More than half of the patients admitted to public hospitals are undernourished. But if the well-nourished minority stay long enough, there’s a good chance they’ll be malnourished by the time they’re discharged.
It’s not just that they don’t get enough food — way below the health department “ration scale” and patients’ energy requirements, according to a study of meals served at three Cape Town hospitals.
“Patients would eat more if the food was appropriate, and in some cases food is not provided at appropriate times,” says University of the Western Cape dietetics lecturer Marieke Theron. “People who are sick need higher amounts of energy and other nutrients like protein to aid their recovery.”
When patients don’t eat enough of the right foods, hospital stays lengthen, costs go up, there’s a greater chance of hospital-acquired malnutrition and mortality risk rises, according to a 2019 study led by Prof Renée Blaauw of the human nutrition division at Stellenbosch University, who found that 54% of patients were undernourished on admission
Theron alerted the Western Cape health department to her findings when the research was published in the South African Journal of Clinical Nutrition towards the end of 2021. “I wanted to give them the opportunity to do something about the situation and I wanted to assist them however I could,” she says.
No such luck. A meeting was set up several months later but health officials didn’t arrive, and the department says this was “due to technical issues with virtual meeting platforms”. After receiving questions from the FM, officials contacted Theron again.
In the meantime, the research may have had at least some impact. “One hospital has started the process of finding a supplier of yoghurt,” says Theron.
The additional yoghurt could be in response to her suggestion of regular protein-containing snacks between meals, and any extra costs will probably be offset by savings from shorter hospital stays, fewer complications and improved recovery rates, says Theron.
The hospitals where she sent final-year student dietitians to weigh and analyse plates of food and leftovers when she was at the University of Cape Town have between 945 and 172 beds.
The same amount of money can be used to adapt the foods in such a way that they are more appropriate for people who are sick, lying in a bed and struggling to eat large plates of food, served at inappropriate times
— Marieke Theron
Almost 130 patients filled in questionnaires that aimed to find out if relatives were bringing them food, what they thought of the hospital meal service and what their appetites were like.
The scores weren’t terrible for topics such as meal service quality, staff/service issues and meal size, ranging between 60% and 100%. But when patients were asked to rate the quality of food, the lowest score was 47% and the highest 88%.
At the central hospital, Theron’s analysis found low protein intake was directly linked to poor food quality and staff/service issues, which is why “the problem of hospital food service is a much more complicated issue than the ration scale alone”, she says.
Her paper acknowledges the ration scale, which specifies the raw amounts of food ingredients each patient should receive daily, and says the Cape Town hospitals are falling far short of its guidelines. But it says the key metric is the energy and protein needs of patients, and this is where the alarm bells are louder.
Theron calculated the daily energy requirements for the 71 male patients in her study at 8,255kJ-8,970kJ, and for the 57 female patients at 7,104kJ-7,333kJ. But at the central hospital, they were consuming 32% (men) and 29% (women) less.
Protein requirements were 73g-87g for men and 78g-80g for women, but patients at the smallest hospital were eating just over half of what they needed.
There were significant differences in the amounts of energy and protein the hospitals provided and overall, the smallest hospital was bottom of the class: fruit served only once in three days, no protein in one lunch and the lowest scores in every aspect of the patient satisfaction questionnaires.
Theron sent her paper to the provincial health department more than a year ago and uploaded it to the national health research database, but spokesperson Mark van der Heever says officials “have not yet had the opportunity to engage the data collected by the researcher, so we are unable to comment”.
In general, though, he says the department’s approach to hospital food is rigorous. Guided by national policy, the Western Cape has comprehensive “food service management implementation guidelines”, standardised menus served on 14-day or 21-day cycles, and a management system that monitors adherence to ration scales.
The efforts of hospital dietitians are supplemented by “quality improvement support visits” that use “a comprehensive assessment tool”, and attempts to maintain quality include evaluation of meals by hospital managers, patient satisfaction surveys and plate wastage studies.
“It is also noted that patients request food from family and friends visiting even if it is not in accordance with the dietary requirements advised by the clinical team,” says Van der Heever. “This often happens due to the unsubstantiated perception of meals in the hospital.”
Theron says snacks are the right solution but they should come from the hospital, not visitors. And she says it won’t blow the budget to tackle the institutional problems her research flags.
“The same amount of money can be used to adapt the foods in such a way that they are more appropriate for people who are sick, lying in a bed and struggling to eat large plates of food, served at inappropriate times,” she says.
“Ultimately, hospitals should at least serve the correct amounts of food so that the 40% of people who have a normal appetite and who did not get additional food from their families or friends will have enough food to recover as speedily as possible.”
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