‐hours meal service Avoid high‐fat foods, which delay gastric emptying Encourage the patient to avoid drinking large quantities when eating Consider prokinetics, for example metoclopramide, to encourage gastric emptying

Dietary supplements

If patients are unable to meet their nutritional requirements with food alone then they may require dietary supplements. These may be used to improve an inadequate diet or as a sole source of nutrition if taken in sufficient quantity. Table 8.11 summarizes the key features of nutritional supplements currently available.

Table 8.11 Oral nutritional supplements

Type of supplement	Description	Indications for usec08-note-0006	Practical usage
Nutritionally complete/ supplementary	Whole‐protein, milk‐based supplements containing vitamins and minerals Usually 1.5–2.4 kcal/mL and 6–10 g protein/100 mL Some contain dietary fibre	Standard criteria: Disease‐related malnutrition Intractable malabsorption Pre‐operative preparation for malnourished patients Dysphagia Proven inflammatory bowel disease Following total gastrectomy Short bowel syndrome Bowel fistula	Usually liquid and available in a bottle; milkshake or yoghurt style Used to increase energy and protein intake Used in addition to food or as main source of nutrition, e.g. in dysphagia
Nutritionally complete/ supplementary	Fruit‐juice‐style supplements Whole protein, generally low in fat Not full complement of vitamins and minerals Usually low in fat‐soluble vitamins	Standard criteria (as above)	Liquid available in a bottle Used to increase protein and energy intake Used in addition to food Can be used in recipes, e.g. jelly, and can be blended with other drinks, e.g. lemonade, ginger ale, soda water or tonic water
High protein and energy	Protein and carbohydrate supplement Usually small volume, e.g. 30 mL	Biochemically proven hypoproteinaemia	Liquid available in bottles or sachets Can be drunk as a ‘shot’ or added to food and drinks
Protein and fat	Protein and fat supplement Usually taken as a small volume, e.g. 40 mL Contains vitamins and minerals	Disease‐related malnutrition Malabsorption states Other conditions requiring fortification with a high‐fat or high‐carbohydrate (with protein) supplement	Can be drunk as a ‘shot’ or added to food and drinks
Protein, fat and carbohydrate	Protein (cows’ milk) Fat and carbohydrate supplement as a powder Not full complement of vitamins and minerals	Disease‐related malnutrition Malabsorption states Other conditions requiring fortification with a high‐fat or high‐carbohydrate (with protein) supplement	Usually presented as a powder that is reconstituted with whole milk and provides approximately 2 kcal/mL Often has a sweet flavour and is made into a milkshake, but manufacturers’ recipes include ice cream, and fortification of soup, desserts and cakes Some savoury flavours available

^*	UK Advisory Committee on Borderline Substances (ACBS) criteria (BAPEN [11]).

Source: Adapted from Shaw and Eldridge ([165]).

Table 8.12 Difficulties that may be experienced by patients during eating and drinking and their potential implications

Difficulty experienced	Implications
Coughing and choking during and after eating and/or drinking	Indicates laryngeal penetration or aspiration ( Langmore et al. [81]; Smith Hammond [173]).
Wet or gurgly voice quality	Indicates laryngeal penetration or aspiration ( Langmore et al. [81]).
Drooling/excess oral secretions	Indicates less frequent swallowing and is associated with dysphagia ( Langmore et al. [81]). May result from poor lip seal.
Nasal regurgitation	Indicates impaired velopalatal seal ( Leslie et al. [83]).
Food/drink pooling in mouth	Indicates lack of oral sensation from intraoral flaps or may be a sign of cognitive impairment ( Logemann [87]).
Swallow is effortful	May indicate weakness in muscles required for swallowing ( Logemann et al. [88]).
Respiration rate on eating/drinking is increased	Increased respiration rate may be associated with risk of aspiration ( Leslie et al. [83]).
Signs of recurrent chest infections and pyrexia	This may indicate aspiration pneumonia as a consequence of dysphagia ( Leslie et al. [83]).
Patient reports swallowing problems	Patient‐reported outcome (PRO) measures are commonly used to capture patient experience with dysphagia and to evaluate treatment effectiveness ( Patel et al. [134]).
Patient reports food sticking	Patient‐reported outcome (PRO) measures are commonly used to capture patient experience with dysphagia and to evaluate treatment effectiveness ( Patel et al. [134]).
Additional time required to eat a meal	Taking a long time to eat may indicate dysphagia ( Leslie et al. [83]).
Avoidance of certain foods	Patients will avoid food items that they find difficult to swallow ( Leslie et al. [83]).
Weight loss	Patients may eat less due to difficulty swallowing ( Leslie et al. [83]).
Poor oral hygiene	Aspiration of secretions in those with poor oral hygiene may result in aspiration pneumonia ( Langmore [80]).

Specialist supplements

Supplements designed for specific patient groups are also available. For example, there are some aimed at patients with dementia, chronic obstructive pulmonary disease, renal problems or dysphagia.

Vitamin and mineral supplements

When dietary intake is poor, a vitamin and mineral supplement may be required. This can often be given as a one‐a‐day tablet supplement that provides 100% of the dietary reference values. Care should be taken to avoid unbalanced supplements and those containing amounts larger than the dietary reference value (FSA and Expert Group on Vitamins and Minerals [56]). Excessive doses of vitamins and minerals may be harmful, particularly as some vitamins and minerals are not excreted by the body when taken in amounts exceeding requirements. Additionally, vitamins and minerals may interact with medication to influence its efficacy; for example, vitamin K may influence anticoagulants such as warfarin (NICE [124]).

Patients being discharged from hospital on nutritional supplements

It is important to ensure that patients who require continued oral nutritional supplements in the community are discharged with a suitable supply. The decision on choice of supplement will usually be made by the prescriber and should be based on clinical need and patient acceptability. Where more than one suitable option is available, the ease of use in a community setting, likely compliance and the impact on primary care budgets may be factors to be weighed up in the choice of supplement. Clear guidance should be given to the prescriber in the community, including on the anticipated outcome and duration of need. Monitoring should also be put in place to ensure that the use of oral nutritional supplements remains appropriate, that they are being tolerated and that the nutritional status of the patient is changing in accordance with the goals set by the patient and healthcare professional.

Anticipated patient outcomes

It is anticipated that feeding an adult will ensure safe delivery of the meal in a comfortable environment such that the patient has a pleasurable and positive experience, promoting adequate nutritional care.