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NIHR Signal Enriched food and snacks can increase nutritional intake in older people in hospital

Published on 20 March 2018

doi: 10.3310/signal-00573

Enriching hospital food with energy or protein may improve nutrition in older people in hospital.

Studies assessed in a systematic review showed consistent effects of enriched or fortified foods compared with usual nutrition. The extent of increased consumption varied depending on the amount and type of foods added.

Malnutrition is common in older people in hospital, but patients may not enjoy consuming oral nutritional supplement drinks. This finding supports the Government’s strategy for improving food and drink standards in NHS hospitals. Preparing foods containing added energy or protein is a simple way to increase nutrient intake that is likely to be cheaper than alternatives.

Flexibility in meal preparation and providing snacks when patients want them rather than at defined intervals may also be beneficial.

Share your views on the research.

Why was this study needed?

Older people are at risk of malnutrition when admitted to hospital, which can have long-lasting consequences. The 2017 NIHR themed review Comprehensive Care reported that after hospital admission those over 70 have slow functional recovery. Poor nutrition is also associated with complications such as pressure ulcers and infections. The reviewers sought to highlight the need for hospital staff to be vigilant around nutrition and to consider the other factors that contribute to malnourishment such as poor appetite, unfamiliar diets, unpalatable supplements and increasing energy needs.

Oral nutrition supplement drinks are commonly used, but patients often dislike their taste, texture, and effects on the digestive system. This review aimed to evaluate whether enriching the diet by providing meals high in energy and protein (defined as fortification) or providing additional snacks (defined as supplementation) could increase energy and protein intake among older people in hospital or rehabilitation centres.

What did this study do?

The systematic review identified 10 studies investigating energy- or protein-based fortification or supplementation in 546 adults aged over 60 years on average. Four studies were randomised controlled trials, and six were described as non-randomised experimental studies. Eight compared with usual nutrition and two compared with oral nutritional supplements. 

Two studies came from the UK, three from the Netherlands, two from Sweden, and others from Denmark, Spain and Australia. Settings were mostly general hospital or elderly care wards or rehabilitation centres. Studies were published 1996 to 2015. Quality varied from low to high. Combining the results in meta-analysis was not feasible because of variations in study design and outcome measures. This means that the overall effect and strength of the evidence is less clear.

What did it find?

  • Three studies comparing energy-based enrichment with usual nutrition showed the enrichment strategies increased energy intake by between 250 and 450 calories per day. This was mostly achieved by adding dairy products like cream or oils.
  • Three studies comparing protein enrichment with usual nutrition all showed the enrichment strategies to increase protein intake by 12-40g a day. Examples were protein-enriched yoghurt or bread.
  • Two studies assessing both protein and energy enrichment showed an increased intake of both nutrients: one study by about 700 calories and 16g of protein, and the other by five calories and 0.2g protein per kilogram body weight.
  • Two studies compared food enrichment with traditional oral nutritional supplement drinks and showed inconsistent results. One study found no difference in protein or energy intake between groups. The other reported that supplement drinks increased energy and protein more than food enrichment. However, this study was available as a conference abstract only, so the findings should be treated with some caution.
  • Four studies reporting on the acceptability of enriched foods. Two indicated little difference in taste preference between enriched foods and control products, while two found increased consumption of enriched foods. Two additional studies assessing cost effectiveness suggested that enriched foods may have a lower cost-per-calorie-consumed than oral nutritional supplement drinks.

What does current guidance say on this issue?

The NICE guideline on nutritional support recommends the following methods for oral nutrition support in people with or at risk of malnutrition:

  • fortified food with protein, carbohydrate and/or fat, plus minerals and vitamins
  • snacks
  • oral nutritional supplements
  • altered meal patterns
  • the provision of dietary advice.

The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals set several ‘required standards’ to improve food and drink across the NHS. The report recognised that some people might need more energy-rich food and drink to meet their daily nutritional needs than others.

What are the implications?

Providing energy or protein-fortified foods to older people in hospital seems a practical method to increase their nutritional intake.

The study mix makes it difficult to get a good indication of the best approach, but improvements seem consistent across all strategies. Cost-effectiveness data was also limited, but it's expected that meal enrichment would be cheaper than supplement drinks.   

This supports the Government’s strategy for improving food and drink standards in NHS hospitals. Together, these developments could influence future guidance in this area.

Flexibility in meal provision, and ensuring older people have necessary support at mealtimes, may also help.

Citation and Funding

Mills SR, Wilcox CR, Ibrahim K, et al. Can fortified foods and snacks increase the energy and protein intake of hospitalised older patients? A systematic review. J Hum Nutr Diet. 2018. [Epub ahead of print].

The authors were supported by the University of Southampton National Institute for Health Research (NIHR) Academic Foundation Programme, the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex.  Some of the authors were supported by Southampton Biomedical Research Centre.

Bibliography

Bally MR, Blaser Yildirim PZ, Bounoure L, et al. Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(1):43-53.

Covinsky K, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalised with medical illnesses. J Am Geriatr Soc. 2003;51(4):451-8.

Department of Health and Social Care. The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals. London: Department of Health and Social Care; 2014.

NIHR DC. Comprehensive care. Older people living with frailty in hospitals. Southampton: NIHR Dissemination Centre; 2017.

NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. CG32. London: National Institute for Health and Care Excellence; 2006.

Why was this study needed?

Older people are at risk of malnutrition when admitted to hospital, which can have long-lasting consequences. The 2017 NIHR themed review Comprehensive Care reported that after hospital admission those over 70 have slow functional recovery. Poor nutrition is also associated with complications such as pressure ulcers and infections. The reviewers sought to highlight the need for hospital staff to be vigilant around nutrition and to consider the other factors that contribute to malnourishment such as poor appetite, unfamiliar diets, unpalatable supplements and increasing energy needs.

Oral nutrition supplement drinks are commonly used, but patients often dislike their taste, texture, and effects on the digestive system. This review aimed to evaluate whether enriching the diet by providing meals high in energy and protein (defined as fortification) or providing additional snacks (defined as supplementation) could increase energy and protein intake among older people in hospital or rehabilitation centres.

What did this study do?

The systematic review identified 10 studies investigating energy- or protein-based fortification or supplementation in 546 adults aged over 60 years on average. Four studies were randomised controlled trials, and six were described as non-randomised experimental studies. Eight compared with usual nutrition and two compared with oral nutritional supplements. 

Two studies came from the UK, three from the Netherlands, two from Sweden, and others from Denmark, Spain and Australia. Settings were mostly general hospital or elderly care wards or rehabilitation centres. Studies were published 1996 to 2015. Quality varied from low to high. Combining the results in meta-analysis was not feasible because of variations in study design and outcome measures. This means that the overall effect and strength of the evidence is less clear.

What did it find?

  • Three studies comparing energy-based enrichment with usual nutrition showed the enrichment strategies increased energy intake by between 250 and 450 calories per day. This was mostly achieved by adding dairy products like cream or oils.
  • Three studies comparing protein enrichment with usual nutrition all showed the enrichment strategies to increase protein intake by 12-40g a day. Examples were protein-enriched yoghurt or bread.
  • Two studies assessing both protein and energy enrichment showed an increased intake of both nutrients: one study by about 700 calories and 16g of protein, and the other by five calories and 0.2g protein per kilogram body weight.
  • Two studies compared food enrichment with traditional oral nutritional supplement drinks and showed inconsistent results. One study found no difference in protein or energy intake between groups. The other reported that supplement drinks increased energy and protein more than food enrichment. However, this study was available as a conference abstract only, so the findings should be treated with some caution.
  • Four studies reporting on the acceptability of enriched foods. Two indicated little difference in taste preference between enriched foods and control products, while two found increased consumption of enriched foods. Two additional studies assessing cost effectiveness suggested that enriched foods may have a lower cost-per-calorie-consumed than oral nutritional supplement drinks.

What does current guidance say on this issue?

The NICE guideline on nutritional support recommends the following methods for oral nutrition support in people with or at risk of malnutrition:

  • fortified food with protein, carbohydrate and/or fat, plus minerals and vitamins
  • snacks
  • oral nutritional supplements
  • altered meal patterns
  • the provision of dietary advice.

The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals set several ‘required standards’ to improve food and drink across the NHS. The report recognised that some people might need more energy-rich food and drink to meet their daily nutritional needs than others.

What are the implications?

Providing energy or protein-fortified foods to older people in hospital seems a practical method to increase their nutritional intake.

The study mix makes it difficult to get a good indication of the best approach, but improvements seem consistent across all strategies. Cost-effectiveness data was also limited, but it's expected that meal enrichment would be cheaper than supplement drinks.   

This supports the Government’s strategy for improving food and drink standards in NHS hospitals. Together, these developments could influence future guidance in this area.

Flexibility in meal provision, and ensuring older people have necessary support at mealtimes, may also help.

Citation and Funding

Mills SR, Wilcox CR, Ibrahim K, et al. Can fortified foods and snacks increase the energy and protein intake of hospitalised older patients? A systematic review. J Hum Nutr Diet. 2018. [Epub ahead of print].

The authors were supported by the University of Southampton National Institute for Health Research (NIHR) Academic Foundation Programme, the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Wessex.  Some of the authors were supported by Southampton Biomedical Research Centre.

Bibliography

Bally MR, Blaser Yildirim PZ, Bounoure L, et al. Nutritional Support and Outcomes in Malnourished Medical Inpatients: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016;176(1):43-53.

Covinsky K, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalised with medical illnesses. J Am Geriatr Soc. 2003;51(4):451-8.

Department of Health and Social Care. The Hospital Food Standards Panel’s report on standards for food and drink in NHS hospitals. London: Department of Health and Social Care; 2014.

NIHR DC. Comprehensive care. Older people living with frailty in hospitals. Southampton: NIHR Dissemination Centre; 2017.

NICE. Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. CG32. London: National Institute for Health and Care Excellence; 2006.

Can fortified foods and snacks increase the energy and protein intake of hospitalised older patients? A systematic review

Published on 13 January 2018

Mills, S. R.,Wilcox, C. R.,Ibrahim, K.,Roberts, H. C.

J Hum Nutr Diet , 2018

BACKGROUND: Undernutrition affects over 44% of hospitalised older people, who often dislike oral nutritional supplements (ONS). This review summarises the evidence for an alternative strategy, using energy and protein dense meals (via fortification) or snacks (supplementation) to increase the dietary energy and protein intake of older inpatients. METHODS: A search was conducted through PubMed, EMBASE, CINAHL and the Cochrane database of systematic reviews (May 1996 to May 2016) that used fortification or supplementation to increase the energy or protein intake of patients (mean age >/=60 years) in hospitals or rehabilitation centres. RESULTS: Ten articles (546 patients, mean age 60-83 years) were identified. Compared with usual nutritional care, six studies using either energy or protein based fortification and supplementation significantly increased intake of energy (250-450 kcal day(-1) ) or protein (12-16 g day(-1) ). Two studies enriched menus with both energy and protein, and significantly increased both energy (698 kcal day(-1) and 21 kJ kg(-1) ) and protein (16 g and 0.2 g kg(-1) ) intake compared to usual care. ONS was similar to supplementation in one study but superior to fortification in another. Four studies reported good acceptability of enriched products and two studies that found they were cost-effective. CONCLUSIONS: Compared with usual nutritional care, energy- and protein-based fortification and supplementation could be employed as an effective, well-tolerated and cost-effective intervention to improve dietary intake amongst older inpatients. This strategy may be particularly useful for patients with cognitive impairment who struggle with ONS, and clinical trials are required to compare these approaches and establish their impact on functional outcomes.

Expert commentary

We know the demands of being in hospital are obvious, not least on the number of calories needed to deal with the rigours of being ill. Nearly everyone loses weight unintentionally – especially older adults. 

I know I have seen lots of supplements on bedside tables not being drunk. They are usually the wrong flavour or too warm to be tolerated. The idea of supplementing hospital food with protein and energy for vulnerable groups makes intuitive sense.

This review provides evidence to do just that and suggests it’s a much better alternative than endless decorative bottles. 

Dr Ollie Minton, Macmillan Consultant & Honorary Senior Lecturer in Palliative Medicine