According to World Health Organization, good nutrition is a guarantee of health.

Though, malnutrition isn’t only present in developing countries. This major public health problem also shows up in developed countries.
Ironically, it turns out that hospitalization is a risk factor for undernutrition. Indeed, it affects up to more than half of all the patients in hospitals. The deterioration of nutritional parameters for adults and the apparition of undernutrition for children that aren’t suffering severe pathologies point out a quantitatively insufficient supply of energy and macronutrients.
 

Undernutrition leads to the aggravation of existing pathologies (infectious risks, complications, etc.) and dramatically increases the length of hospital stay as well as the risk of mortality. In addition to reducing the life expectancy, it limits the quality of life: the dependance of elderly or frail people is accelerated and lowered immune defenses prevent patients from fighting the disease, which very often leads to the need for additional care and longer treatment. All this obviously has major economic consequences.

But what are the causes of this phenomenon of patients’ undernutrition ?

Depending on the reasons for their hospitalization, some patients can face feeding difficulties related to their pathologies (decreased hunger, swallowing problems, pain when eating, etc.). But these are not the only factors that lead to undernutrition.

Apart from gustatory quality, temperature and presentation of meals, various factors are responsible for this issue. As the portions are standardized, they are very rarely adapted to the wishes of each patient and in addition to that, many of them lack time to eat because their meal is interrupted by a medical procedure. Eating is often difficult because of the lack of ergonomic adaptation for bedridden or immobilized patients. They also sometimes find it difficult to open certain packages.

[gr-alert type=”green” icon=””]The American psychologist Paul Rozin develops the notion of cognitive disgust as the idea that the subject has about food: what it is and where it comes from. In the hospital, patients aren’t aware of any of that and may associate their food with negative impressions given off by the environment. The idea that “you are what you eat” is even more present in the hospital environment.[/gr-alert]

As the meal is sometimes served in plastic boxes, it certainly inspires hygiene and food safety, but also impersonal, sanitized, and tasteless food. Moreover, during room service, patients lose all notion of the conviviality of the meal.

All these issues highlight the need to separate feeding from the other activities that take place in the hospitals. But this is a rather complex matter, that would require a complete overhaul of hospital catering’s organization.

How are the meals organized in hospital ?

Hospital catering production is unnecessarily complicated by menus variations based on too many different types of “feeding regime”, sometimes self-prescribed without real medical justification. A rigorous simplification is essential in order to rethink the organization of meals.

The logistics of the meal service are deficient because they are complex, expensive, and poorly managed. The time between delivery and service as well as the lack of training of staff are causing a significant degradation of the organoleptic qualities of the products, which explains why they’re often not eaten.

Organoleptic qualities properties of a food perceived by the sensory organs: taste, smell, touch (texture/constistency), sight (appearance)

On top of that, the serving of food is quite often a topic that is pushed into the background by the nursing staff, because they’re overburdened by time constraints and the increasing complexity of the care burden. Therefore, meals are served and cleared at fixed times, which implies that staff schedules are not necessarily correspond to the ideal eating habits of patients. For example, in the hospital, dinner is usually served around 6pm, resulting in a prolonged night-time fasting of more than 12 hours, which can be dangerous for some patients. Furthermore, the current organization of the staff doesn’t allow any flexibility according to the patient’s activities or unforeseen needs (medical examination, visit of a relative, need for a snack to compensate for an insufficient meal, etc.). It also seems logical that individual and cultural preferences lead to differentiated provision.

This scope for improvement points to a promising field on which it would be possible to provide solutions for setting up self-service facilities or restaurants in the hospital. This innovative operation would bring patients closer to the production sites and reduce the logistical burden. It will provide a wider choice of meals and a wider range of dining options. This would imply profound changes in both the organization and architecture of the hospital but would result in substantial savings. It would also lead to a revaluation of food production and therefore of kitchen staff.

In 2002, some Nutrition Liaison Committees (“CLAN” in French) have been created on a local and regional scale. Non-mandatory, their role is limited to advising the management and the Medical Commission (CME in French).

Their aim is to work towards improving the provision of food and nutrition for patients in hospitals. Unfortunately, they are still little known to hospital staff.

Some obligations have also been defined by decree: “Compliance with minimum requirements for the variety of dishes served ; four or five different courses offered at each lunch or dinner ; the adaptation of the dishes offered to the tastes and health condition of the patients ; compliance with portion size and meal frequency requirements”.

Unfortunately, these indications are not sufficient yet, as they rely on the goodwill of the hospitals to adapt the operation of the meals. Very few of them do so, it is up to the State to impose such standards. Senior health executives and health executives also have an important role to play: if they do not push their staff to pay attention to meals, no dynamics will be created around feeding and catering time.

All these failures of the hospital catering system result in food losses (overproduction and non-consumption) that represent a significant cost for hospitals. Indeed, it’s the institutional catering in medico-social establishments that records the greatest volume of waste.

According to the French Hospital Purchasing Group (RESAH), “between 3 and 10% of prepared meals reach their use-by date without being distributed and 37% of food served to patients and residents isn’t consumed”.

A better management of meals and services, better adapted to patients’ expectations, could limit this food waste.

For example, trays that have been reheated but not served and not eaten are thrown away in their entirety. In a social approach, we could imagine an anti-waste system in which these trays and their contents would, for example, be offered for consumption to people in need outside the hospital (after having signed a document informing them that the food has been reheated beforehand, so that this does not pose a problem in terms of compliance with health standards).

Moreover, for hygienic reasons, meals are very often served in plastic boxes and food is wrapped in plastic, which leads to an extremely large amount of plastic. Imagine the food waste of an uneaten tray, coupled with the plastic waste of food that hasn’t even been unwrapped… even though plastic boxes can be replaced by trays and crockery, it would be in the spirit of the times to find an alternative to plastic for storing food in hospitals.

Egalim Law (a French law that aims to balance trade relations in the agricultural sector as well as allow healthier and more sustainable food), promulgated and validated by the Constitutional Council confirms the prohibition of certain plastic utensils (straws, cutlery, meal trays, disposable lids, boxes, etc.) in institutional catering services from January 1st 2020. The prohibition of plastic is expected to be extended to other products by January 1st 2025. This will for example apply to every food cooking container, heating container, and serving container that is made of plastic. Given the quantities of plastic waste recorded in the medico-social centers, this law should be enforced in every health establishment and not only suggesting it as a simple recommendation, which seems to be the case nowadays.

In addition to this, the EGALIM law actively participates in the fight against food waste and obliges institutional catering to make donations in case of surplus. How about applying this obligation to the hospital sector as well?

In accordance with this law, since January 1st 2022, hospital catering must include 50% of quality products, including 20% from organic farming. This is a hopeful goal for the hospital catering for the future, but one that is currently quite difficult to achieve.

What about the patients’ place as citizens?

Even if they’re hospitalized, patients remain citizen and should be able to be responsible for their choices and consumption patterns. Indeed, their main aspirations are healing and returning to their ordinary life. This is why offering them a real capacity for food choice and giving them the possibility to know where, how and by whom their meals are prepared are ways to give them back their place as citizen. Especially since, from a medical point of view, mobility is essential for the recovery of non-immobilized patients. Moving to eat would be beneficial to them.

Hence, hospitals need to be rethought as places to live and not only as places to care. The current system causes the patient’s satisfaction to be forgotten, which should be the overall objective. This raises the question of the place given to the patient, their needs, and desires. Mobile and autonomous patients should be able to eat in more appropriate places (dining rooms, restaurants, self-service food, etc.) throughout the day. Bedridden patients should be offered innovative foodstuffs and culinary services that can facilitate food intake throughout the day. Material innovations (trays, dishes, etc.) would also be great to present the products to the patients in a pleasant way.

It is obvious that improving hospital nutrition would simply result in a virtuous circle as it would reduce the length of stay and re-hospitalization, as well as reducing waste. Hospital catering should no longer be seen as an economic issue, but as a full-fledged treatment and as a good patient care. A better organization of catering would also free up some time for the healthcare staff, that could therefore devote themselves more quickly to their tasks and to their job : caring.

What future for hospital catering?

Meal being the 1st and not the least medication, in this perspective of improvement, how about considering reserving the service of the meal to a staff specially hired to perform this task ? This would ease the burden on healthcare staff and make the moment of the service much more appropriate and professional. The staff in charge of catering would be specialized in the field and would be able to provide a social aspect that the healthcare staff is not always able to provide (exhaustion, work overload, lack of time…). Patients would thus have the opportunity to find a moment of pleasure and escape during catering, and their care would be more effective, because caregivers could focus on these medical tasks. Their length of stay in hospital should logically decrease, as well as the risk of malnutrition and the hospitalization costs.

A new approach to hospital catering is entirely possible, without financial folly, with healthy raw materials and more human-centred working methods.

Sources 

• https://www.acadpharm.org/dos_public/Avis_78.pdf
• https://hal-anses.archives-ouvertes.fr/hal-00378371/document
• https://www.resah.fr/Ressources/FCK/files/Guides%20Resah/Resah-Editions-Guide-Alimentation.pdf
• https://www.gipse.eu/documents/wa_files/alimentation%20et%20regimes%20dexclusion%20a%20lhopital%20(003).pdf
• https://www.academie-medecine.fr/prise-en-charge-de-la-denutrition-a-lhopital-savoir-diagnostiquer-la-denutrition-et-ses-risques-de-complications-pour-mieux-les-prevenir-et-les-traiter/
• https://www.chu-poitiers.fr/denutrition-quelques-chiffres/