Canadian Hospital Food Service Practices to Prevent Malnutrition

Hospital food provision is a cornerstone of care. It impacts patient and health system outcomes including satisfaction, clinical outcome, and costs [1–3]. Medical nutrition therapies, such as fortifying foods, liberalizing diets, nutrition supplements, and offering food choices have improved patient intakes of energy and protein [3]. Poor food intake may be caused by patients not being able to open packages, missing meals, or not liking the food [4]. Patients who are malnourished and consume 50% or less of food on their meal trays in hospitals have longer length of stay and increased risk of mortality [5]. National foodservice standards have been established in countries with an aim to optimize food provision to reduce risk for malnutrition [6–10]. The Council of Europe adopted a resolution in 2003 [6], which acknowledges the problem of malnutrition in hospital, declares access to food in hospital as a fundamental human right [11], and provides evidence-based recommendations related to food and nutritional care in hospital including standards for hospital foodservice provision. Currently, there are no common pan-Canadian standards for hospital foodservice related to malnutrition, and little is published about foodservice practices in Canadian hospitals. A Food in Health Care Working Group of the Canadian Malnutrition Task Force (CMTF), including foodservice directors and clinical nutrition leaders from across Canada, was formed in 2018 to address hospital foodservice practices related to malnutrition. Building upon the Integrated Nutrition Pathway for Acute Care (INPAC) [12], the working group developed guiding principles for Canadian hospital foodservice practices to prevent malnutrition (Figure 1). Applicability/validity of these guiding principles towards developing a national hospital foodservice standard was assessed by the group through a study of current practice, barriers, and enablers of foodservices in Canadian hospitals.

Hospital foodservice evidence and standards [13, 14] and the guiding principles informed the scope of the Canadian Hospital Foodservice Practice survey. The diverse hospital foodservice practices identified were deemed well suited to be assessed by survey. The co-chairs (JS, HF) developed a preliminary draft that was revised collaboratively and iteratively by 14 working group members from 8 Canadian provinces/territories and representing CMTF, Dietitians of Canada, the Canadian Society of Nutrition Management, and Nourish Healthcare. The survey included 55 questions on hospital demographics, foodservice organization and interdisciplinary collaboration, food production and meal service, menu standards, diets and meals, practices to prevent malnutrition, outcome assessment, and barriers/enablers to optimise practice (Supplementary File 1¹). The working group recruited participants with extensive knowledge on the survey topics (inclusion criteria: foodservice/nutrition manager in a Canadian hospital) through health authorities and professional networks in their respective regions from July to September 2018. Recruitment of participants aimed at a diverse sample from across Canada including various types of hospitals and geographical locations (Table 1). Potential participants were invited by e-mail with a link to provide informed consent to complete the self-administered survey via Survey Monkey. The survey was estimated to take 25 minutes to complete with no incentive offered. The study was approved by the Langara Research Ethics Board.

Quantitative data were analysed using IBM-SPSS^® Statistics (version 24.0, 2016, Armonk, New York) by frequency for categorical/ordinal variables and mean ± standard deviation (SD) or median ± interquartile range (IQR) and/or maximum and minimum for normally or non-normally distributed continuous variables, respectively. Qualitative questions were thematically coded manually by JS and a research assistant (TS) based on the question form and a review of all responses. Additionally, a qualitative research consultant (LEL) used NVivo^© (QSR International, version 12 Plus, 2018, Burlington, Massachusetts) for in-depth analysis. NVivo autocoding generated a list of themes (based on frequency) to provide initial insight on main themes and prioritize subsequent manual coding. LEL read responses to prioritize questions in depth to elicit key words and phrases commonly reported in the responses. Key words and phrases were queried to collate responses of similar meaning and initial coding was queried for additional information. When the review of the question responses and queries failed to yield any substantial new information, LEL outlined the qualitative analysis including topic descriptions, number of references to phrase/word, and key quotes illustrative of responses. The French data set was translated into English, collated with the English data set, and coded by themes of the English data set.

A total of 598 invitation e-mails were sent, with 400 individuals responding to the invitation, and 114 were excluded related to no informed consent (n = 9), no responses (n = 88), only demographic responses (n = 8), international (n = 1), not a hospital (n = 7), and other (n = 1). Forty eight percent (n = 286) of requested surveys were included in the analysis with 90% completed in English (n = 258) and 10% in French (n = 28).

This study is the most comprehensive to our knowledge of Canadian hospital foodservice. Another study on food and nutritional care in hospitals in 12 European countries in 1999 [15, 16] identified similar barriers, e.g., negative views of hospital food; lack of awareness of the problem of malnutrition; inadequate education, collaboration, and defined responsibilities among staff groups; lack of patient-centered menus and meal service allowing for choice and flexibility; and lack of prioritization of foodservices as an important part of therapeutic care. Consistent with our findings, this study [15] also found suboptimal practices of only offering 3 meals, no snacks at specific times and the “general menu” was most common, whereas energy- and protein-dense menus were available, but not widespread. In response to these observations, the Council of Europe adopted a resolution in 2003 [6], which acknowledges the problem of malnutrition in hospital, declares access to food in hospital as a fundamental human right [11], and provides approximately 100 evidence-based recommendations for food and nutrition care in hospital.

The resolution recommends nutrition-risk screening as an essential first step of nutrition care in all hospitalized patients [6], which is consistent with the Canadian Integrated Nutrition Pathway for Acute Care [12]. Contrary to this, only about a third of the survey respondents in the current study confirmed that patients were being screened for risk of malnutrition at admission, although about a quarter were not aware whether screening was done and of those that answered yes, a third didn’t know which tool was used. This apparent lack of awareness of nutrition care practice by foodservice managers is perhaps not surprising since risk status was typically not considered in diet ordering and about 40% of sites did not have a reporting structure combined with clinical nutrition services.

Another recommendation of the Council of Europe resolution is to develop national standards for hospital food provision to prevent malnutrition [6] and many countries have such standards [7–10]. Canada lacks national standards for hospital foodservice and a comprehensive review of food procurement and nutrition standards in public facilities recommended that: “given that meals are medically necessary hospital services under the Canadian Health Act, re-classify nutrition and foodservices from operations (cost focus) to patient care (health focus)” [17]. This recommendation is consistent with survey responses regarding the negative culture and attitudes towards hospital food as a support service instead of an essential part of care.

Any regional Canadian recommendations for hospital food are typically consistent with dietary recommendations for population health (e.g., limiting salt, fat, and sugar content of menus) [17]. This lack of focus on patients at risk of malnutrition is demonstrated in survey responses, e.g., CFG is a second most important factor influencing menu planning. Therapeutic diets were the top factor impacting menu planning, which is disconcerting considering that diabetes and cardiac diets were the most common therapeutic diets whilst high-energy, high-protein diets were less common in light of evidence supporting liberalized diets to promote adequate intake [18–21] and the association of restrictive therapeutic diets with increased risk for malnutrition [22].

In contrast to these Canadian findings, UK hospital food standards [7] have a different approach, which differentiates between “eating for health” in individuals at risk of malnutrition (i.e., high-energy, nutritionally dense food/drink) versus “healthy eating” to promote health in those not at risk (i.e., Eatwell Guide [23]) and promote a “patient-focused food and drink strategy”. This UK strategy has been supported by various initiatives, such as the Better Hospital Food Project [24] and Protected Mealtimes [25], aimed at improving patient food intake. Additionally, consistent with our observations that insufficient budgets were the most common perceived barrier to optimal foodservices, UK standards were deemed less effective when voluntary and/or not backed by adequate funding [26].

Prioritization of foodservice in health care as medicine has been identified as a lesson for Canada to learn from Denmark [27]. This has resulted in positive changes in foodservice practices as demonstrated by a Danish study [28] comparing practice from 1995 to 2003. This study found a decrease in centralized production (from 99% to 80%), increase in satellite kitchens (from 1% to 20%), decentralized plating or buffets (from 31% to 65%), more educated cooks/catering assistance (from 29% to 51%), and fewer unskilled workers (from 45% to 25%) allowing for point of service, personalized portion sizes, and higher-quality food produced in-house. These changes in practice are consistent with the survey themes on optimal foodservices of the current study, i.e., patient-centered, flexible, and allow for choice of quality food produced in-house by skilled staff. Another Danish study found that providing education and delegating responsibility to health care assistants for patient-centered nutrition care, such as ordering personalized food for nutrition risk patients, resulted in a decrease in food waste from 55% to 18% [29].

Although practices varied among sites, themes regarding optimal foodservices were mostly consistent and support the relevance and validity of the guiding principles, which could be used as a charter for hospital food policy and inspire the development of hospital foodservice standards to prevent malnutrition by a standard setting organization (Figure 1). The survey results are a call to action to address multiple gaps in and opportunities to optimize hospital foodservices aligned with evidence to prevent malnutrition, including:

We would like thank members of the Canadian Malnutrition Task Force Working Group for Food in Healthcare who informed the guiding principles and survey questions and shared the survey to potential respondents across Canada (Leslie Carson, Elaine Chu, Stephanie Cook, Elma Hrapovich, Jacqueline Noseworthy, Jennifer Reynolds, Michel Sanscartier, and Heather Truber) and foodservice/nutrition managers who took the time to share about their foodservice practices and views in the survey. Also, thank you to Laura E. Lagendyk for her expert guidance and Tillie Stainsby’s support in conducting the qualitative analysis.