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Effectiveness of mealtime interventions in improving nutritional intake in adult patients in the acute care setting: a systematic review.

JBI Database of Systematic Reviews and Implementation Reports: Volume 9 - Issue 48 - p 1–14
doi: 10.11124/jbisrir-2011-437
Systematic Review Protocol

Primary Reviewer

Gail Whitelock BSc, CFJBI, APD1 2

1MSc Clinical Sciences Candidate, The Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Adelaide SA 5005, Australia.

2Senior Dietitian, Department of Clinical Dietetics, Royal Adelaide Hospital, Adelaide, SA 5000, Australia

Secondary Reviewer:

Mary-Anne Ramis BN1 3

3Research Nurse, Nursing Research Centre, Mater Health Service, South Brisbane, QLD 4101, Australia

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Review Objective/Question

The objective of this review is to identify, assess and synthesise the available evidence on the effectiveness of mealtime interventions that improve nutritional intake in adult patients in the acute care setting. Interventions reviewed will not include nutritional interventions that are related to the actual food or fluids offered or ordered, for or by the patient, but rather will include interventions that evaluate or alter the environment and/or circumstances of the patient's mealtimes. Mealtimes will be taken to mean both designated mealtimes and/or other times when patients may eat or drink.

The review question is: What are the effects of identified mealtime interventions in improving the nutritional intake of adult patients in the acute care setting?

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Malnutrition has been well documented over the last few decades as being a common problem in acute care hospitals which is often unrecognised and untreated. 1-3 In the acute care setting malnutrition is known to effect between 20-50% of patients depending on the primary disease state and criteria used to determine nutritional status. 1,2,4 Malnutrition is associated with a number of adverse complications including increased morbidity and mortality, delayed wound healing, increased infection rates, functional decline and increased length of stay in hospital.1,4,5

Malnutrition can be taken to mean both under- and over-nutrition. However, despite this definition, it is under-nutrition which has been adopted by many healthcare professionals to be the common meaning of malnutrition. Under-nutrition has been defined by Allison as “a state of energy, protein or other specific nutrient deficiency which produces a measurable change in body function and is associated with worse outcome from illness as well as being specifically reversed by nutritional support”.6 For the purposes of this systematic review the term malnutrition will refer to the state of protein energy under-nutrition.

There have been numerous studies addressing the subject of malnutrition in the acute care setting by healthcare professionals from a variety of disciplines. Many focus on aspects of identifying malnutrition and its treatment through nutritional provision like modified menus, oral nutritional supplements or enteral feeding.7,8 However, despite the development in recent years of validated nutritional screening tools to assist in identifying patients at risk of malnutrition and the technological advances in patient nutritional provision through enteral feeding products, oral nutritional supplements and food service production malnutrition remains an issue in acute care hospitals which is costing healthcare providers and patients alike.4,9.

Even when diagnosed as being malnourished or identified as being at risk of malnutrition and provided with an individualised tailored meal plan, patients may still have an inadequate nutritional intake due to suboptimal environmental factors, organisational and physical barriers.10 The following scenarios may contribute to an inadequate nutritional intake:

  • missing meals due to medical and surgical procedures being performed at mealtimes
  • extended and/or inappropriate periods of fasting
  • food and fluids not being available when required
  • food and fluids placed out of reach
  • lack of assistance with opening food and fluid packaging
  • lack of assistance with feeding and set up for meals
  • disturbances during mealtimes including noise, smells and staff interruptions
  • lack of the necessary encouragement to eat

In a bid to better manage malnutrition in hospitals organisations like Age UK, the British Association of Parenteral and Enteral Nutrition (BAPEN) and the Council for Europe have been promoting strategies such as ‘protected mealtimes’ and the ‘red tray system’ as supportive nutritional interventions to promote optimal eating and feeding practices in hospitals.11,12 Given this interest in supportive nutritional practices which relate more to the environment and circumstances of eating, this review proposes to examine those interventions which promote optimal eating and feeding for adult patients in the acute care setting which are not solely nutritional screening or interventions based on the provision of additional energy and protein.

It is also envisaged that this review will assist in formulating some guidance with regard to supportive environmental and nutritional practices in acute care.

An initial limited search has been undertaken to ascertain the suitability of the proposed topic and to determine if this or a similar review had already been conducted. The following related articles were found:

  • Joanna Briggs Institute (JBI) Systematic Review by Vanderkroft et al in 2007 entitled ‘Minimising under nutrition in the older person’.13 This review was undertaken in the acute care setting and set out to identify best practices to minimise under-nutrition in patients aged 65 years and older. The review included 29 identified studies from 1980 to 2005. The interventions in the included studies related to additional nutritional provision from modified menus, oral nutrition supplementation or enteral feeds. Although conducted in the same setting as the intended review, Vanderkroft's review was specific to elderly patients and focused on nutritional provision interventions.
  • Joanna Briggs Institute Systematic Review Protocol ‘The effectiveness of interventions to reduce under-nutrition and promote eating in older adults with dementia: a systematic review’ by Jackson was registered in 2009.14 The protocol indicates that the author will be considering both direct nutritional provision and related nursing, food service, dietetic and feeding practices. Although these related practices are also the intended focus of this review the population groups are different in that this protocol indicates that the author intends only to focus on patients with dementia and not other disease states and that a variety of care settings will be reviewed.
  • The Cochrane review by Milne et al in 2009 entitled ‘Protein and energy supplementation in elderly people at risk from malnutrition’.8 This review examined 62 randomised and quasi-randomised controlled trials conducted with elderly patients who were provided with additional energy and protein primarily from oral nutritional supplements. As this review did not examine supportive nutritional practices and its focus was on elderly patients it is deemed sufficiently different to the intended review.
  • Review in the Journal of Clinical Nursing by Jefferies et al in 2011 entitled ‘Nurturing and nourishing: the nurses’ role in nutritional care.’15 The aim of this qualitative systematic review was to describe what nurses could do to reduce the incidence of malnutrition in patients in acute care and long term hospitals. The review examined what nurses could do to facilitate access to food, support the mealtime environment and prevent prolonged and repeated periods of nil-by-mouth. The review identified 73 papers from 1998 to 2008 and used JBI appraisal instruments to evaluate the literature. The outcome of this review was used to produce eight nursing standards to form the basis of a hospital policy. This review examined patients in both acute and long term care and was only concerned with exploring the nurses’ role and not that of other staff members.
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Inclusion Criteria

Types of Participants

The review will consider publications that include male and female adults aged 18 years old and over, from any ethnic background, who are inpatients in acute care hospitals with any diagnosis. The review will consider patients who obtain their nutrition by oral route and exclude patients who are enterally or parentrally fed.

The review will exclude patients in intensive care or high dependency facilities, palliative care and end of life patients. Other healthcare settings such as rehabilitation, transitional care and residential aged care facilities will not be considered.

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Types of Intervention

Interventions may include but will not be limited to:

Organisational practices

Food Service practices

Nursing practices

Medical practices

Dietetic practices

Dietetic/Diet/Nutrition Assistant practices

Volunteer practices

Family/carer practices

The following mealtime interventions have been identified as having the potential to influence nutritional intake and therefore will be examined in the first instance:

  • Focused or set up for meals practices where a pre-mealtime routine of getting patients ready for mealtimes occurs. This practice may include washing hands, toileting, ensuring space available for meal tray and correct position for eating.
  • Meal delivery systems or targeted feeding assistance practices e.g. ‘red tray system’ where patients previously identified as requiring feeding assistance have their meal delivered on a red tray which acts as a visual cue to all staff that the patient requires feeding assistance.
  • Feeding assistance practices where patients are provided with feeding assistance by nursing staff, nursing/dietetic/nutrition assistants or volunteers.
  • ‘Protected meal times’ where patients are allowed to eat undisturbed at mealtimes and do not undergo medical procedures during this time.
  • Ward dining rooms where patients eat in a designated room or area specifically designed for mealtimes and free from other ward distractions.
  • Ward kitchens/pantries which allow patients 24 hour access to food and fluids.
  • Nutrition support teams who consider more than just the foods or fluids prescribed for the patient but also the delivery of the above practices.

Interventions which solely relate to the actual food or fluid offered or ordered, for or by the patient, will not be considered. Strategies to promote the identification of malnutrition e.g. nutritional screening will not be included in this review.

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Types of Outcome

The primary outcomes of interest are measures of improved dietary intake and/or nutritional status. These may include actual or subjective measures of plate waste, documented food intakes, patient weight, Body Mass Index (BMI) and malnutrition status as determined by nutritional screening or assessment tools. Secondary outcome measures of length of stay in hospital and all-cause mortality will also be considered.

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Types of Studies

This review will consider any experimental studies including Randomised Control Trials (RCTs) and quasi-RCTs. In the absence of these studies or in the event of insufficient data being available the review will extend to other study designs primarily prospective observational studies.

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Search Strategy

The search strategy aims to find published and unpublished studies reported in English language. A three step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article.

A second search using all identified keyword and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies.

The following databases will be searched:




Informit - Health

Cochrane Clinical Trials Register


Australian Digital Theses Program

Index to Theses

Proquest Dissertations & Theses

The following keywords have been identified for use in the initial search:


Food service

Dining rooms


Feeding methods

Eating behaviour

Feeding assistance

Assisted feeding

Feeding volunteers

Red tray

Protected mealtimes

Focused mealtime


Nutritional intake

Food intake

Dietary intake

Diet records

Plate waste

Body Mass Index

Weight loss

Length of stay

Nutritional status






Acute care



Exclusion terms will include enteral feeding, tube feeding, PEG feeding and parenteral feeding.

In addition, this review will also search the following organisations publications, reports and web sites:

Australian State and Federal Government Departments of Health

National Health Service, UK

Age UK

Dietitians Association of Australia

British Dietetic Association

American Dietetic Association

Dietitian of Canada /Les diététistes du Canada

Australasian Society for Parenteral and Enteral Nutrition

British Association for Parenteral and Enteral Nutrition

European Society for Parenteral and Enteral Nutrition

Australian Nursing Federation

Royal College of Nursing UK

American Nurses Association

Canadian Nurses Association

Selected journals that feature a number of papers from the first, second and third searches will be hand searched to locate any additional papers which may meet the search criteria.

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Assessment of Methodological Quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standard critical appraisal instruments from the Joanna Briggs Institute Meta Analysis Statistics Assessment and Review Instrument (JBI-MAStARI), (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer experienced in the topic and the systematic review process.

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Data Collection

As this review will focus on quantitative measures, the data will be extracted using the JBI data extraction tool MAStARI, (Appendix II). The primary and secondary reviewers will extract the data independently.

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Data Synthesis

Data from the studies will, where possible, be pooled in statistical analysis using JBI-MAStARI, with results displayed in a forest plot. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated.

Heterogeneity will be assessed using the standard Chi-square with a random effects model considered for the presentation of statistics. Methodological differences encountered, for example differences in study design, may be explored by sub-analysis where appropriate. Where statistical pooling is not possible the findings will be presented in narrative form.

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Conflicts of Interest


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As this systematic review forms part of a submission for a MSc Clinical Sciences, a secondary reviewer will only be used for critical appraisal and data entry stages of the review.

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1. Watterson C, Fraser A, Banks M, Isenring E, Miller M, Silvester C et al. Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care. Journal of Nutrition & Dietetics. 2009: 66; 3.
2. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. British Medical Journal. 1994; 2008: 945-948.
3. Butterworth CE. The Skeleton in the Hospital Closet. Nutrition Today. 1974; 9: 2: 4-8.
4. Stratton RJ, Green CJ and Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Wallingford: CABI Publishing, 2003.
5. Middleton MH, Nazarenko G, Nivison-Smith I, Smerdely P. Prevalence of malnutrition and 12 month incidence of mortality in two Sydney teaching hospitals. Internal Medicine Journal 2008; 31: 455-461.
6. Allison SP. Malnutrition, disease and outcome. Nutrition 2000;16 (7/8):590-593.
7. Jones JM. Nutritional screening and assessment tools. New York: Nova Science Publishers Inc, 2006.
8. Milne AC, Potter J, Vivanti A & Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition (Review). Cochrane Database of Systematic Reviews. 2009, Issue 2. Art. No.: CD003288.
9. Lennard-Jones JE et al. A Positive Approach to Nutrition as Treatment. Kings Fund Centre. 1992.
10. Naithani S, Whelan K, Thomas J, Gulliford MC & Morgan M. Hospital inpatients' experiences of access to food: a qualitative interview and observational study. Health Expectations 2008; 11: 294-303
11. Age Concern. Hungry to be Heard - The scandal of malnourished older people in hospital. London: Age Concern, 2006.
12. Council for Europe - Committee of Ministers. Resolution ResAP(2003)3 on food and nutritional care in hospitals, 2003.
13. Vanderkroft D, Collins CE, Fitzgerald M, Lewis S, Neve M and Capra S Minimising undernutrition in the older inpatient. International Journal Of Evidence-Based Healthcare 2007; 5: 3 110-181.
14. Jackson J et al. Systematic Review Protocol - The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review. JBI protocol 2009.
15. Jefferies D. Johnson M & Ravens J. Nurturing and nourishing: the nurses' role in nutritional care. Journal of Clinical Nursing 2011; 20: 317-330.
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Appendix I JBI critical appraisal tools MAStARI







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Appendix II JBI data extraction tools MAStARI





© 2011 by Lippincott Williams & Wilkins, Inc.