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Clinical Nutrition (2005) 24, 10781088

http:/ /intl.elsevierhealth.com/journals/clnu

ORIGINAL ARTICLE

The prevalence of malnutrition in hospitals can be reduced: Results from three consecutive cross-sectional studies
Jacqui OFlynn, Hilary Peake, Mary Hickson, David Foster, Gary Frost
Department of Nutrition and Dietetics, Hammersmith Hospital NHS Trust, Fulham Palace Road, London W6 8RF UK
Received 8 April 2005; accepted 21 August 2005

KEYWORDS
Malnutrition; Prevalence; Inpatients; Nutrition care strategy; Hospital; Prevention

Summary Aims: To assess and compare the rates of malnutrition in Hammersmith Hospital NHS Trust over a 5-year period following changes in hospital nutrition care strategies. Methods: Design: Three consecutive cross-sectional studies carried out in 1998, 2000 and 2003. Setting: Inpatients at Hammersmith Hospital NHS Trust. Participants: A total of 2283 inpatients aged over 16 years old, 686 in 1998, 780 in 2000, 817 in 2003. Inpatients excluded: ventilated patients, ante/post-natal women and people aged o16. Interventions: Improvements in the catering service and nutrition education provision in 2000, and the implementation of a nutrition screening tool and Better Hospital Food in 2003. Main outcome measure: Prevalence of malnutrition. Results: There was a reduction in the prevalence of malnutrition in 2000 and 2003 from baseline data in 1998 (1998: 23.5%, 161/686; 2000: 20.4%, 159/780; 2003: 19.1%, 156/817; Po0.001). The odds ratio of being either at risk of malnutrition or malnourished was reduced in both 2000 and 2003 by approximately 33% (P 0:001). Indicators of good nutritional practice also improved: Weighing patients on admission increased from 37.5% (257/686) in 1998, to 42.9% (335/780) in 2000, and 59.6% (487/817) in 2003 (Pp0:001). Dietetic referrals also increased from 31.5% (216/686) in 1998 to 41.6% (340/817) in 2003 (Po0:001)(no change in 2000, 31%, 242/780). Appropriate referrals also improved, results showing that the proportion of malnourished patients who were referred showed a dramatic increase in 2003 (1998: 91/161, 56.5%; 2000: 85/159, 53.5%; 2003: 111/156, 71.2%; P 0:003).

Corresponding author. Tel.: +44 20 8846 1445.

E-mail address: mhickson@hhnt.nhs.uk (M. Hickson). 0261-5614/$ - see front matter & 2005 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved. doi:10.1016/j.clnu.2005.08.012

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Conclusions: The prevalence of malnutrition in hospital can be inuenced by the implementation of a variety of nutrition care strategies, which target identication of malnutrition and its treatment. & 2005 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Introduction
Malnutrition is a well-recognised problem in hospitals, with the prevalence estimated between 2850%.1,2 In 1992, it was estimated to cost the NHS in excess of 266 million annually, through increased length of stay, readmission and increased treatment costs.3 There is good evidence to suggest that improvements to catering4,5; increased use of articial nutritional support6; and improved pain management and nausea control to improve appetite will increase a patients nutritional intake and status. There is some evidence to indicate improvements in nutritional status will positively affect length of stay and mortality.7,8 Nevertheless, due to the complex aetiology, malnutrition is a difcult problem to treat. To reduce malnutrition a coordinated team approach, spanning all hospital disciplines, is required.9 Education to use nutritional assessment tools and other resources is needed to improve knowledge, detection and treatment of malnutrition.10 To date, there has been no systematic examination of whether introducing coordinated nutritional strategies can decrease the prevalence of hospital malnutrition. This paper describes strategies implemented at Hammersmith Hospital since 1998, which aimed to reduce malnutrition, and how the prevalence changed during this time. We hypothesise that changes made in hospital nutrition care strategies reduce the prevalence of malnutrition in hospital patients.

The nutritional assessment tool

The assessment tool is shown in Fig. 1. Prior to 1998, there was no suitable nutritional assessment tool able to assess 700800 patients within a 2-week period in an acute hospital setting. We therefore developed, piloted and validated1113 a simple, quick and accurate tool based on the subjective global assessment14 and the RCN assessment tool.15 It was validated against a previously validated tool,12 and showed close agreement (82%) between the two tools.

Data collection
The nutritional assessment tool was completed by dietitians from patient notes, by patient interview and by visually assessing the patients appearance. Percentage weight loss was calculated from weight history (if available), using any previously documented weights or by comparing current weight to the patients reported usual weight. Weight was measured using ward scales (various manufacturers) by either ward staff or the dietitian. Height was either measured using ward stadiometer (various manufacturers), or by demi-span (using a at metal tape measure) if the patient was unable to stand. If a measurement was not possible the patients reported height was used. To ensure reproducibility of the data and inter-rater reliability all dietitians were trained in the methodology for anthropometric measurements, and provided with written instructions and individual support, during the data collection phase. In a minority of patients it was not possible to obtain data to derive the BMI (approximately 16% of patients), usually because patients were unable to be weighed. In these cases the dietitian made a judgement to categorise the patient as either underweight or normal weight, to allow the assessment score to be calculated. On interview, the patients were asked about their current oral intake and presence of symptoms such as nausea, vomiting, pain and dysphagia. At the end of the interview a subjective examination of the patients appearance (skin, eyes, teeth, tongue and frame structure) was conducted, which was based on the subjective global assessment.14 The assessment tool assigned a score to each

Method
Using a validated nutrition assessment tool, dietitians measured the nutritional status of all adult hospital in-patients in 1998 (baseline), 2000 and 2003. In each year the assessment occurred in the rst 2 weeks of February to control for seasonal variation in mortality and disease. The time period of 2 years between the rst and second studies, and 3 years between the second and third were chosen to allow time for the nutrition care strategies to be implemented and become established practice. This time period was chosen through experience of implementing largescale changes in this organisation.

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1080 J. OFlynn et al.

Figure 1 Nutrition assessment tool.

response and these were totaled and then used to classify the patients nutritional status. A total score of 05 classied the patients as not at risk; 615 classied the patients as at risk; and 416 classied patients as malnourished. Demographic data, patient diagnosis, consultant treating the patient and whether a referral had been made to the dietitian were also recorded. The date of admission and assessment were noted. Data was also collected on whether the patient was weighed on admission or during their hospital stay. Riverside Research Ethics Committee and Hammersmith Hospital Ethics Committee gave ethical approval. Adult hospital in-patients (416 years) at Charing Cross, Hammersmith and Ravenscourt Park Hospitals were eligible for inclusion irrespective of their length of admission. The following patient groups were excluded: ventilated patients (both cardiac and intensive care) due to the difculties in accurately assessing these patients, and ante/ post-natal women as the tool did not take into account weight changes due to pregnancy. Our aim was to include as many patients as possible to reduce bias, so wherever possible we assessed people with communication barriers (language or

cognitive impairments) with the help of relatives, carers or interpreters, and used food record charts or nursing documentation to complete assessments.

Nutritional care strategies implemented

Following the baseline assessment (1998), various strategies were devised to reduce malnutrition. The rst to be implemented were a nutrition nurse education module (part of the continuing education program) and a change from a plated to bulk catering system. The education module initially consisted of three half-days training covering nutritional assessment, enteral and parenteral nutrition and nutritional support. The course used both lectures and case studies and was delivered by two senior dietitians. The initial course evaluation identied low attendance as the main problem, thus the course was reduced to one full day and is now an established part of the continuing education programme for nurses. The change in catering practice was initiated after research demonstrated that intake was signicantly lower using a plated catering system compared to a bulk system.4 The

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The prevalence of malnutrition plated system meant individual meals were plated cold in a central kitchen, transported to the ward chilled, then reheated on the plate and served immediately to the patient. This often resulted in poor food presentation, poor taste and texture and dry food. The bulk system meant the ward food requirement was served in bulk containers and then transported chilled to the ward. The bulk containers were then reheated and each individuals meal was then served on the ward and delivered to the patient. This improved the presentation of food, as well as the taste, texture and moisture content, and resulted in increased food intake and reduced wastage. The 2000 study measured the change in prevalence of malnutrition attributed to the initiation of these two strategies. The 2003 study examined the impact of implementing the use of a trust wide nutrition-screening tool, which aimed to identify patients at risk of malnutrition on admission and during hospitalisation, and Better Hospital Food meals and the availability of snack boxes that were introduced into the Trust in 2002. The screening tool is included in Appendix A and includes: weight on admission, and two questionsOver the last 3 months has the patient: (1) Unintentionally lost any weight? (2) Been eating less than usual? If yes is answered to either of the questions a nutritional risk is indicated and more detailed assessment and care plan is completed. If both questions answer no, patients are weighed and reassessed weekly. It was designed to screen patients on admission by nursing staff and to identify people who are either undernourished or are at nutritional risk. It was designed in collaboration with the nursing staff and had to be simple, quick and reliable. Pilot work (unpublished) showed good reliability, validity and specicity. It was introduced to all wards with the support of the nursing directorate and ward-based training was provided. The use of the tool has been regularly audited and has shown continuing appropriate use in most wards. Training was targeted to underperforming wards to improve screening. 1081

Results
There was no statistical difference between the 1998, 2000 and 2003 study groups for sex, BMI, hospital length of stay or the time point during admission when the assessment was completed (Table 1). However, the median age was signicantly lower in 2000 compared to the other two years (P 0:002), and the numbers in each specialty also differed (Po0:001), with an increase in patients in elderly medicine in 2003. The median length of stay between admission and assessment for malnutrition was not signicantly different between the 3 years. A total of 132 (19.2%) patients in 1998, 82 (10.5%) in 2000 and 62 (7.6%) in 2003 did not have a nutritional assessment completed. Reasons included; language barrier, refusal to take part, in theatre, unresponsive, not available on the ward, discharged before the assessment took place. The data shown in Table 2 and Fig. 2 indicates there was a statistically signicant reduction in average nutritional score (improvement in nutritional status) from 1998 to 2003; a reduction in those malnourished; and an increase in those at risk or not at risk. The strategies we implemented can only affect patients while in hospital and cannot be expected to inuence malnutrition prevalence on admission. Therefore, we examined the relationship between malnutrition and year of audit, while controlling for age and length of hospital stay at the time of nutritional assessment, using logistic regression (see Table 3). This analysis shows that the odds ratio of being either at risk of malnutrition or malnourished was reduced in both 2000 and 2003 by approximately 33% (P 0:001). Other data collected as indicators of good nutritional practice also improved during the study period. Weighing patients on admission increased signicantly throughout the study period; 1998 (257/686, 37.5%), 2000 (335/780, 42.9%), and 2003 (487/817, 59.6%) Pp0:001. As did referrals, which increased in 2003 (340/817, 41.6% of all patients assessed) from 2000 (242/780, 31%) and 1998 (216/686, 31.5%) Po0:001. To assess if referrals were being made appropriately the proportion of malnourished patients who were referred was examined and this showed a dramatic increase in 2003 (2003: 111/156, 71.2%; 2000: 85/159, 53.5%; 1998: 91/161, 56.5%; P 0:003). In order to investigate whether increasing prevalence of obesity could have inuenced the results, we compared all patients for whom we had an admission BMI (weighed within 2 days of admission). As it was not part of the study data collection to obtain admission weight the numbers

Statistical analysis
All data were entered onto an access database, and then transferred to SPSS (version 11.5, Chicago, IL, USA) for statistical analysis. Categorical data were compared using w2 -test. Analysis of variance was done using the KruskalWallis test, as the data were non-parametric. Logistic regression was used to examine the relationships between malnutrition over the time of the intervention and with length of stay and age.

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Table 1 Demographics of the study population in the three study years.
1998 Sample size n Gender Median age (years) IQR Median BMI (kg/m2) IQR (kg/m2) Missing data Underweight Normal or overweight Missing data 686 Male: 320 (46.6%) Female: 366 (53.4%) 69 51.879.6 23 2026 227 (33.1%) 52 (7.6%) 496 (72.3%) 138 (20.1%) 2000 780 Male: 365 (46.8%) Female: 415 (53.2%) 64.6 48.576.2 24 2027 202 (25.9%) 48 (6.2%) 530 (67.9%) 202 (25.9%) 8 3.521 1 (0.1%) 76 (9.7%) 34 (4.4%) 379 (48.6%) 291 (37.3%) 0 (0%) 2003 817 Male: 400 (49%) Female: 417 (51%) 67.8 51.779.3 24 2127 143 (17.5%) 55 (6.7%) 646 (79.1%) 116 (14.2%) 9 228 13 (1.6%) 140 (17.1%) 27 (3.3%) 343 (42%) 294 (36%) 13 (1.6%) #o0.001 P value

J. OFlynn et al.

#0.59 *0.002 *0.02

]0.58

Median length of stay until 10 assessed (days) IQR 425 Missing data 6 (1%) Specialty Elderly Medicine Haematology Medicine Surgery Missing data 54 (7.9%) 34 (5.0%) 338 (49.3%) 256 (37.3%) 7 (0.6%)

*0.1

*Kruskal wallis analysis, ]Chi-squared, IQR interquartile range.

Table 2 years. Year

Average nutritional score and proportion in each nutritional status category in each of the three study 1998 686 9 417 161 (23.5%) 205 (29.9%) 188 (27.4%) 2000 780 7 214 159 (20.4%) 231 (29.6%) 308 (39.5%) 2003 817 7 214 156 (19.1%) 264 (32.3%) 335 (41%) P value #o0.001 #o0.001

Sample size Average nutritional score IQR Malnourished At risk Not at risk (adequately nourished)
]Chi-squared, IQR interquartile range.

for this analysis are limited. The results are shown in Table 4. No signicant differences were found between the 3 years.

Discussion
The principal ndings
This study set out to dene the prevalence of malnutrition within the Trust and compare the rates of malnutrition in 2003 and 2000 after the implementation of nutrition care strategies designed to reduce malnutrition. The baseline pre-

valence of malnutrition was comparable to other studies,1 and the data shows that rates were reduced in 2000 and 2003. The data also indicated a change in nutritional practice at ward level, with an increase in the numbers of patients weighed on admission, and an increase in the number of malnourished patients identied and referred for dietetic intervention.

Strengths and weaknesses of the study

The main strength of this study is the consistent use of the same methodology, including the assessment

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The prevalence of malnutrition
Percentage of patients in each malnutrition category in the three study years.
45.0

1083

1998
40.0
39.5 41.0

2000 2003
32.3 29.9 29.6

Percentage of total patients

35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Adequately nourished (not at risk) At risk
27.4 23.5 20.4

19.1

Malnourished

Malnutrition category

Figure 2 Percentage of patients in each malnutrition category in the three study years.

Table 3 Logistic regression to examine the relationship between malnutrition and time of audit, while controlling for age and length of hospital stay at the time of audit. Year 1998 2000 2003 Odds Ratio 1.00 0.68 0.66 95% condence intervals 0.530.86 0.530.83 P

0.001 o0.001

1998 baseline; At risk of malnutrition and malnourished groups were combined for this analysis and compared to the not at risk group.

Table 4 Comparison of BMI in patients who were measured within 2 days of admission, to evaluate whether increasing BMI of the population could lead to a reduced prevalence of hospital malnutrition. Year of study 1998 2000 2003 n 71 99 151 Mean (SD) 24.14 (4.69) 24.85 (4.7) 25.21 (4.96) One-way ANOVA P 0.32

tool, over 5 years, to enable a direct comparison of malnutrition prevalence rates in one trust on three occasions. Measures were included to ensure reproducibility and the validated assessment tool included both objective and subjective parameters

to enable a holistic assessment of nutritional status. In addition, the data collection phases were all carried out in the same 2 weeks each year, to control for the confounding effects of season on morbidity and mortality rates. Our results show that malnutrition can be reduced by rapid and effective targeting of nutritional support, better catering services, and increasing the knowledge and awareness of malnutrition in clinical staff. Either treatment or prevention of malnutrition could explain the results of this study. The average time between admission and assessment in this study was approximately 10 days in each study year, suggesting 10 days is enough time to alter nutritional state. It could be argued that this time is not enough to treat malnutrition, but deterioration to a malnourished state can be extremely rapid and it is possible that by giving good nutritional care, this deterioration could be prevented in 10 days. Additionally, although it is unlikely that signicant changes would be detected using anthropometry alone in 10 days, the assessment took into account a whole host of factors that could show change over a small time frame, for example, changes in dietary intake. This effect is maximised by the large sample size, which improves the power of the study. Hospital specialty demographics show that there was an increase in the number of patients in elderly medicine between the study years. It would be expected that malnutrition rates would increase in this situation, as it has been shown that increasing age is a predictor of malnutrition.1 However, the malnutrition rates still fell despite this change, adding further strength to the conclusion that

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1084 implementation of the nutrition care strategies can affect malnutrition prevalence. One problem with the study is the possibility that the study sample is biased. The use of a questionnaire that required the patient to answer several questions meant that the assessment of non-English speakers, those with dementia or other communication difculty, and those who were unconscious or sedated, could not be completely assessed. However, we made every effort to include as much information as possible from these patients. These groups are at greater risk of malnutrition,16,17 thus the actual prevalence of malnutrition may be higher than measured. However, as the study has used the same methods each year, the results are still valid for comparison between the years. Caution may be needed when comparing with other published research. There are also two problems associated with the collection of anthropometric data. If height or weight were not available, the weight loss calculation was left blank, and weight status was estimated as either underweight or normal/overweight to enable the assessment score to be completed. A measured BMI is clearly preferable to an estimated category but we believe that there was sufcient justication to take this approach. All the data was collected by dietitians who are experienced in estimating weight status and training was given to ensure estimates were consistent. The alternative of having missing data would mean the power of the study would be reduced. Secondly, in some cases reported height was used when it was not possible to measure height accurately. This is justied as research has shown a close agreement between reported and measured height.18,19 It is possible that other factors, apart from our nutritional care strategies, have changed during the 5-year study period and have caused malnutrition rates to drop. It is well known that the prevalence of obesity in the general population is rising and thus the average BMI of patients on admission could have increased with time. We did not collect the weight on admission but our data shows no difference in BMI, between the study years, at the time of assessment. The additional analysis to compare only those patients who were weighed at admission also shows no signicant differences between study years. It seems unlikely that an increase in population BMI over time has affected our results. There is no evidence in the literature to suggest that the BMI of patients on admission to hospital is increasing. Additionally, it is known that BMI is a crude indicator of nutritional risk, and a range of other factors need to be taken J. OFlynn et al. into consideration, particularly weight loss. We used a holistic assessment rather than just anthropometric measurements, so patients who were overweight could be classed as at risk of malnutrition, due to factors such as percent weight loss, diagnosis, complications, appetite, food intake, etc. This would also serve to negate any effect of a general increase in BMI. Changes in hospital case mix could also inuence overall malnutrition. We examined Trust data for each study year and found no difference in the mean age of patients or the average length of hospital stay. However, we did nd an increase in the number of emergency cases and a drop in elective cases. Emergency admissions are more likely to be malnourished than elective,20 therefore the changes in case mix found would only increase the prevalence of malnutrition. This large London trust covers a catchment area that includes both very wealthy and very deprived areas, thus any changes in the economic prosperity of patients should be reected in both the wealthy and poorer sectors of society, and would not affect our results overall. Studies have shown that malnutrition increases during hospital stay,2,21 thus the longer patients are in hospital the more likely they are to be malnourished. However, we have shown that there was no difference between the three studies in the length of stay when the assessment was done (Table 1), which controls for this confounding variable.

Comparison with other studies

We know of no other studies that have compared the rates of malnutrition after major strategic interventions have been implemented. However, the initial prevalence rates are comparable to other published work,1,2,22,23 and are at the lower end of the spectrum. Caution is needed when comparing to other studies as the criteria used to assess malnutrition risk is different. This is a common problem in most studies investigating malnutrition prevalence.1 Corish et al.21 aimed to duplicate McWhirter and Penningtons2 methods, yet the rates of malnutrition were 11% and 40%, respectively, indicating different populations may well have different rates of malnutrition. The results of this study may suggest a lower rate of malnutrition is this area or, as discussed earlier, may reect the bias of the sample. Studies also show that malnutrition rates increase during hospital stay2,24,25 and it is this increase in malnutrition that can be addressed by the

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The prevalence of malnutrition implementation of improved nutritional care strategies. The two core strategies implemented during this study, altering the catering service and nutrition screening and education, both have evidence to suggest their effectiveness. The main catering service alteration was to change the system from a plated to bulk service. Wilson et al demonstrated that bulk service increased patients energy and nutrient intake and reduced food wastage compared to the plated system.4 The Better Hospital Food initiative was introduced by the government and aimed to bring hospital catering services up to certain standards, increase patient intake and reduce wastage. These changes are supported by the report by the Association of Community Health Councils highlighting problems with hospital catering.26 The availability of snacks in-between meals was also initiated and has been shown to increase energy intake.5 Since poor appetite and reduced food intake play a central role in the pathogenesis of malnutrition these measures may have prevented the development of malnutrition after admission. In order to provide nutritional support it is crucial to identify those at risk quickly. The second strategy was to introduce a nutrition-screening tool so all patients were screened for their risk of malnutrition within 48 hours of admission. This was combined with an education program to ensure the screening was done effectively, and appropriate care planning was followed where patients were identied with, or at risk of, malnutrition. The success of this particular strategy is illustrated by the increase in the number of patients weighed on admission, and the numbers of malnourished patients who were referred to the dietitian for nutritional support. A total of 71.2% of all malnourished patients were referred in 2003, up from 53.5% in 2000, which compares with 25% from a recent published study.27 Once a person is identied as malnourished, aggressive nutritional support can be undertaken, including the use of food fortication, oral supplements and articial nutrition support. Such support has been shown to improve nutritional status and, although the data is less clear, seems to reduce mortality.7 It is interesting to note that audits of articial nutrition use in this hospital have shown increases in use over the past 6 years. This reects both the increase in appropriate dietetic referrals and the reduction in malnutrition. The success of the screening tool was helped by the education provided to support its use. Studies have shown that developing nutritional tools in conjunction with education can improve 1085 knowledge, and the detection and treatment of malnutrition.28

Meaning of the study: possible explanations and implications for policymakers

A certain percentage of patients admitted to hospital will inevitably be malnourished, and hospitals cannot inuence this. Nevertheless, rates of malnutrition have been shown to rise during hospital stay2,24 and this is what hospitals should be striving to prevent. This study has shown a signicant reduction in the prevalence of malnutrition is possible. The likely cause of the reduction is the implementation of a variety of nutritional care strategies. However, the pragmatic design of the study does not enable us identify which of the strategies has been the most successful. It is probable that the combination of several strategies, all with the principle aim of identifying and reducing malnutrition, are required, and our data supports this view.

Unanswered questions and future research

This study uses cross-sectional data, which does not enable us to track one group of patients throughout their hospital stay. To further establish the effectiveness of these nutritional strategies a longitudinal study is required, which can demonstrate how successfully malnutrition is prevented and treated during hospital stay.

Conclusion
This large study has shown that in practice the prevalence of malnutrition in hospital can be inuenced by the implementation of a variety of nutrition care strategies. These strategies should be multi-disciplinary and target identication of malnutrition and its treatment.

Acknowledgements
Conception and design: HP, JOF, GF, DF, Jacqui Bratram and Suzanne Evans for their assistance in piloting the assessment tool, Alison Firth for the design of the database. Data collection: JOF, HP, MH, Members of the Department of Nutrition and Dietetics Hammersmith Hospitals NHS Trust, Suzanne Evans for coordinating the data collection as Charing Cross Hospital.

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1086 Analysis and interpretation of data: JOF, MH, HP, GF, Winston Banya (statistician) for the logistic regression analysis, Alison Firth for data entry in 1998. Drafting the article: JOF, MH, GF. J. OFlynn et al. Revising it critically for important intellectual content: JOF, MH, GF, HP. Final approval of the version to be published: JOF, MH, GF, HP, DF.

Appendix A

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Addressograph label

NUTRITION SCREENING TOOL

Ward: _________ Date: ___________ Nurses signature: ________________ Weight on admission: _______(kg)

To be completed on admission for every patient Over the last 3 months has the patient: (a) Unintentionally lost any weight? (b) Been eating less than usual? Yes Yes No No

If YES to either of the above OR in your professional opinion, the patient is at risk of undernutrition, carry out nutrition assessment tool. If NO to both, re-assess weight weekly as circumstances can change.

References
1. Corish CA, Kennedy NP. Proteinenergy undernutrition in hospital in-patients. Br J Nutr 2000;83:57591. 2. Mcwhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ 1994;308:9458. 3. Lennard-Jones JE. A positive approach to nutrition as treatment. A report on the role of enteral and parenteral feeding in hospital and at home. London: Kings Fund Centre; 1992.

4. Wilson A, Evans S, Frost G. A comparison of the amount of food served and consumed according to meal service system. J Hum Nutr Diet 2000;13:2715. 5. Gall MJ, Grimble GK, Reeve NJ, Thomas SJ. Effect of providing fortied meals and between-meal snacks on energy and protein intake of hospital patients. Clin Nutr 1998; 17:25964. 6. Doshi MK, Lawson R, Ingoe LE, Colligan JM, Barton JR, Cobden I. Effect of nutritional supplementation on clinical outcome. Clin Nutr 1998;17:308.

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7. Potter J, Langhorne P, Roberts M. Routine protein energy supplementation in adults: systematic review. BMJ 1998;317:495501. 8. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22:2359. 9. Best C, Thomas S. Improving practice with a nurse nutrition team. Nurs Stand 2001;15:414. 10. Bond S. Making eating better. In: Bond S, editor. Eating matters. Newcastle-upon-Tyne: The Centre for Health Service Research; 1997. p. 12569. 11. Peake H. Appendix 6. University of Surrey, Rohampton Institute; 2000. 12. Chang RWS, Richardson R. Nutritional assessment using a microcomputer 2. programme evaluation. Clin Nutr 1984;3: 7882. 13. Peake H, Evans S, Maltby AA, Bartram J, Frost G. Determining the incidence of hospital trust malnutrition to plan and target nutritional support strategies. Proc Nutr Soc 2000;59:139A. 14. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 1987;11:813. 15. Nutrition standards and the older adult. London: Royal College of Nursing, 1993. 16. Incalzi RA, Capparella O, Gemma A, et al. Inadequate caloric intake: a risk factor for mortality of geriatric patients in the acute-care hospital. Age Age 1998;27:30310. 17. Quirk J. Malnutrition in critically ill patients in intensive care units. Br J Nurs 2000;9:53741. 18. Spencer EA, Appleby PN, Davey GK, Key TJ. Validity of selfreported height and weight in 4808 EPIC-Oxford participants. Public Health Nutr 2002;5:5615.

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19. Weekes L. An evaluation of recalled versus measured height as an aid to identify malnourished patients in hospital. Proc Nutr Soc 2001. 20. Riley RH, Burke V. Prevalence of obesity in surgical patients: a comparative survey in the United States and Australia. J Qual Clin Pract 1997;17:14754. 21. Corish CA, Flood P, Mulligan S, Kennedy NP. Apparent low frequency of undernutrition in Dublin hospital in- patients: should we review the anthropometric thresholds for clinical practice? Br J Nutr 2000;84:32535. 22. Hill GL, Blackett RL, Pickford I, et al. Malnutrition in surgical patients. An unrecognised problem. Lancet 1977;1: 68992. 23. Larsson J, Unosson M, Ek AC, Nilsson L, Thorslund S, Jurulf P. Effect of dietary supplement on nutritional status and clinical outcomes in 501 geriatric patientsa randomised study. Clin Nutr 1990;9:17984. 24. Pichard C, Kyle UG, Morabia A, Perrier A, Vermeulen B, Unger P. Nutritional assessment: lean body mass depletion at hospital admission is associated with an increased length of stay. Am J Clin Nutr 2004;79:6138. 25. Fettes SB, Davidson HI, Richardson RA, Pennington CR. Nutritional status of elective gastrointestinal surgery patients pre- and post-operatively. Clin Nutr 2002;21: 24954. 26. Burke A. Hungry in hospital?. London: Association of Community Health Councils for England and Wales; 1997. 27. Kelly IE, Tessier A, Cahill A, et al. Still hungry in hospital: identifying malnutrition in acute hospital admissions. Quart J Med 2000;93:938. 28. Eating matters. Newcastle upon Tyne: The Centre for Health Services Research, 1998.