Issues in patient care
Energy and nutrient intake in acute care 55
and in¯uence normal eating behaviour, compromising the
validity of the study. The dietary requirements of
individual patients were not assessed and compared to
individual intakes. The approach was to estimate the food
intake of a large number of patients at many separate meals
over several weeks. This has enabled general patterns of
food intake in the study population of acute medical
patients to be established, and the identi®cation of
important problems with their food intake.
diet is meat. However, a considerable number of patients
consumed very low amounts of protein and iron, which
has implications for those with trauma, surgery, infections
and compromised immunity, who have greater require-
ments for these nutrients (Bastow et al., 1983; Truswell
et al., 1990). Vitamin C, calcium and zinc are important for
tissue repair and maintenance of immune function (Olde
Damink & Soeters, 1997; Rollins, 1997; Westwood, 1997).
About half the patients in this study consumed very low
amounts of these nutrients. The vitamin C content of the
hospital diet, after adjustment for cooking and storage loss,
is about double the recommended daily intake for a typical
older bedridden medical patient, and much of it is in the
fruit juice provided at breakfast. Most of the calcium is also
provided at breakfast. The ®nding that breakfast was the
most poorly eaten meal of the day is a partial explanation
for the poor intake of calcium and vitamin C.
The results of the study indicate that the nutritional
intake of many patients was poor, even though the
standard hospital diet theoretically provides suf®cient
energy and nutrients. This is in broad agreement with
published studies from Europe (Todd et al., 1984; Westin
et al., 1988; Simon, 1991; Klipstein-Grobusch et al., 1995;
Incalzi et al., 1996). Although individual patients' intakes
were not studied over 24-h periods, the general pattern of
daily food intake may be inferred from the large amount of
data collected. Nutritional analysis of standard hospital
meals has been used as a reference. Together, the standard
hospital breakfast, lunch and evening meal provide close to
the recommended daily intake of energy, calcium and zinc,
and double the recommended daily intake of protein, iron
and vitamin C for a typical older medical patient, although
of course individual dietary requirements are likely to vary
considerably from this (Truswell et al., 1990).
There is no one single reason for a poor nutritional
intake in hospital and clearly the maintenance of an
adequate intake is more critical for some patients.
A number of factors in¯uence patients' food intake while
they are in hospital, including patient factors, food service
arrangements and factors associated with the nursing staff
and ward routines. Patients do not necessarily order a
nutritionally adequate diet while in hospital (Todd et al.,
1984; Incalzi et al., 1996); hospital food may not be
enjoyed and they may have physical dif®culties with eating
(Todd et al., 1984; Kayser-Jones & Schell, 1997). The
hospital food service is organized such that patients order
meals in advance, with little opportunity to alter menu
choices later (Kowanko et al., 1999). Although the menu
offers choices it cannot cater for all individual needs and
preferences. Food service staff vary in their ability to
communicate with patients and understand their individ-
ual needs. Busy nurses have little time to encourage
patients to eat and to assist those unable to feed themselves
(Isaksson, 1982; Kayser-Jones & Schell, 1997; Kowanko
et al., 1999). Nurses may lack the knowledge to provide
good nutritional care and some do not value this activity as
legitimate nursing work (Arrowsmith, 1997; Perry, 1997;
Kowanko et al., 1999). Meals may be missed due to
investigations and treatments (Eastwood, 1997), and in
this hospital breakfast is often rushed due to other
morning activities such as ward rounds and hygiene
routines (Kowanko et al., 1999).
The energy value of the food consumed by patients in
this study varied considerably, but it is worrying that on
average the energy intake of over one-third of patients was
less than 50% of that provided by standard hospital meals.
This pattern of intake suggests that the daily energy
consumption of a large proportion of patients would be
unlikely to meet even the basal metabolic needs of a typical
bed-resting 65-year-old patient, with even greater poten-
tial to affect the recovery of younger, more active patients,
or those recovering from physical trauma or infection, who
have a greater metabolic need (Truswell et al., 1990).
Carbohydrate and fat intake were not analysed separately
in this study because energy value was considered a more
useful indicator of adequacy of the diet. Underweight
patients consuming dangerously low amounts of energy
will deplete their protein stores, further compromising
their nutritional status.
Protein, iron, calcium, vitamin C and zinc were chosen
for nutritional analysis as they represent key nutrients
required for healing and immunity (Olde Damink &
Soeters, 1997; Rollins, 1997; Westwood, 1997). Protein is
abundant in the standard hospital diet and consequently
the majority of patients' protein intake was adequate. The
pattern of iron intake was similar to protein, which was
expected because the major source of iron in the hospital
The results of this study as well as parallel studies
on nursing knowledge and attitudes about nutrition
(Kowanko et al., 1999), and a review of the literature
(Kowanko, 1997) are being considered by the hospital,
along with a recently published compilation of strategies
used in UK hospitals to improve nutritional care (Bond,
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 51±57