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Crea un sito web gratis Webnode. Ti piace questo stio? Respiratory problems. Impaired digestion. Impaired absorption.

Excess losses from the gut. Modified metabolism. Metabolic response to disease. Metabolic consequences of impaired organ function. Prior to investigative procedures or operations, missed meals due to these procedures or avoidance of food due to diarrhoea.

Sore mouth due to disease process or partial gastrointestinal obstruction. Dysphagia e. Physical handicap, arthritis, dementia.

Pulmonary disease. Pancreatic insufficiency, enzyme deficiencies e. Intestinal resection short bowel syndrome , mucosal damage e.

High output fistulae, protein-losing enteropathy, short bowel syndrome. Malignancy cancer , trauma, chronic sepsis, multiple organ failure, advanced HIVinfection.

Renal disease, liver disease, pulmonary disease. Individual factors of central importance are difficulties in swallowing or chewing, including poor oral health Gariballa et al.

Emotional problems depression are one of the most common reversible causes of undernutrition particulary in old persons Cederholm et al.

Alternatively, even subclinical nutritional deficiencies result in depressed cognitive state Sullivan et al. A specific cause of undernutrition is 31 identified among patients with eating disorders, particulary patients suffering from anorexia nervosa.

These patients do not want to eat because they have an intense fear of gaining weight and undue preoccupation with body shape - even when they are underweight American Psychiatric Association Other causes are old age Beck et al.

In France healthy male hospital employees, years of age, were offered exclusively the food served to the patients at that hospital for 5 consecutive days Ravel et al.

The food provided 9. This underlines the difficulties to achieve a sufficient energy intake in sick patients. If systemic factors are present eating without aid is difficult Kennedy et al.

Also, there are the effects of hospitalisation and treatment on nutritional status, including inappropriate dietary choice, the interruption of meals by staff, missed meals due to therapeutic or investigative procedures, and lack of flexibility in hospital food service systems Pennington Other causes It is a long-standing surgical tradition, and still routinely performed Cheatham et al.

Besides, a recent meta-analysis, which compared enteral feeding or free oral intake started within 24 hours after surgery with the traditional nil-by-mouth routine found a decrease in risk of infections and length of stay among patients fed early Lewis et al.

For many years overnight fasting has been a routine before surgery to reduce the risk of aspiration of stomach contents during anaesthesia.

However, studies have shown that the stomach is emptied 90 minutes after ingestion of both a carbohydrate-rich drink and water Nygren et al.

It appears that the patients could be allowed free intake of clear energycontaining fluids until 2 hours before anaesthesia, but many patients are starved for longer periods preoperatively than is physiologically necessary Holmes Difficulty in finding the optimal scheme for bowel preparation before a diagnostic barium enema is reflected in the large number of preparation schemes.

In spite of data showing that the importance relies on the type of medication used in the cleansing protocol Present et al.

An effective management of patients implies that it is necessary to go further than solely to assess nutritional status, but also to address the underlying causes of undernutrition, since their correction may result in improvement without elaborate nutritional support.

Effective management of undernutrition, therefore, is not solely a nutritional exercise. The undernutrition must be seen in the context of an overall clinical picture Allison This implies that disease-related undernutrition should be treated as any other clinical diagnosis.

This effect has also been demonstrated in patients who were only mildly undernourished, but exposed to severe catabolic stress Green see table 2.

Table 2. Fractured femur Oral supplements reduce complications and LOS among old women with low skin fold measurements A 3. Liver cirrhosis4 Providing adequate enteral nutrition or TPN improves some parameters of liver function in patients with chronic alcoholic liver diseases with poor food intake.

Data are inconclusive to determine whether the morbidity and mortality is decreased A. AIDS TPN, enteral and oral nutritional support may prevent or reverse weight loss and replenish body cell mass in patients who have poor food intake or malabsorption, and do not have an active opportunistic infection A.

Trauma gastrointestinal surgery Patients in good nutritional status fed by early enteral nutrition have fewer complications than those given TPN A.

In a number of cases it would seem unethical to perform such trials. If so one has to rely on uncontrolled published experiences or case reports level C recommendation Klein et al.

The clinical benefit of nutritional support has primarily been obtained by means of artificial nutritional support.

However, in recent years nutritional support studies using energy-dense menus have also been published Barton et al.

All studies have demonstrated an increased energy intake by using energy and protein dense menus, but unfortunately none of these studies have examined the effect on clinical outcome.

In the study by Gall et al. In the study by Barton et al. With the use of the scoring system presented in table 2.

A high number of studies have found no clinical beneficial effect of artificial nutritional support, primarily in the form of parenteral nutrition Klein et al.

This has resulted in level A recommendations against the routine use of parenteral nutrition for patients receiving chemotherapy, radiotherapy or waiting for surgery American College of Physicians , Buzby et al.

Overuse and improperly use of artificial nutritional support could explain the lack of positive findings Souba , Torosian Another explanation could be that the duration of the nutritional support was too short.

Also, there are inadequate data to assess the efficacy of parenteral nutrition in patients who are severely undernourished Koretz et al.

Finally, disease-related undernutrition is caused by many factors see table 2. Only randomised controlled trials will ultimately teach when to feed and how.

The positive effect of postoperative nutritional support demonstrated in undernourished old people recovering from hip fracture Klein et al.

The scientific evidence was found to be weak, and it was recommended that future studies should be conducted with specific consideration on sample size, methodology and outcome assessment.

However, nutritional support should always go hand in hand with other correctional measures. Nutritional support pre- and post-hospitalisation The average length of stay in somatic European hospitals is between 5 and 10 days.

However, these figures cover a wide distribution, stressing the importance to assess the nutritional risk of the patient already at the admission to the hospital.

The authors concluded that with a 5- to 7-day acute in-patient stay, the impact of nutritional support on nutritional status is limited, and that nutritional support should be extended to pre- and post-hospitalisation periods.

Studies have shown that patients followed for up to 4 months after discharge had not regained their preoperative weight Beattie et al.

A study of old female patients after discharge from hospital for emergency and elective orthopaedic surgery suggests that nutritional losses continue for some time after discharge.

Studies have shown that nutritional support either preoperatively or after discharge improve both the nutritional status and the well being of patients Beattie et al.

Otherwise efforts and costs in hospitals will be lost. This should not lead to the misconception that one should not have to care very much about these problems in hospitals: 1 Many of the nutritionally at risk patients have a long stay in hospitals.

And 3 When discharged from hospital, it will be the duty of the hospital to prescribe a treatment plan to be followed, and also in some cases the hospital will be responsible for follow-up after discharge.

Immune-modulating oral or enteral nutritional support Certain key nutrients L-arginine and L-glutamine, ribonucleic acid RNA and the n-3 essential fatty acids EFA seem to be able to modulate a variety of inflammatory, metabolic, and immunological processes when ingested in excess of the normal daily requirements.

Meta-analysis of recent trials suggests reduced risk of infections, fewer days on a ventilator, and reduced length of intensive care and hospital stay, and reduced hospitalisation costs, but mortality does not appear to be affected Beale et al.

Thus, a level A recommendation i. Besides, consensus recommendations regarding its use were made U. Summit Consensus Panel Another question is whether benefits of immunemodulating nutritional support in patients suffering from shock, sepsis and organ failure are equal to those in moderately traumatised surgical patients.

In this context it should be noted that meta-analyses did not show any improvements in the former group of patients, rather demonstrated a tendency towards a poorer outcome Beale et al.

These results might be a serious warning to the unrestricted use of immune-modulating formulas in the most seriously ill patients Heyland et al.

Finally, no studies have examined the clinical benefit of immune-modulating nutritional support among the majority of patients - those who are not critically ill or suffering from surgical stress.

In a study from Denmark the use of appropriately designed and targeted energy and protein dense hospital menus prevented the weight loss normally observed during hospital stay Kondrup et al.

Others have been quite successful in improving the intake of ordinary hospital food with simple means. These sip feedings can be a valuable addition to the hospital food for some patients with low intake.

Hospital food, including sip feedings, can often bring intake to desired levels, and only if these measures fail or are inappropriate artificial nutritional support becomes necessary Lennard-Jones The majority of the early published studies of nutritional support, used parenteral nutrition.

However, since then studies reporting the effect of enteral or oral supplements sip feedings has been steadily increasing table 2.

Conclusions from a systematic review Potter et al. The benefits of routine nutritional supplementation are not restricted to particular subgroups or trials.

More old people than young adults have been studied, and for each outcome the old people seem to benefit as much as the young.

Considerable uncertainties remain; thus large pragmatic randomised controlled trials of routine oral or enteral nutritional supplementation are justified.

In general better hospital food provision may diminish the necessity to use sip feeding and artificial nutrition, and allow earlier weaning from these treatments.

This may cause worthwhile reductions in costs and offset any increased expenditure on food service. Sip feedings should not be used as a substitute for the adequate provision of normal food, and should only be used if there are clear clinical indications Allison The caring professions have an ethical duty to recognise and treat undernutrition, as part of optimal care for patients - usually by attention to drinking and eating but also by means of artificial nutritional support.

Only when such care prolongs the period of dying or maintains an unacceptable quality of life should artificial nutritional support be reconsidered Lennard-Jones All professionals are influenced by own personal experiences.

There are specific instances, however, where force is legal and even ethical, e. Withholding or withdrawal of artificial nutrition and fluids often implies ethical considerations, and it is a decision that is always difficult and often controversial.

Unlike other medical treatments, food and feeding has an emotional and symbolic significance for many people playing a significant role in religious, cultural and ethnic traditions, and has evolved as a symbol of caring and comfort ASPEN As a consequence, some physicians, hospitals and judges have held that withdrawal of artificial nutrition and fluids from a patient in a persistent vegetative state would be similar to murder.

However, professional medical groups and courts of final jurisdiction have consistently concluded that artificial nutritional support is legal medical treatment and not basic care.

Furthermore, where there is evidence that the patient would not want such treatment, its withdrawal is an acceptable medical practice Lennard-Jones , Paris Today a wealth of techniques to deliver artificial nutrition exists.

As evidence accumulates that undernutrition impairs and nutritional support improves outcome, the more it becomes apparent that failure to consider these techniques, is not only a failure of the duty to do good and avoid doing harm, but may well be construed as negligence and lead to court.

Artificial nutritional support will often be initiated in patients with e. An expensive but ineffective nutritional treatment provided to one patient might reduce the resources in money, staff and equipment available to treat another patient who might benefit.

It is not easy to recognise when the patient is close to the end of life, and when artificial nutritional support is futile or indeed harmful or uncomfortable.

Even though such 40 cases could be settled by court, it is important to bear in mind that relatives are acutely aware of the smallest details of care as their loved one dies and recall incidents long afterwards.

It is essential that their memories should be free from anger or resentment against the physicians and other health care professionals at this critical time LennardJones The European Association for Palliative Care has made guidelines, which deal with some of the raised topics Bozetti b.

Also the 4 principles of beneficence, nonmalfeasance, autonomy and justice may be used to assist the physician in the decision as to whether to feed or not to feed MacFie The decision to terminate artificial nutritional support does not mean that oral intake should be terminated.

Ordinary hospital food and fluids should be offered to all patients capable of oral intake. Providing food and drink is an important expression of concern and caring Gastmans Hence, all attempts to maximise the actual or illusory sense of nurturing, caring and comfort provided by ordinary food should be encouraged ASPEN Children 2.

Besides, children cannot survive starvation as long as adults because of their lesser stores of energy substrates relative to their higher rate of energy expenditure Cunningham Assessing and treating undernutrition Screening paediatric patients at risk of undernutrition is relatively easy to perform by evaluating the growth charts weight-for-age, height-for-age and weight-for-height.

There is general agreement that all children admitted to hospital should have a growth chart that is updated weekly, but often the reality is that this is not done.

The use of growth charts is also important in children after discharge, especially in those with chronic disease Fjeld et al. Assuring that all children admitted and followed as outpatients have an updated growth chart is pivotal in improving nutrition in hospitals.

There are 2 main types of undernutrition in children: wasting low weight-for-height and stunting low height-for-age.

The anthropometric indicator most often used is weight-for-age, but this is inferior to weight-for-height and height-for-age, as a low weight-for-age does not distinguish between wasting and stunting.

The 3 anthropometric measures can be expressed as percentiles, standard deviation scores SDS or percent of median Fjeld et al.

As in adults, nutritional risk assessment should involve both nutritional status and severity of disease. Such simple screening methods have been developed and found useful among paediatric patients Reilly et al.

A simple strategy for improving the intake of ordinary food by undernourished hospitalised children is given in table 2.

Increase energy density and frequency of meals. Favourite dishes should be available round the clock. No reasons to focus on protein The protein requirement is almost covered when the intake energy requirement is covered.

Give a multi vitamin-mineral This will cover for some of the possible deficits due to tablet the disease or an unvaried menu.

As in adults, ordinary food should always be the first choice of nutritional support. If that is not sufficient the energy density of the ordinary food should be optimised.

Sip feedings could also be used, but children often do not like these. If energy intake is still not sufficient enteral feeding should be started without unnecessary delay.

Parenteral nutrition should only be started if nutrition via the enteral route is not sufficient Michaelsen Enteral nutrition seems as effective as parenteral nutrition in maintaining nutritional status Papadopoulou et al.

In the first 3 years of life a traumatic incident could lead to total refusal of food. Enteral feeding should be used in this case.

If the child is over 3 years, psychological treatment should be considered Wilson Children under 4 years need nutritional support within 24 hrs after surgery due to their low energy reserves.

Children above this age should meet their nutritional requirements within 3 days after surgery. Early start of nutritional support is also recommended in children with cancer den Broeder et al.

Few children start to regain weight and height during hospitalisation. However, the use of long-term artificial nutritional support after discharge has been found to result in improvements Kist et al.

The magnitude of the problem Relatively few studies have assessed the prevalence of undernutrition among children in hospitals.

However, a common finding is that a significant proportion of the children are underweight-for-age, stunted or wasted Hendrikse et al.

As in adults, the prevalence of undernutrition increases during treatment and after discharge Lenssen et al. The data about the causes of undernutrition are sparse, except with regard to the disease related causes, e.

There is no clear assigned responsibility with regard to nutritional care and support, and food service.

There is a lack of nutritional practices, which suggests that improved education with regard to clinical nutrition is needed for all health care professionals involved in the nutritional care and support of the patients.

More specifically the staffs need appropriate training and suitable protocols and aid by nutritional support teams for the early identification and treatment of nutritional risk patients.

Beside this there is a need for improved communication and co-operation between different staff categories. In spite of the apparent gloomy situation several initiatives are going on to improve the situation including the initiation of nutritional education programmes.

Table 3. The impact on parenteral nutrition when a nutrition support team NST authorises the supply Newton et al.

Therefore, it is important that physicians, nurses, dieticians and food service staff, and hospital management work together, as for example in an NSC.

It is, however, important to look at the provision of meals in hospital food service systems as a management issue. Hospital food service is a complex process where food becomes meals and where meals become nutrition, and where many different actors are involved.

Therefore, management must give priority to create the organisational framework in which food service and nutritional issues can be discussed.

Responsibilities for the NSC could be to negotiate and manage the food service system and nutritional support, and to ensure that the hospital purchasing authorities include contract specifications regarding food service and nutritional supports, to establish NSTs, to set standards for the nutritional risk screening, so that risk patients are recognised, to develop protocols for the action to be taken, when a risk patient is identified and to implement an agreed process of audit in this context see Silk , for suggestions for further responsibilities.

Some of the suggested responsibilities for the NST could be to implement the standards of nutrition support agreed by the NSC, monitor patients receiving nutritional support and audit its clinical activities see Howard and Jonkers et al.

The recommendations are very similar. Still, responsibilities seem to be unclear in many wards table 3. A study from Denmark has shown that there is a lack of agreement between nurses and physicians when asked who they think are responsible for the nutritional care of the patient Rasmussen et al.

In practice, however, this seldom functions. In a survey of the hospitals in the Nordic region the specific requirements for communication were outlined based on meal ordering, time frame, information, flexibility and co-operation Nordic Council of Ministers, One characteristic of these hospitals was that the food service and ward personnel had co-operated in the design of meal order forms.

Other characteristics were a varied food delivery system, menu choices, and existence of contact persons and NSCs.

There were some discrepancies in the answers from, respectively, ward and food service staff. As an example, the management of 12 hospital food services stated that the patients had a choice of menu, however, in only 5 of the hospitals the ward staff were aware of this.

In England a new role of ward housekeeper is being developed. The ward housekeeper will be part of the ward team and will be responsible for making sure that patients receive a food service, which meets the needs of the patients.

They will play an important role in communication. None of the official recommendations from, respectively, Denmark, Sweden, Norway and Finland deal with the communication and co-operation between hospitals and 47 primary health care sector.

Today this kind of communication is virtually non-existent, however, due to the very short length of stay for many patients, communication between hospitals and primary health care sector should be improved.

Also the nutritional treatment plan should include suggestions for monitoring, e. In practice however, routine nutritional risk screening and assessment is generally not performed at admission or during hospitalisation table 3.

When it is performed body weight, recent weight loss and BMI are used most frequently as screening tools. Neither is nutritional counselling commonly practised.

Finally, the use of nutritional support for undernourished patients and nutritionally at-risk patients is sparse and inconsistent.

The most common explanations why nutrition-related practices are not done are lack of time, staff, nutritional education and interest, while none of the European countries put the blame on the quality of the food Appendix 2.

The reported lack of nutritional practices are documented in many studies Almdal et al. The prevalence of nutritional assessment, recording of food intake and body weight measurement according to a Danish survey Rasmussen et al.

Examples of these were misapplication of nutritional support, misuse of parenteral nutrition, too short treatment periods and high rates of complications Braga et al.

There does not seem to be consistency across Europe with respect to nutritional support practices Howard et al. Hence, European hospitals face two major common problems: 1 Lack of clearly defined responsibilities in planning and managing nutritional care.

And 2 Lack of cooperation between different staff groups see also Appendix 4. The gloomy situation may not apply to intensive care patients Preiser et al.

However, recent data show that nutrition support provided is inappropriate Montejo et al. It must be recognised that there are several initiatives going on in the European countries to improve the situation with respect to the nutritional practices see Appendix 2.

In the United States sufficient nutrition is part of the general requirements for approval of hospitals. These requirements have formed the basis of similar standards in the Danish Copenhagen hospital corporation, now undergoing accreditation by the Joint Commission International.

All patients identified, as nutritionally at risk by the patient screening mechanism shall undergo a formal nutritional assessment.

The formal nutritional assessment shall be performed by or under the supervision of a clinical dietician or a physician and be documented and available to the patient care providers.

A NST shall function to assess and manage patients to be nutritionally at risk. The patients shall be monitored for therapeutic and adverse effects and clinical changes that may influence nutritional support.

Reassessment and the resulting changes in the nutritional support plan shall be documented. The same is the case with regard to the nurses and most other health care professionals Appendix 2.

Apparently only clinical dieticians acquire some knowledge and skills in nutrition during pre-registration training. This assumption is certified in a survey where different staff members completed a questionnaire regarding undernutrition.

The results showed that the clinical dieticians had most correct answers followed by the medical students.

Hence one major common problem exists in Europe - the lack of sufficient educational level with regard to nutrition among all staff groups.

Teaching has lagged behind nutritional research, which has forged ahead, increasing the gap between knowledge and practice.

This means that it might be difficult for individual physicians, who use nutritional support techniques only occasionally see e.

PayneJames et al. According to a European survey performed by the education committee of the European Society of Parenteral and Enteral Nutrition ESPEN in there were no organised post-graduate courses identified for either physicians or nurses in any of the participating countries Howard et al.

The same interest in nutrition was found in a Danish survey, however, with exception of the ICUs, there was a large discrepancy between attitudes and practices Rasmussen et al.

Based on the survey performed by the education committee of ESPEN some general educational themes that could benefit from a more focused approach were identified table 3.

Educational themes that should require high priority Howard et al. The content of training programmes for clinical staff.

Nutritional assessment methodology. Nutritional assessment. Estimation of nutritional requirements. Nutrient metabolism. Regulation of metabolic pathways.

The impact of nutritional disorders on clinical status. Nutritional support and outcomes. Nutrition in specific diseases. Specific nutrient-related diseases.

Physicians A study conducted by a working party of the British Association of Parenteral and Enteral Nutrition BAPEN found that almost half of the physicians, who did not know whether their patients had been weighed, regarded measurement of body weight as unimportant.

This reason was also given by approximately two thirds of the physicians who did not ask simple questions about recent weight loss and altered food intake Lennard-Jones et al.

Lately some important initiatives in this context have been started see also Appendix 2. Also, national nutrition societies were requested to inform health and educational authorities as well as the medical schools FENS Until now only the IUNS has received the recommendations, and further work has apparently been suspended B.

Miranda-daCruz, personal communication. It is now the official programme in the field. Chambers of physicians in the various federal states, as well as other organisations are offering the curriculum.

Participation in this hour course is certified by the chambers, but some legal aspects still need clarification.

In medical schools comprehensive nutrition education is not yet available Schauder et al.

The United States has already introduced nutrition education in the majority of medical schools Schulman This has happened by means of free distribution of computerassisted instructions see e.

Also, the above-mentioned courses in nutritional support, which are held each year by ESPEN, are helping to meet some of the identified specific needs.

Finally, relevant contacts in relation to improvement of education could be the Standing Committee of European Doctors www. Nurses Compared to physicians the nurses seem to show a greater interest in the nutritional care and support of the patient Lennard-Jones et al.

Nurses generally find it difficult to identify risk patients, to set up nutrition plans and monitor the effect of the nutritional 1 WFME has its own journal: Medical Education 53 support Rasmussen et al.

The results indicate that the nutrition related training given to all nurses should be reevaluated and restructured to be more relevant to clinical practice.

This might be accomplished by means of e. Besides knowledge about optimal practice with regard to nutritional care and support could be improved by means of societies for nurses involved in clinical nutrition, as is seen in e.

Clinical and general dieticians Clinical and general dieticians seem to receive the most up-to-date training Appendix 2. However, their educational level and responsibility are in practice very varied.

The Finnish clinical dieticians obtain a master degree, and work with specialised care, while the German general dieticians only have limited access to patient data, and are mainly occupied in the kitchens producing diets on a medical indication.

The role played by the clinical and general dieticians in hospital nutrition management varies widely throughout Europe, probably caused by several factors, including education, clinical awareness of the benefits of nutritional support and access to adequate financial resources.

Minimum educational standards for the practice of nutritional support of clinical dieticians Howard et al. There should be a common standard at first-degree level for all nutritional support clinical dieticians.

There should be an identified programme of post-graduate studies for clinical dieticians both clinical and academic leading to specialisation in nutritional support.

There should be an innovative approach to providing clinical support by clinical dieticians for emerging specialists. ESPEN should investigate the potential for developing an accredited and integrated European standard in nutritional support.

Food service staff may not be aware of the importance of providing highly nutritious food to ill patients. One result of this is the lack of a powerful voice for food service systems, unlike clinical services, when it comes to financial control and the allocation of budgets.

Nutrition is not taught on all courses and what is taught may be insufficient. Also, there is an educational lack with regard to management.

As can be seen from Appendix 2. In some countries, e. United Kingdom the role of the dietician is not split into the 2 areas of clinical and administrative.

When dieticians do not manage food service, it is important that they have some input into monitoring food service contracts, particularly in relation to nutritional quality and patient satisfaction.

Among other things this means that they might need additional help and support from new grades of staff.

This help could be provided by part-time care assistants employed by the hour or by ward housekeepers usually of domestic orderly grade.

Common to these staff members is their lack of nutritional knowledge. In practice this means that the staffmembers who have the closest contact with the patient in relation to food, are the ones who know least of all about nutrition.

Carefully designed and detailed job description and specification of their area of responsibility, as well as a proper nutritional in-house training programme, is crucial to obtain a benefit of their aid Allison Other occupational groups, which could play a role, are pharmacists in relation to the composition of enteral and parenteral nutrition, drug-nutrient interactions etc.

Patients The majority of patients are not aware of the importance of a good nutritional status to secure a proper treatment see section 5.

Therefore the topic of education and information of the patient should receive high priority in the educational themes at all levels.

The teaching should cover preventive as well as therapeutic aspects of nutritional care and support. Still, as in adults undernutrition often goes unrecognised Hendrikse et al.

There are only few paediatric NSTs in Europe, which reflects a lack of focus on nutritional problems in children.

The lack of knowledge about the nutritional needs of children has been suggested as one of the major causes of neglecting this group of hospitalised patients Howard et al.

However, food service is not merely a hotel function and the food served is part of the clinical treatment. Out-sourcing of food service is increasing.

Major efforts are needed from the management in order to secure that all significant terms and conditions in relation to food service are described in the contract.

Arrangements for food preparation, distribution and serving should deliver hospital food of defined standards in terms of nutritional quality, balances, palatability and temperature.

Each method of food preparation and distribution has its advantages and disadvantages in terms of nutrient losses, menu flexibility, food wastage, food hygiene requirements, staff skills in the kitchen, staff skills in the wards, and other factors.

The choice of method should therefore depend on the patients in question. It involves decisions on a range of issues including food service technology, food service management, and organisation of food service and serving systems, food purchasing management, human resource management and distribution systems.

Many of these decisions are political issues, and adoption and implementation of a meal, or a food or a nutrition policy at hospital or regional level can be a way to address these issues.

Improving nutrition requires a change of both attitudes and routines. In many cases the food service is regarded as a subject matter that can be addressed separately, and as a simple task any food service operator could handle.

Compared to the attention consumers pay to food the low status of food service and nutrition in hospitals at management level is surprising.

But also the attitudes of the physicians and nurses are important. Food cannot solely be regarded as something that is prescribed by a physician and as a result eaten by the patient.

The meal is a complex cultural and social phenomenon for the patient. A successful meal includes eating in a proper environment, having choices, friendly staff, good information about meal options, and the possibility to eat with relatives or other patients.

Improving hospital nutrition is far from just being a question of changing attitudes of the physicians and nurses.

A changed attitude of the hospital management is necessary giving priority to such matters as food policy and management of food service and nutritional aspects table 4.

Setting up an NSC and taking active part in this. Taking into account the potential cost of complications and prolonged hospital stay due to undernutrition when assessing the cost of ordinary food and nutritional support.

Taking into account the different patient needs when deciding on serving systems. Taking into account the social context of eating when number of staffs on duty, serving hours, dining environment etc.

Apparently, most countries use in-house food service Appendix 3.

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