Diabetes is one of the most prevalent diagnoses seen in hospitalized patients in the United States, accounting for ∼ 38% of all patients admitted to hospitals.1  Research on the benefits of glucose control in the hospital setting has focused primarily on critically ill cardiovascular patients.15  Hyperglycemia has been linked to immunosuppression, increased coagulapathies, increased infection rates, endothelial dysfunction, and prolonged lengths of hospitalizations.2,6  A diabetic population is at greater risk for developing complications if glucose levels are not controlled.

Improved glycemic control is dependent on establishment of glycemic targets, adjustment of diabetes medication regimens (including insulin), monitoring of glucose trends, and assessment of eating behaviors. Accordingly, to understand glycemic control in the hospitalized population, it is important to examine meal consumption, as well as pharmacological therapies.7  Unfortunately, eating patterns and actual nutritional intake are not well understood for this population.2  Thus, the aim of this study was to explore meal consumption patterns of hospitalized patients with diabetes.

The research questions included:

  1. What is the average daily meal consumption of hospitalized patients with diabetes receiving subcutaneous insulin therapy?

  2. Is there a difference between actual meal consumption and estimated nutritional requirements in hospitalized patients with diabetes?

  3. What factors affect meal consumption in hospitalized patients with diabetes?

Setting and sample

Investigators recruited a convenience sample of patients from two medical and two surgical units in a large, urban, tertiary care facility in the Midwest. Adult patients diagnosed with type 1 or type 2 diabetes, > 20 years of age, who were receiving subcutaneous insulin were included. Patients receiving steroid therapy, oral glucose-lowering agents, tube feedings, parenteral nutrition, or pre-packaged kosher meals and those who could not understand English were excluded. The study took place from July to November 2007 with approval of the institutional review board.

Study design

Dietitians identified subjects during their daily rounds. All participants gave verbal consent. The average length of stay for these units was 3.7 days; as a result, investigators collected data for a 4-day period. They observed meals starting with lunch on day 1 and continuing until dinner on day 4 or until patients were discharged or transferred to a non-study floor. Participants received meals at the same times as all other hospital patients.

Trained data collectors conducted visual reviews of meal trays at patients' bedside before food service staff collected trays. They assigned a percentage of consumption to individual food items and then averaged these percentages according to a specific set of parameters to obtain a total meal consumption percentage for documentation on a meal consumption log. To compare actual intakes to estimated nutrition needs, investigators determined subjects' resting energy expenditure (REE) using the Mifflin-St. Jeor predictive equation.8  Investigators multiplied a combined stress and activity factor of 1.3 by the REE to estimate each person's caloric needs.

If patients consumed < 100% of a meal, data collectors asked about factors that contributed to the lower consumption. Data collectors asked the same question to all patients. Patients could volunteer more than one reason.

Meal consumption log

Investigators developed this log to record observational and interview data. The log included patient demographics, estimated nutritional requirements, prescribed diet, percentage of meal consumption, and reasons for not consuming an entire meal. They used a predetermined list of reasons to explain patients' rationale for incomplete meal consumption.9 

Data collector training

A registered dietitian (RD) on the research team provided standardized data collection training to the other members of the research team. The training emphasized the importance of accuracy and consistency of meal consumption observations. Data collectors recorded food consumption percentages using a five-point scale: 0, 25, 50, 75, and 100%.1012  Each team member completed a pictorial quiz to ascertain their learning and participated in extensive practice sessions before collecting study data. Researchers assessed concordance of data collectors with two RD investigators and continued until they achieved 100% inter-rater reliability.

Hospital meals

This hospital provides patients with meals from multiple heat-and-serve convenience kitchens. The prepackaged and frozen entrees have predetermined and consistent portions sizes without significant ingredient variation. Food service staff members serve individual meals according to established guidelines for an array of diet orders, or any combination of diet orders, as prescribed by physicians. Orders may change frequently based on patients' medical needs. For patients with diabetes, physicians may order a “carbohydrate-controlled diabetic diet,” allowing patients to choose as many as 90 grams of carbohydrate per meal. There is no minimum selection amount required, and not all patients with diabetes are given a carbohydrate-controlled diet.

Patients choose foods from a diet-specific menu that offers diverse choices for entrees, beverages, side dishes, and desserts for the following day. Newly admitted patients and those who did not choose specific items receive a nutritionally complete meal specific to the diet order.

Table 1.

Demographics

Demographics
Demographics

Diet analysis

This study focused on evaluating calories, protein, and carbohydrate only. A nutrient content database maintained by the hospital's food service department provided information about food quantity and the calorie, protein, and carbohydrate content for each serving of food. To ensure consistent calculation of meal consumption, researchers developed an automated tool that calculated nutrient values for each food item based on percentages consumed. Researchers did not include in consumption observations or analyses any foods served or consumed in addition to the food on the main three daily meal trays.

Statistical analysis

Researchers used SPSS (V 17.0, IBM Corporation, Somers, N.Y.) for statistical analysis. They calculated means and standard deviations (SDs) to determine average daily meal consumption for the sample. They used a one-way analysis of variance (ANOVA) test to determine whether mean consumption differed by group (research question 1). Paired t tests were used to determine whether differences existed between actual intake and required intake for the sample as a whole and for medical and surgical groups separately (research question 2). To identify factors that affect nutritional intake, they reported frequencies (research question 3).

Table 2.

Comparison of Caloric Needs and Caloric Intake by Day*

Comparison of Caloric Needs and Caloric Intake by Day*
Comparison of Caloric Needs and Caloric Intake by Day*

Study Results

Of 434 subjects included in this study, more than half were male, and just over 60% were white. Ages ranged from 27 to 94 years, and the mean age was 65.9 years. BMI ranged from 11 to 101 kg/m2, with a mean of 31.4. Almost 54% of subjects were classified as obese (BMI ≥ 30 kg/m2), and approximately one-fourth were overweight (BMI 25–29.9 kg/m2). Means and SDs (for continuous data) and frequencies and percentages (for categorical data) were calculated and used to describe the sample (Table 1).

Researchers performed one-way ANOVA tests to determine whether BMI varied by age, race, or sex. There was a significant difference in BMI by age, with oldest subjects (> 81 years of age) having the lowest average BMI (P < 0.001). There was also a significant difference in BMI by sex, with women having a higher average BMI than men (P = 0.003). However, there was no difference in BMI by race (P = 0.841).

Investigators observed 2,945 meal trays. Not all patients were provided carbohydrate-controlled diets. To compare average daily caloric needs with actual caloric intake (by direct observation), researchers used paired t tests and examined data from days 2, 3, and 4 separately. Analysis revealed a significant difference (P < 0.001) between average daily caloric needs and actual daily caloric intake for all 3 days (Table 2). Subjects consumed merely 37–39% of the number of calories required to meet their estimated daily metabolic needs. There were no differences in actual intake by day, nor were there differences based on age. A significant difference in actual caloric intake by sex was found for day 2 (P = 0.016), with men having a higher caloric intake than women. However, this was not significant for days 3 or 4. Finally, an examination of the data to determine whether actual caloric intake differed by meal revealed no significant differences.

To compare actual carbohydrate intake (measured using direct observation) to average daily carbohydrate recommendations based on a standardized chart (Table 3), researchers used paired t tests for data from days 2, 3, and 4 independently. Analysis revealed a significant difference (P < 0.001) between average daily carbohydrate recommendations and actual daily carbohydrate intake for all 3 days (Table 4). Subjects consumed only 43–46% of the recommended amount of carbohydrate. Additionally, patients had a mean actual protein consumption of 36–38 g daily.

Investigators calculated total meal consumption percentages by observing the actual amount eaten of individual meal items and dividing that by the number of items served at the meal to determine a meal consumption average. This was predicated on the premise that percentages of meals consumed do not necessarily correlate to amount of total calories and protein eaten.

This analysis revealed that 44–59% of patients generally ate ≤ 50% of any offered meal (Table 5). More specifically, 18–34% of patients ate no food, including those patients who were not supposed to have any food intake, such as those with NPO (nothing by mouth) orders. Breakfast was the meal for which the highest percentage of patients had a meal consumption of 0%. Conversely, 12–25% of patients consumed all of their meals. By day 4, the number of patients who consumed 100% of their meals increased, and the number of patients who consumed ≤ 50% of their meals decreased.

With regard to the percentage of meals eaten and calculations of actual caloric, protein, and carbohydrate intake, the study results indicated a 4.3% error rate. Meal observations were assigned the designation of error when observers did not clearly account for food items, including high-sugar or calorie-containing condiments such as syrup, honey, and other packets.

Investigators conducted patient interviews to elicit factors contributing to their consuming < 100% of a meal. Reasons for inadequate meal consumption were divided into four categories: patient-related issues (42.2%), treatment issues (32.6%), illness-related issues (15.1%), and nursing-food service issues (1.9%) (Table 6).

Patient-related and treatment issues were given most often as reasons why patients did not fully consume their meals. Of the patient-related issues, feelings of fullness, not being hungry, loss of appetite, and dislike of offered items were cited most often. Treatment issues such as having an NPO order and not being in their rooms during meal times were also commonly cited. The most cited illness-related issues were nausea, vomiting, feeling ill, being too tired to eat, and being asleep during mealtimes.

Factors of less impact included pain, chewing or swallowing difficulties, food temperature problems, portion sizes, meal tray inaccessibility, or the need for assistance to eat. Of note, nursing-food service issues were least influential. Very few patients cited interfering variables such as a need for assistance to eat, tray inaccessibility, or receipt of items differing from their food selections. Some patients (1.4%) were unable to communicate a reason for not eating. Finally, 6.9% of the reasons cited were nonspecific.

Table 3.

Standardized Chart to Determine the Amount of Carbohydrate per Meal that a Patient Should Ideally Consume*

Standardized Chart to Determine the Amount of Carbohydrate per Meal that a Patient Should Ideally Consume*
Standardized Chart to Determine the Amount of Carbohydrate per Meal that a Patient Should Ideally Consume*

Discussion of Findings

The primary focus of this study was to examine patterns in and identify factors affecting meal consumption in hospitalized patients with diabetes. The study population was primarily acutely ill, elderly patients with type 1 or type 2 diabetes. The majority of subjects were either overweight (25.8%) or obese (54%), and meal consumption was low. Reasons for insufficient meal consumption included patient-related, treatment, illness-related, and nursing-food service issues. The findings indicate this was primarily because of decreased appetite and either having NPO orders or not being present when meals arrived.

This study confirms Butterworth's observation in 197413  that failure to observe food intake and withholding meals for diagnostic testing contribute to poor meal consumption. The results demonstrate a disparity between macronutrient consumption recommendations and actual consumption by hospitalized patients with diabetes. Subjects consumed only 37–39% of their estimated caloric needs and 43–46% of the recommended carbohydrate intake. Mean protein intake was 36–38 g/day, which is less than Dietary Reference Intakes recommendations.14 

Table 4.

Comparison of Carbohydrate (CHO) Needs and Carbohydrate Intake by Day

Comparison of Carbohydrate (CHO) Needs and Carbohydrate Intake by Day
Comparison of Carbohydrate (CHO) Needs and Carbohydrate Intake by Day

These outcomes validate the findings of previous European studies of plate waste1518  that concluded that meal consumption is inadequate in hospitalized patients and that caloric and protein intake is suboptimal.

Primary reasons for insufficient food and beverage intake noted in previous research have included decreased appetite, NPO status, patients being not present when meals arrived, feelings of illness, personal preference, and organizational factors such as lack of assistance with meals and plate wastage.19,20  Although the current study did not reach all of the same conclusions as these other studies, this difference in findings could be the result of variances in study design and patient demographics.

Study limitations

This study used a convenience sample from a single facility. However, the large sample size and selection of four units with a diverse group of patients made it fairly representative of the general population. Although observational studies can be affected by data collection quality, extensive training was provided and reliability was monitored to ensure valid data collection.

Table 5.

Percentages of Meals Consumed by Day

Percentages of Meals Consumed by Day
Percentages of Meals Consumed by Day

Snacks and between-meal food and beverage intake were not recorded. Patients may have obtained food from other sources and consumed more calories, carbohydrate, and protein than meal consumption analysis indicated.

Patients were enrolled in the study for a maximum of 4 days. As a result of the short time frame, significant improvements or declines in meal intake may not have been detected.

Conclusions and Future Research Directions

The current standard of care relies on nurse-driven nutrition screening tools to identify patients who are at nutritional risk on admission.2022  Those at high nutritional risk may be referred to an RD for nutrition assessment, intervention, and ongoing monitoring and evaluation. But other nutrition indicators such as modified diets or poor meal intake may not be well monitored throughout patients' hospitalization.

The responsibility for collecting and documenting meal consumption is often delegated to nursing assistants who may have only brief training about the nuances of recording accurate meal consumption data. Hospitals may not have a consistent procedure for assessing meal consumption.2327  Meal consumption patterns should be included in handoff communication to dietitians and technicians, as well as to oncoming nurses to enhance knowledge of nutritionally at-risk patients.

Table 6.

Reasons for Inadequate Meal Consumptions

Reasons for Inadequate Meal Consumptions
Reasons for Inadequate Meal Consumptions

Additional research is needed to address and document all food and beverage intake rather than that which occurs only at scheduled mealtimes. Future studies could explore glycemic control and insulin adjustment related to meal consumption (especially carbohydrate intake) and the diabetes-specific factors (e.g., hypoglycemia or hyperglycemia) that may be associated with meal consumption. Moreover, the effects of room service or “meals-on-demand” interventions on meal consumption and euglycemia are worthy of rigorous investigation.

This study indicated that NPO orders and patients being away from their rooms at mealtimes accounted for 32% of the reasons for poor meal consumption. Room service on-demand meal delivery programs may be helpful in increasing nutritional intake when patients are away from their rooms during regular mealtimes.9,28,29  These results also suggest that meal plans in the hospital may not require caloric or carbohydrate restrictions. A more liberal menu may encourage greater overall food and beverage intake.

The authors thank Courtney Gravens, MSN, RN, Dawn Etchall, MSN, RN, Terry Rowland, and Kathy Shymske for their invaluable assistance with data entry; Jason Findley for his expertise in designing the database and for assistance with statistical analysis; and Mary Beth Zeni, ScD, RN, for her thoughtful review and editing of this article.

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