Similar BMI values from the present study (Tables 1 and 5) were reported in other studies, such as the one carried out in Brazil with ward inpatients with a BMI of 24.85 Kg/m2 (SD = 4.25) and ICU patients with a BMI of 25.1 kg/m2 (SD = 5.41)7; in Colombia with a BMI of 26.2 Kg/m2 (SD = 4.3)12; and in Europe with a mean BMI of 26 kg/m13 all using NutritionDay data, which corroborates our results and also does not report a statistical BMI differences compared to the other study groups.
The HSL uses oral supplementation and enteral nutrition (EN) in clinical units similarly to other hospitals in Brazil but significantly more than in the rest of the world (Table 1) and in other studies also using the NutritionDay database8,14. This can be explained by the greater complexity of the patients treated at the HSL, since in the clinical units both inpatient and semi-intensive units were evaluated, and also because in some countries the insurance companies do not reimburse supplementation costs15. In ICUs, the use of oral supplementation is also higher at the HSL than in other groups, which can be explained by the greater number of patients consuming an oral diet (Table 5).
Oral supplements are considered a key nutritional intervention approach for patients who can eat orally but do not meet the recommended amount14,16. Therefore, at the HSL, patients consuming less than 60% are indicated for oral supplementation, which would also justify the greater use of these products in the hospital. Adherence to the consumption of oral supplements in our hospital is checked at the time of the bedside visit (at least 3 times a week) and is asked whether the patient is consuming the entire supplement, more than half, half, less than half or not joined. Additionally, we look in the room for leftover or unopened jars. If there is no adherence to the use of supplementation, we offer alternatives such as flavorless supplements or those included in preparations and reinforce the importance of their consumption for nutritional restoration.
Regarding the outcome, the mortality rate in clinical units (5.6%) exceeded the world rate (3.3%) (Table 1), which can be explained by the Brazil status as a developing country where patients are in general hospitalized in more severe conditions. However, compared to other hospitals in Brazil (13.3%) and to other studies such as the one by Pearcy et al.2 and Tatsch et al.7, the HSL mortality rate is lower and can be justified because, despite being in a developing country, it is a private hospital with more resources than the average in the country and in some regions of the world.
The implementation of processes for patients at nutritional risk is associated with decreased mortality11, decreased length of hospital stay, and better outcomes15. As for nutritional care protocols (Table 2), the HSL has standardized nutritional care with a specialized nutrition team and well-established protocols. The most relevant point of improvement is weight on admission. Although it is higher than the world mean (57.7%), in 2019 it reached 66.4% of patients, which is below the percentage reported in other studies such as that by Ostrowska (72.9%)13. However, continuous data analysis over the years (Table 7) helped implement new procedures, such as an institutional indicator with a goal of weighing at least 70% of patients on admission and educational actions involving the multidisciplinary team, which significantly increased this measurement between 2017 and 2020, from 33.3% to 79.5, respectively (p = 0.000).
Studies have shown that patient involvement in health care actions improves service quality. For example, decreased appetite can be a barrier to adequate nutrition; however, it can be reduced by informing the patient about the importance of eating enough8. Over the years, HSL has prioritized patient involvement, with several actions implemented, such as initiating discharge guidelines at the beginning of hospitalization so that the patient has time to assimilate the information and clarify doubts, and using a whiteboard in the room with the main information about the patient’s care plan. These measures significantly increased the perception of patient involvement in their treatment compared to other hospitals in Brazil and worldwide (Table 3).
Appropriate nutritional care, including meal quality control, has shown beneficial effects on patient outcomes7. The HSL has shown a tendency toward increased food satisfaction and a significant increase in total meal consumption (Fig. 2). This percentage is higher than the one seen in other studies, such as Hiesmayr et al., who reported that less than 50% of hospitalized patients ate the entire meal offered, with a negative impact on their clinical outcomes8. Additionally, the number of reports of patients who did not eat well due to meal quality decreased (not liking the diet or finding the taste and odor unpleasant) (Table 7), which is due to the monthly monitoring of meal satisfaction through indicators that generate action plans at critical points.
Although patient satisfaction and total meal consumption showed no significant differences at the HSL compared to other hospitals in Brazil and the world (Table 4), only 4.5% of the patients reported not liking the food served, a result well below that found in the study by Varella et al.12, which showed that 22.2% of patients reported not consuming the whole meal because they did not like the food. Other reasons for lower consumption at the HSL are related to disease symptoms, not to the quality of the meals (Fig. 1), corroborating the main reasons mentioned in other studies that used the NutritionDay5,8.
A multidisciplinary team's commitment to the nutritional care process is essential for obtaining positive results5,8. In this context, a positive point was the reduced number of patients mentioning chewing and swallowing difficulties as a reason for inadequate consumption over the years, which is mainly due to joint multidisciplinary actions, mainly involving speech therapists (Table 7).
Some studies highlight that patients reduce intake not only due to disease or lack of appetite, but also due to changing habits or dissatisfaction with food preparation and service5, and that this situation can be reversed with simple interventions such as protected mealtimes, more meal options, and additional snacks8. As for the questions regarding the institution’s support for food intake, standardized procedures exist for adapting the dietary regimen both in terms of preferences and adapting meals to the clinical conditions of the patient (Table 4). However, we saw an opportunity for improvement in meal sizes. Although we have two meal sizes (whole or half meal), this is a dietary adaptation and not a standardization; in addition, we can be more flexible in adapting meal sizes to patients with certain symptoms such as nausea and vomiting.
Tables 5 and 6 show the results for ICU patients. Some studies show that inpatients receive suboptimal EN17, reaching a mean adequacy of 60%18. Protocols addressing common factors that delay EN help avoid them before they become a problem2. As for the calorie offer in relation to calorie estimate, the HSL has a mean adequacy of 90.2% (which reaches the institutional target of 80%). This adequacy reaches 102.7% in other Brazilian hospitals, dropping to 80.8% around the world.
The Simplified Acute Physiology Score (SAPS) is one of the most extensively validated scores for critically ill patients19. Although our mean SAPS (42.3 points) exceeded the rest (39.9 points) (Table 5), it remains lower than that of other hospitals in Brazil (51.8 points), as HSL follows the international patient care standards. This may explain the lower mortality rate in ICU patients than in the rest of Brazil and the world (p = 0.000). This standardization also includes the nutritional care provided at the ICUs (Table 6).
Implementing a screening routine is positively associated with providing specialized nutrition to patients at risk of malnutrition8. As for screening and nutritional assessment (Table 7), until 2018, the HSL used the BMI and a nutritional assessment tool that considered food intake, diagnosis, and clinical conditions but was not validated. Aiming at better nutritional care and in accordance with international guidelines2, after 2019, the HSL adopted the NRS2002 screening10 for screening and developed a tool based on the GLIM guidelines for nutritional assessment that considers both phenotypic and etiological patient information11. In addition, body composition is also systematically evaluated in cases of nutritional risk20.
The frequency of some dietary restrictions has increased over the years (Fig. 3), which is also reported for the other groups (Table 1). These restrictions appear to be associated with adhering to a healthier diet, with reduced consumption of simple sugars or fats, which are positive changes as they aim for a healthy diet that reduces malnutrition and reverses unfavorable chronic disease tendencies21,22. Thus, the composition of the meals served in the hospital changed over the years, with a decreased use of processed products. In addition, some diets were standardized, such as gluten- or lactose-free and vegetarian diets. However, educational activities are important to discourage unnecessary restrictions, always aiming for a balanced diet that contributes to a full recovery. To this end, we provide a healthy eating guide and recipe books for patients23.
Some limitations of the present study are the voluntary participation in the NutritionDay and the extensive databases, which may lead to missing data and non-homogeneous reports. Finally, data collection was affected by the COVID-19 pandemic in 2020, which may have interfered with the results obtained.