Visual plate waste in hospitalized patients: length of stay and diet order

Nutrition Research Newsletter, Nov, 2006

Previous studies have demonstrated that protein energy malnutrition and weight loss often follow hospitalization. It has been shown that >91% of patients admitted to sub-acute care are either malnourished or at risk of malnutrition. Reasons for the high prevalence of malnutrition among hospitalized patients include poor recognition and monitoring of nutritional status, inadequate intake of nutrients for several days, severe illness that may limit food consumption, and patients being at nutritional risk before hospital admittance. To alleviate a patient's risk of malnutrition, hospitals have used strategies such as implementing new menus and food delivery systems, innovative nutrition screening programs, and improving patient meal satisfaction. Therefore, the purpose of this pilot research was to investigate visual lunch plate waste using these variables. By minimizing plate waste, patient nutrition could be optimized along with a reduction in hospital costs.

Six hundred and seventeen patients (aged >18 years) admitted consecutively over a 46-day period to a 233-bed hospital in Richmond, IN, were examined. Using the CBORD Diet Office database (version 5.0.1,2005, CBORD Group Inc., Ithaca, NY), which manages food and nutrition services, patient information such as sex, length of stay (LOS), diagnosis at admittance, and diet order were collected. Patients' LOS at the hospital ranged from one to 46 days. To maintain patient confidentiality, upon admittance to the hospital, each patient was assigned a subject number. Using the hospital's current conventional food service system, visual plate waste during lunch was measured for four consecutive days. In this food delivery system, meals were delivered according to a set schedule and did not accommodate patients' specific schedules. Twenty-four hours in advance of food delivery, patients had the option to choose an entree, two side dishes, and a dessert. If a patient did not make a menu selection or was not admitted at the time of meal selection, the patient received a standard tray. In addition, this food delivery system did not allow for subsequent diet changes or changes in patients' appetite. Because the objective of the research was to record plate waste during lunch, breakfast and dinner were excluded.

For this research, lunch tray tickets were used as a reference to compare foods ordered to those actually consumed by patients. A lunch tray ticket clipped to a patient's tray indicated the types and amounts of food ordered. Visual plate waste was defined as eating 50% or less of the ordered food. To determine if there was 50% plate waste, food left on the tray was compared to the lunch tray ticket. Lunch consumption was classified into three groups: patients who ate >50%, those who ate <50%, and those who did not eat lunch. Patients who took a few spoonfuls/bites of their entire meal (that is, of entree, side dishes, and dessert) were categorized as having not eaten their lunch. During the four consecutive lunch periods, a simple checklist was used to record the amount of food eaten by patients. For consistency and accuracy of data collection, all meals were served in patients' rooms by the same investigator. All trays were picked up an hour after the lunch period.

Data from 346 patients were analyzed. Patients' mean [ or -] standard deviation age was 64 [ or -] 26.56 years and 57.5% were women. On admittance to the hospital, >25% of patients had more than one diagnosis and were classified as other. The most common diet orders were regular, cardiac, and diabetic. Mean LOS was 3.63 [ or -] 4.70 days. Cardiac diet orders were low in total fat, saturated fat, and cholesterol, whereas diabetic diet orders had a restriction on the amount of carbohydrate and were classified as low, medium, or high. During the visual lunch plate waste study, when the meals were served, a total of 323 (93.4%) patients accepted the tray, seven (2.0%) refused the tray, eight (2.3%) were not in the room, and eight (2.3%) had been either discharged or were under a nothing by mouth order. From a pool of 346 patients, 36.7% (n=127) ate >50% of the food served, 46.2% (n= 160) ate <50%, and 17.1% (n=59) did not eat their lunch.

LOS had a relationship to plate waste indicating that for every day a patient was in the hospital, the odds of plate waste increased by 14.1%. Depending on the type of diet order, visual plate waste either increased or decreased. In patients receiving a diabetic diet order, odds of visual plate waste decreased by 61.2%, indicating there was reduction in plate waste. Conversely, in patients receiving altered consistency diet orders, odds of visual plate waste increased by 344% signifying a tremendous increment in plate waste. The other diet orders did not have any significant effect on plate waste.

Few or no studies have primarily compared visual plate waste to factors such as diet order, LOS, diagnosis at admittance, and sex. In the present study, LOS and type of diet order had an effect on visual plate waste. Duration of stay in the hospital appears to result in increased visual plate waste. Similarly, observations were noted with types of diet order and plate waste in that visual plate waste increased in patients receiving altered consistency diets. An increase in hospital costs and the need for adequate patient nutrition makes it imperative to look at factors that affect visual plate waste.

This pilot study showed that altered consistency diets and longer LOS resulted in greater visual plate waste in a conventional foodservice system. Continued plate waste in patients may inhibit food consumption, affecting nutritional status, and predisposing to malnutrition. Registered dietitians working in acute-care facilities need to develop strategies to create cost-effective, nutritionally balanced, altered consistency diets that would improve patient food compliance. Other strategies to encourage food consumption for patients in the hospital or before admittance include nutrition education, developing palatable foods that have greater acceptance, catering to patients' scheduling needs, developing alternate approaches to traditional menu systems (such as spoken menus), conducting focus groups or surveys to determine menu acceptance, and tasting of innovative foods. Last, but not least, future research could focus on the relationships between medications, anesthesia, food delivery systems, menu modification, LOS, types of diet orders, and their effectiveness on plate waste.