Hunger-free hospital initiative: fighting “the skeleton in the hospital closet”

Malnutrition secondary to hospital stay has been underestimated for decades. In 1974, Dr. Butterworth, Jr. published his seminal article, The Skeleton in the Hospital Closet,[1] outlining the serious problem of physician-induced malnutrition of hospital patients in the United States. Indeed, hospitalized patients have the highest incidence of malnutrition[2]; in both developing and developed countries, the incidence of malnutrition among hospitalized patients is remarkably higher than that of community residents.[3] Outside the hospital, malnutrition may be caused by reduced intake, disease, or aging. However, in hospitals, patients are experiencing hospital-related or hospital-specific malnutrition-inducing factors, such as lack of proper screenings, a shortage of health care professionals, unsatisfactory hospital diets, interference from medical procedures. Geriatric patients, hospitalized children, and patients with chronic diseases are more vulnerable to malnutrition. Clinical trials in Europe have revealed that up to 20% to 60% of patients are malnourished on hospital admission, and 30% to 80% of patients will have some degree of weight loss during their hospitalization.[4] The occurrence of nosocomial malnutrition (NM) or hospital-acquired malnutrition (HAM) further aggravates disease-related malnutrition (DRM)[5–26] (Figure 1).Figure 1.: A list of recent research studies on DRM[ 5–26 ] (%). The SGA tool was used to assess malnourished status, and the NRS-2002 survey tool was used to screen for the risk of malnutrition. COPD, Chronic obstructive pulmonary disease; DRM, disease-related malnutrition; NRS, Nutritional Risk Screening; SGA, Subjective Global AssessmentMalnutrition has adverse effects on both the patient, family, and society as a whole. An international, multicenter, multidisease, and large-scale study found that patients at nutritional risk have significantly higher mortality rates (12% vs. 1%), longer hospital stays (9 vs. 6 days), and more complications (hazard ratio 3.47) compared with patients not at nutritional risk.[27] Malnutrition also increases medical costs creating a burden on family and society. The Food and Agriculture Organization (FAO) of the United Nations stated in 2014 that at least $2.1 trillion was spent to combat undernutrition and food deficiencies globally.[28] The direct cost of malnutrition in the United Kingdom was estimated to be 19.6 billion pounds, accounting for 15% of total medical expenses in 2011–2012.[29,30] Nutrition therapy not only provides nutrients, but can also regulate metabolism and improve immunity to fight against diseases. It has been demonstrated that nutritional treatment for hospitalized patients reduces the length of hospital stays, avoids complications, and improves survival rates.[30] The use of oral nutritional supplements (ONS) has shown obvious decreases in medical expenses by 12.2% to 21.6% and in hospital stays by 2.3 days (~21%).[3,31] Nevertheless, no widely accepted solutions have been proposed to appropriately solve this important medical problem despite its high incidence rate and severe consequences. More than 40 years has passed since Dr. Butterworth’s publication in 1974, Dr. Butterworth’s skeleton is still in the hospital closet as Souza et al pointed out in their review in 2015.[32] Herein, the Hunger-Free Hospital (HFH) is advocated. This review aims to raise the awareness of NM, by attempting to inspire research to address hidden hunger in hospitals and to optimize hospital management and administration. At an HFH, patients are provided with reasonable, healthy, and cost-effective nutritional therapy to prevent HAM and treat DRM effectively. Strengthening the nutrition diagnosis Malnutrition definition and assessment tool A lack of clear definitions and diagnostic criteria puts a burden on health care providers when giving nutritional advice and nutritional therapy prescriptions. A new global consensus from leaders in malnutrition—the Global Leadership Initiative on Malnutrition (GLIM) criteria advocates that malnutrition be defined as non-autonomous weight loss, reduced energy reserve, and protein deficiency, which is also known as protein-energy malnutrition (PEM).[33] The current main assessment parameters of malnutrition are: (1) body mass index (BMI) or weight change per unit time for body weight, (2) fat mass for energy reservation, and (3) muscle mass for protein. GLIM criteria for the diagnosis of malnutrition includes one phenotypic criterion (weight loss, low BMI, or reduced muscle mass) and one etiologic criterion (reduced food intake or inflammation).[33] Systematic review and meta-analysis showed a better diagnostic value for the GLIM criteria compared to the subjective global assessment (SGA) as a reference standard, and have the potential to be used as a gold standard for diagnosing malnutrition in clinical practice.[34] Hvas et al weighed each items of GLIM criteria and developed a scored-GLIM system, validating and evaluating studies concluded that the accuracy and net clinical benefit of scored-GLIM system were similar to scored- patient-generated (PG)-SGA but higher than GLIM both in nutrition assessment and in survival prediction for patients with cancer.[35] Nutrition assessing team All level-III hospitals (tertiary hospital) should set up nutrition assessing team (NAT). Just as Computed Tomography (CT) team or ultrasound team in the hospital, NAT is an independent unit from clinical nutrition department. Its duty is solely responsible for nutritional screening and assessment of all patients. After the technicians finish the nutrition screening and/or assessment, Physician Nutrition Specialist will make the nutrition diagnosis. Dual diagnosis Nutrition status should be considered as one of the clinical vital signs as temperature, pulse, respiration, and blood pressure. All patients admitted to hospital should routinely receive nutrition screening. A dual diagnosis, which consists of diagnosing the primary disease and the nutritional status, should be implemented in hospitals on admission. A nutritional diagnosis aims to identify the patient’s nutritional status and determines whether the patient is at any risk of malnutrition. Identifying the patient’ s nutritional status allows for a personalized treatment regime that suits his/her medical needs. A plus nutritional diagnosis should be seen as an essential part of the routine measures on admission. At present, nutritional diagnoses are rarely performed in hospitals. Standardizing the nutrition care Nutrition support team A multi-disciplinary nutrition support team (NST) is important for it allows a rich array of specialists of different disciplines to work together effectively as one team.[33] Cong et al[34] reported that in esophageal cancer patients undergoing chemoradiotherapy, those assigned to an NST showed better nutritional status, reduced side effects, and improved compliance of treatment and rates of therapeutic completion compared to controls. Hvas et al[35] reported that an NST improved the utilization of clinical enteral and parenteral nutrition, enhanced the safety of parenteral nutrition, and reduced nutrition-related complications. However, more than 90% of top-ranking hospitals in China have not established NSTs. The application of NSTs in hospitals is essential for the construction of HFHs. At an HFH, the NST and the clinical nutrition department work closely to provide adequate and accurate nutritional support to patients in need. Nutrition wards or nutrition care unit Level-III hospitals (tertiary hospital) are encouraged to set up nutrition wards or nutrition care unit (NCU). A nutrition ward or NCU is the professional unit to care the patients with severe malnutrition or the malnourished patients with severe complications. As malnutrition affects patient’s physiology, psychology, behavior, function, and structure, the efficacy of the nutrition treatment needs to be evaluated comprehensively. A dynamic monitoring of parameters and their changes throughout a nutritional treatment is necessary in order to adjust therapeutic protocols accordingly and appropriately. A period of 2 to 4 weeks is recommended as a standard treatment course for patients with severe malnutrition since the body takes time to response to nutrition. Therefore, in an HFH, nutritional diagnosis and treatments should be incorporated into the routine care path for patients with major chronic diseases and for surgical patients, especially patients with malignant tumors. Additionally, diagnostic and treatment therapies should be standardized, as shown in Figure 2.Figure 2.: Diagnostic and therapeutic standardized processes of nutrition. EN, enteral nutrition; MD, Metabolic Disorder; ONS, oral nutritional supplements; SPN, supplemental parenteral nutrition; TF, tube feeding; TPN, total parenteral nutrition.Enhancing nutrition education, training, and competencies Physicians are viewed as critical and credible sources of nutritional guidance and dietary information for patients.[36] However, in a recent survey, 77% of hospital directors from different hospital departments believed they were not meeting the graduate medical education (GME) requirements in nutrition. Doctors at other levels may be even worse. Insufficient nutrition knowledge and inappropriate diet counseling may cause unpredictable consequences for malnourished patients. Doctor-provided nutritional care may be inadequate due to low nutrition knowledge, low confidence, and unfavorable attitudes toward incorporating nutrition in patient care.[37] Therefore, a doctor’s lack of nutritional knowledge may result in misinformed patients, which could lead to worse clinical outcomes. Thus, efforts to improve undergraduate medical education (UME) and GME in nutrition are needed, including a minimum of 25 course hours in nutrition-related lectures and/or hands-on experience, incorporating nutrition education into residency programs, and setting up fellowship programs.[38] Optimizing therapeutic dietary regimens and reducing interference from medical activities Treatment interference is a serious hinder to sufficient intake of hospitalized patients. Patient intake may be significantly reduced by invasive or prolonged medical examinations or treatments, for instance, colonoscopies, operations, hepatobiliary B ultrasounds, etc. In some countries, including the United Kingdom, Canada, and Australia, protected mealtime policies have been introduced in hospitals to promote a conducive eating environment, to provide adequate supportive assistance while eating, and to place food first during mealtimes.[39,40] Arranging for examinations to occur outside of mealtimes is crucial to reduce fasting time and to protect mealtimes. The timing of the administration of treatments or drugs is also important. Medical activities requiring fasting and bowel preparation should be arranged in the morning to allow for an early diet restoration. Drugs that suppress appetite and disturb gastrointestinal function should not be taken before meals. Medical activities and operations should not be arranged during breakfast, lunch, or dinner times to protect mealtimes and the eating environment. Intravenous infusions may negatively affect a patient’ s appetite, therefore limiting the use of intravenous infusions may encourage a patient’ s dietary intake. Improving hospital diet service The HFH improves the hospital diet, increases frequency and duration of supply, ensures food security, and provides ready-to-use nourishment. Standardized diet in the hospital Internationally, only a few countries or regions, such as Wales, Scotland, Victoria, New South Wales, and New York City, have uniform dietary standards in hospital. A study in the United States and the United Kingdom compared the diets in hospital and in prison, and found that the supplies of energy, protein, and other nutrients in hospitals were inferior to those in prisons.[41] A survey in Canada[42] analyzed 84 menus in three large hospitals and found that the mean energy for all menus was 1281 to 3007 kcal, the protein was 49 to 159 g (0.9–1.1 g/kg/d), and the energy was less than 1600 kcal in about 45% of the menus. When compared with dietary reference intakes (DRI), common menus met 0%, 7%, 57%, and 100% of the requirements for fiber, calcium, vitamin C, and iron, respectively. When compared with Canada’s Food Guide (CFG), only 35% of the menus met the dietary recommendations for vegetables, fruit, and milk and alternatives, only 11% met the recommendations for cereal products, and only 8% met the recommendations for meat and alternatives. These examples demonstrate the importance of standardizing hospital diets and strengthening dietary supervision in hospitals. To tackle this problem, New York City issued the Healthy Hospital Food Initiative (HHFI) and formulated 20 requirements for a healthy diet in New York City hospitals.[43] This initiative has set an example for the rest of the world regarding diminishing malnutrition in hospitals. Food security in hospitals Food security is essential in hospitals for two main reasons. First, patients need safe, adequate, and nutritious meals to maintain their health and to recover from illness. Second, a delicious and appealing meal helps to boost patients’ appetites and encourages dietary intake. Caution is needed throughout the food supply chain in the hospital, standardizing the procedure of food preparation. Emphasis needs to be placed on the training of staff and the team building of food handling personnel to improve food processing skills and ensure that sanitation requirements are met. Create a healthy food environment The food environment has an impact on food choice, therefore, creating a healthy food environment is important in an HFH. Many studies[44–47] have outlined the interaction between food environment and food choice; therefore, it is important that an HFH provides a healthy and sound food environment. An HFH with a friendly food environment encourages the intake of healthy food and does not promote the consumption of unhealthy products, such as sugar-sweetened beverages, fried items, ultra-processed food, etc. In particular, it is imperative to set nutrition standards that reduce access to sugary drinks, carbonated drinks, and unhealthy foods in hospitals.[48] Studies have highlighted the need for improving the healthiness of food and the environment in hospitals. Tsai et al[49] stated that in their audits of two major hospitals in Australia, only 7% of fixed outlets and 23% of vending machines provided >75% of every day (“healthy”) foods, and that improvement of the food environment at these hospitals was needed. Moran et al[43] reported that after the introduction of New York’ s HHFI, most hospitals in New York City had adopted a strict nutrition standard. There are many strategies for providing a healthy food environment, including strategic placement of food, increasing the availability and accessibility of healthy food in hospitals while decreasing that of unhealthy products, and optimizing catering services. Improve catering services in hospitals Catering services in a hospital can be improved in the following aspects: increase the frequency of supply, increase the variety and flavor of meals, extend the time of availability of supply, improve the dining environment, and provide dietary advice. Personalizing a plan for additional meals and midnight snacks improves provision for patients. Vending machines and specialty shops can be set up to provide ready-to-use supplementary food (RUSF) and ready-to-use therapeutic food (RUTF). Studies have found that RUSF and RUTF have a definite effect on the treatment of acute or chronic malnutrition caused by a variety of reasons. They are also widely welcomed by children, adults, and elderly patients.[50,51] Supplementing or strengthening certain nutrients such as DHA, EPA, and arginine in RUSF can become RUTF, which not only can effectively treat malnutrition, but can also play a role in the treatment of diseases.[52,53] For instance, RUSF improves the height-for-age and body-mass index-for-age Z scores in children with sickle-cell disease. Malnutrition in hospitals should not remain as a feigned, invisible problem. Immediate action is warranted against malnutrition, and it needs to be more than a slogan or a protocol. An interdisciplinary, heightened action involving administrators, physicians, dietitians, nurses, catering staff, and patients and their family members, is needed to eliminate hospital malnutrition. The HFH initiative is the solution to “the skeleton in the hospital closet.” Acknowledgments We would like to thank the support from the Chinese Society of Nutritional Oncology, Chinese Anti-Cancer Association. Funding This work was supported by the National Key Research and Development Program of China (Project No. 2022YFC2009600). Author contributions Han-Ping Shi and Xin Wang are responsible for the study design, conceptualization, systematic review, project administration, the decision to publish, and manuscript preparation. Yun Yang revised and edited the manuscript. All authors have read and approved the final manuscript. The authors confirmed that this work is original and has not been published elsewhere, nor is it currently under consideration for publication elsewhere. Conflicts of interest None.

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