© Blackwell Science Ltd. 2001 Food Service Technology, 1, pp. 121–122 121

at ward level. The second alternative system was a

menu less system. This is similar to the bulk trolley

service described above but does not use prefilled menu

cards, patients were able to choose their meal at the

time of service. Cook-chill food from the same supplier

was used in all three systems. In each case data were

collected over a 21-day menu cycle, with an equal

number of lunch and supper meals studied. A number

of weekend surveys were also included.

The surveys were carried out on one medical ward

where a total of 173 individual patient meals were

analysed: 51 plated system meals were measured on 25

patients (mean age ± SD 67 ± 17 yr, female = 12); 57

bulk system meals were measured on 29 patients (age

61 ± 14 yr, female = 13); and 65 meals from the menu

less system were measured on 32 patients (age 64 ±15 yr, female = 14). All patients were classified by

nursing staff as ‘eating normally’ and were not pre-

scribed a ‘therapeutic diet’.

Nutrient intake was calculated by standard weighed

food intake methodology (Bingham et al. 1994). Nutri-

tional analysis was carried out using Dietplan 5 (Forest

Hill Software, UK) computerized food tables.

As the data were not normally distributed, results are

expressed as medians with interquartile ranges with a

P < 0.05 been taken as significant. Comparisons

between the catering systems were made using

Kruskal–Wallis one-way analysis of variance. Each

catering style was compared with the plated system

using Bonferroni adjusted Mann–Whitney U-tests.

Results are presented in Table 1. There is no sig-

nificant difference in the amount of energy or protein

served. There is a significant increase in the amount

of energy and protein consumed with both the bulk

and menu less service compared with the plated

service, with plate waste significantly higher with

the plated system as compared to the other two

systems.

Letters

The effect of changes in meal service systems onmacronutrient intake in acute hospitalizedpatients

There is currently concern over the quality of food

offered to, and consumed by hospital inpatients (Sec-

retary of State for Health 2000). This is particularly

relevant as it is recognized that nutritional status dete-

riorates in a large percentage of patients over a hospi-

tal admission, which results in greater treatment costs

(McWhirter & Pennington 1999). Currently, there

is no comparative evaluation of the effects that dif-

ferent hospital catering systems can have on patients’

nutritional intake. This is despite 89% of patients

relying on hospital food to maintain their nutri-

tional status over their hospital stay (BAPEN Report

1999).

The aim of the following cross-sectional study was

to investigate three types of catering systems commonly

used throughout the UK and the effects they have on

nutritional intake and wastage.

Participants, methods and results

Hammersmith Hospital Research Ethics Committee

approved the following study and all participants gave

verbal consent (97/5271).

Over a 3-year period, three different patient meal

service systems were compared. A centrally plated meal

service was used as the reference or control system.

Here, preordered meals are plated chilled in the central

kitchen and transported to the ward where they are

regenerated in heated trolleys on the plate and served

to patients. The alternative systems were, first, the

bulk trolley system where containers holding the total

preordered meal requirements for the ward are regen-

erated. The ward hostess, using individual patient

menu cards completed in advance, then plates the meals

Table 1 Summary of the amount served, amount eaten and percentage wasted on the three catering systems. Results are

expressed as medians with interquartile ranges (IQR)

Nutrients served, Amount of Plated (n = 51) Menu less (n = 65) Menu less Bulk (n = 57) Bulk vs.

eaten and wasted each food vs. Plated Plated

at each meal type Median IQR Median IQR P-value Median IQR P-value

Energy, kcal Served 500 376–576 569 403–721 0.2 438 359–603 1.0

Eaten 341 168–419 432 296–627 0.002 368 307–534 0.05

% Wasted 34 17–51 8 2–27 <0.001 7 1–23 <0.001

Protein, g Served 20.6 18.1–28.7 21.7 16.9–28.6 1.0 20.2 18.1–25.0 1.0

Eaten 12.4 7.7–20.4 17.7 12.3–23.2 0.05 18.6 14.5–23.1 0.006

% Wasted 29 10–64 8 1–27 0.002 5 0–14 <0.001

Comment

Our study has demonstrated that the type of meal

service can have a significant impact on patients’ nutri-

tional intake, which could potentially increase the risk

of malnutrition in vulnerable patient groups. In doing

so, we highlight the vital role that hospital catering

systems play in the well-being of patients and support

recommendations for the setting up of multidiscipli-

nary committees within hospitals to advise on all

aspects of nutritional needs of patients (BAPEN Report

1999; Davis & Bristow 1999).

Alison Wilson, Suzanne Evans & Gary Frost*Nutrition and Dietetics Research Group,

Hammersmith Hospitals NHS Trust, London, UK

Caroline DoréMRC Clinical Trials Unit, London, UK

*For correspondence: E-mail: gfrost@hhnt.org

References

BAPEN Report (1999). Hospital Food as a Treatment. (ed. SP

Allison). BAPEN: Maidenhead.

Bingham SA, Gill C, Welch A et al. (1994). Comparison of

dietary assessment methods in nutritional epidemiology:

weighted records vs 24h recalls, food frequency question-

naire and estimated records. British Journal of Nutrition72:619–43.

Davis AM, Bristow A (1999). Managing Nutrition in Hospital. A Recipe for Quality. 8. Nuffield Trust:

London.

McWhirter JP, .Pennington CR (1999). Incidence and recog-

nition of malnutrition in hospital. British Medical Journal398:945–8.

Secretary of State for Health (2000). The NHS plan. A plan for investment. A plan for reform. The Stationary Office:

London.

Editor’s comment

In much of the so-called Developed World, an over-

consumption of food with a myriad of associated

diseases such coronary heart disease and diabetes is

a major problem. In a recent report in the UK

(National Audit Office 2001) it was shown that obesity

has tripled in the last 20 years and today, nearly two

thirds of men and half of women are overweight or

obese.

However, what is often overlooked is that a large

proportion of the population are actually undernour-

ished and I am not referring to the ‘down and outs’ to

122 Letters

© Blackwell Science Ltd. 2001 Food Service Technology, 1, pp. 121–122

whom food may take second place to drink, drugs and

alcohol. There are many groups, often the very vulner-

able in society; for example, the elderly living either in

their own homes or in care, and those in hospital,

where under-consumption is a major issue leading to

health related problems. Indeed, under-consumption

can occur in situations where it might least be expected

(Marriott 1995).

Under and over-consumption presents all of those

involved in food service with a dilemma but perhaps

the most challenging is under-consumption, and

how the food service professional might address this

situation.

Under-consumption is of concern in hospitals in the

UK, and probably many other countries, and recently,

considerable effort has been devoted to increasing the

profile and raising the standards of hospital food.

However, is that enough and is concentrating solely

on the food, likely to solve the problem? Probably

not, for as every food service professional knows,

the choice and enjoyment of food depends not only

on the food itself, but also on the personal circum-

stances of the consumers, and as argued by many, the

situation under which consumption of that food takes

place.

This brief study reported here by Wilson and

coworkers, addresses some of the nonfood issues that

might affect food consumption, and therefore nutrient

intake in Hospital. By manipulating and changing the

food service/delivery mechanism, they were able to

increase patient intake. Yes, it is easy to criticise the

study design and therefore the validity of the results. It

does, however, illustrate the opportunity and possibil-

ities that these interventions might offer.

We would be very interested to hear from and share

the results of other readers who have undertaken any

similar studies.

J. S. A. EdwardsEditor

References

Marriott BM, ed. (1995). Not eating enough. Overcomingunderconsumption of military operational rations. Institute

of Medicine, National Academy Press: Washington,

D.C.

National Audit Office (2001). Tackling Obesity in England.

Report by the Comptroller and Auditor General. The Sta-

tionery Office: London.