A comparison of the amount of food served and

consumed according to meal service system

A. Wilson, S. Evans and G. Frost
Department of Nutrition and Dietetics, Charing Cross Hospital, Hammersmith Hospitals NHS Trust, Fulham Palace Road, London W6 8RF,
UK

Abstract
Correspondence
Gary Frost,
The Hammersmith Hospitals NHS
Trust,
Department of Nutrition & Dietetics,
Hammersmith Hospital,
Du Cane Road,
London W12 0HS, UK.
Tel.: +44 20 83833048
Fax: +44 20 83833379
E-mail: g.frost@ic.ac.uk
Keywords
catering, food, hospital, nutritional
intake.
Accepted
May 2000

Background Malnutrition affects between 25 and 40% of all

hospitalized patients, the majority of whom receive their main
nutritional intake from the food provided by the hospital catering
system. There is currently very little published information concerning
the nutritional impact on patients of different methods of catering
service.
Objective In the current study the effects of two catering service
systems, plated and bulk service, on food and nutrient intake of
hospital patients were compared.
Methods One-hundred and eight patient meals were surveyed, 51 on
the plated meal and 57 on the bulk meal services. Patients were either
on a general medical or an orthopaedic ward. Weighed food intake data
were collected by weighing food served and comparing it to the weight
of food left on the plate. Equal numbers of lunch and supper dishes
were weighed. Also, a number of weekend surveys were carried out to
take into account variation in service at weekends.
Results Food wastage was greater with the plated system. Comparing
the amount of energy and nutrients consumed by patients according to
meal system: energy intakes were significantly lower with the plated
system (414 6 23 kcal vs. 319 6 22 kcal, P , 0.004). Protein, fat and
carbohydrate intakes were also significantly lower. The main reason for
the observed differences was the higher total food intake of the main
course of the bulk service meals. Energy intake from the main course
was significantly higher among patients receiving bulk service meals
(227 6 10 kcal vs. 165 6 14 kcal, P , 0.006).
Conclusion Catering service systems can have a major impact on the
nutritional intake of hospitalized patients.

Introduction
A consistent finding across many studies is that a
large proportion of hospital inpatients are malnourished (Bistrian et al., 1976; Hill et al., 1977;
Larsson et al., 1990; Moy et al., 1990). Classic work
by Pennington et al. has demonstrated that not only

Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 271275

are there are a large number of patients admitted in

a malnourished state, but that this becomes worse
over inpatient stay (McWhirter & Pennington,
1994). Influential reports such as the Kings Fund
Report `A positive approach to nutrition in the
hospitalized patients', and the more recent economic evaluation of treatment of malnutrition,

271

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A. Wilson et al.

point to the possibilities of large financial savings

(226 million according to the Kings Fund) by
treating this problem (Lennard-Jones, 1992), savings mainly being made through decreased hospital
stay and treatment costs. Although artificial nutrition has received attention in published work, by far
the majority of patients will receive most of their
nutritional intake from the food provided by the
hospital catering system. Recent data concerning
feeding practice show that per 100 hospital beds,
0.6% are fed by parenteral nutrition, 2.1% by tube
feeding, 8.1% receive supplements and 89% rely on
hospital food (Elia et al., 1996). This has led
organizations such as the British Enteral and
Parenteral Nutrition Society, and the Nuffield Trust
to recommend that there should be a multidisciplinary committee within the hospital that will
advise on all aspects of nutritional needs of patients
(Allison, 1999; Davis & Bristow, 1999).
There is very little systematic evaluation of
hospital catering systems and their effect on
patients' nutritional intake. Our own work both
on the introduction of a healthy eating policy and
on the effect of nutritional supplementation show
nutrient intakes to be poor in the most vulnerable
groups (Frost et al., 1991; Hogarth et al., 1996).
Most evaluation of these systems concerns economic capital costs of the system and the running costs
thereafter. There is little work on economic aspects
of the acceptability of the food, the effect of systems
to provide a nutritionally adequate intake or an
evaluation of food wastage. This possibly reflects the
difficulty in building economic models to assess the
balance between capital outlay and the ability of a
system to decrease food wastage, increase patient
intake and decrease malnutrition. However, with
the publication of reports such as `Hungry in
hospital' and `Eating Matters', the quality of food
systems is beginning to be questioned (Association
of Community Health Councils for England &
Wales, 1997).
On-going evaluation of the meal service within
The Hammersmith Hospitals NHS Trust had
shown the need to be concerned over the quality
of the food reaching the patients using a plated food
service. In an attempt to improve meal service to
patients at Charing Cross hospital (CXH), an
evaluation of a bulk trolley meal service was

introduced. This study evaluates the pilot period

for the introduction of a bulk trolley meal service
against the traditional meal service and investigates
the effect it had on patient nutritional intake.

Methods
The aim of this study was to evaluate the effect on
nutritional intake of a pilot introduction of a bulk
trolley system compared to the traditional plated
food system at CXH. This was a unique opportunity
as the introduction was limited to the type of meal
service, the method of food preparation (cook-chill)
was to remain the same and the menu cycle
remained the same. This study is part of the ongoing catering monitoring and audit and was not
subject to ethical approval.
Centrally plated meal service. This was the
traditional method of meal service at Charing Cross
Hospital. Menu cards are filled in at ward level, then
collected centrally in the catering department and
the meals are then plated-up on a belt-run. Once
plated, the meals are transported to the ward in
trolleys. The meals are then regenerated on the plate
and served to the patients directly.
Bulk trolley. Again menu cards are filled in at
ward level and collected centrally. These menu cards
are then used to estimate the bulk supply of food for
the ward. Containers with the approximate amount
of each food item are transported to the ward and
regenerated in bulk. The food is then plated from a
hostess trolley at ward level taking into account
patients' preference and portion required. This
system also allows patients to change their mind
over the choice of menu at point of service. It also
integrates more nursing staff into the meal service.
Patients
One hundred and eight patient meals were
surveyed, 51 on the plated meal and 57 on the
bulk meal services. Patients were on either a general
medical or an orthopaedic ward. Equal numbers on
each ward were surveyed. No patient was on a
`special diet' or had a recorded problem eating. As

Blackwell Science Ltd 2000 J Hum Nutr Dietet, 13, pp. 271275

Meal services and nutrient intake

the menu and the type of food were the same, it was
possible to survey the meals before and after the
introduction of the bulk trolley, at the same time in
the menu cycle, so controlling for change in food
reheating method alone.

Nutrient analysis
This was carried out using Dietplan 5 (Forest Hill
Software, UK) computerized food tables. These
tables use the Composition of Foods 5th edn and the
current supplements.

Weighed food intake

Statistics

In both plated and bulk services, each food item was

weighed as it was put onto the plate. In the case of
the plated service this was in the plating room in the
central kitchen, in the case of bulk service this was
at ward level. Patients were then served their meals
in the normal way. After they had finished eating
the waste was weighed. Each individual food item
was weighed to the nearest 5 g on the same
electronic scale. Each item was weighed as it was
put onto the patient's plate so as not to affect
appearance of the meal. Cumulative weights were
calculated at a later date. Equal numbers of lunch
and supper dishes were weighed. Also, a number of
weekend surveys were carried out to take into
account variation in service at weekends.

All results are expressed as means (SEM). All data

were normally distributed so comparisons within or
between groups was by Student's t-test.

Results
The results are summarized in Table 1. There was
no significant difference in the nutrient content of
the food served to the patients on either the plated
or the bulk systems. The food served at an average
meal by both systems met the NHS Guidelines
(Nutrition Task Force Hospital Catering Team,
1995), i.e. 300500 kcal energy and 1218 g protein
per meal. In both the bulk and the plated system,

Table 1 A comparison of the amount of food served and consumed according to meal service system. Results are expressed as the mean
and SEM
Served
Meal
service
system
Plated

Bulk

Consumed

Meal
breakdown

Amount
(g)

Protein
(g)

Fat
(g)

CHO
(g)

Energy
(cal)

Energy
(kJ)

Amount
(g)

Protein
(g)

Fat
(g)

CHO
(g)

Energy
(cal)

Energy
(kJ)

Total
SEM
Dessert
SEM
Starter
SEM
Main
SEM
Total
SEM
Dessert
SEM
Starter
SEM
Main
SEM

541
16
145
8
131
6
246
14
532
17
133
8
137
7
238
12

22
1
4
0
1
0
17
1
21
1
4
0
1
0
16
1

19
1
7
1
0
0
12
1
19
1
6
1
1
0
12
1

64
2
27
2
6
0
27
2
59
2
24
2
7
0
24
2

499
19
178
15
32
1
270
15
478
20
155
13
37
2
258
13

2099
80
750
16
137
6
1133
63
2010
83
653
54
158
8
1085
52

360{
21
120{
9
121
6
165{
14
455{*
20
125
8
132
8
227*
10

14{
1
4
0
1
0
11{
1
18{*
1
3
0
1
0
14*
1

11{
1
5
1
0
0
7{
1
16{*
1
5
1
0
0
11*
1

41{
3
22
2
6
0
18{
2
51{*
3
22
2
7
0
24*
2

319{
22
146{
14
30
2
178{
15
414{*
23
145
13
35
2
246*
15

1345{
92
617
57
128
7
752{
62
1744{*
96
610
53
149
8
1035*
61

{Denotes a significant difference within group of at least P < 0.05; *denotes a significant difference between groups of at least P < 0.05.

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A. Wilson et al.

not all food was consumed. Wastage was minor in

the case of the bulk trolley system with 87% of food
eaten, whereas 65% was eaten with the plated
system. It is interesting that the main component of
this difference was the main course, 95% of which
was eaten in the case of the bulk system and 67%
with the plated system (P , 0.01). In comparing
the amount of nutrients consumed between the two
systems, there was significantly less eaten with the
plated system in terms of energy (414 6 23 kcal vs.
319 6 22 kcal, P , 0.004), protein (18 6 1 g vs.
14 6 1 g, P , 0.002), fat (16 6 1 g vs. 11 6 1 g,
P , 0.003) and carbohydrate (51 6 3 g vs.
41 6 3 g, P , 0.01).
The main reason for the observed differences was
the high intake in the main course of the bulk
service meal in terms of energy (227 6 10 kcal vs.
165 6 14 kcal, P , 0.006), protein (14 6 1 g vs.
11 6 1 g, P , 0.001), fat (16 6 1 g vs. 11 6 1 g,
P , 0.006) and carbohydrate (24 6 2 g vs.
18 6 2 g, P , 0.006).

Discussion
The main aim for providing a meal service to people
in hospital is to maintain their nutritional status
over a vulnerable period of their life in order to
reduce morbidity and mortality. There appears to
be no published comparison of the effect that the
introduction of changes in catering systems can
have on the nutritional intake of patients, which
would suggest that the primary goal of feeding
people has been forgotten in the list of considerations when new systems are being considered.
Although the meal service in both systems met
the nutritional guidelines for hospital catering
(Nutrition Task Force Hospital Catering Team,
1995), the real issue is the amount that is
consumed. A system may deliver the right mix of
nutrients, but if the food is not eaten it has failed.
This seems to be what is happening to the main
course on the plated system. At the present time this
is not taken into account in catering standards.
Our study has demonstrated that the type of meal
service can make a large difference to patients' food
intake. The pilot assessment of the bulk system
showed it to produce a greater nutrient intake
mainly as a result of the large amount of the main

course being consumed. The reasons for this

increase are unknown as no patient acceptability
data were collected at this time. The observed
differences were the plate presentation and the
greater degree of flexibility on portion size with the
bulk trolley system.
Other aspects of the bulk system which may play
a part are hard to quantify, e.g. more nurses were
involved in the meal service and there was more
contact with patients at meal times.
Obviously, if the full-scale implementation of a
bulk trolley system was to produce a similar
reduction in waste and increase in nutritional
intake of patients, the potential significantly to
affect length of patient stay and decrease morbidity
becomes a realistic goal.
There is a need to evaluate catering systems not
just from the purely financial view point but also
from a nutritional point of view. There is a need to
develop a methodology to carry this out in a
systematic way so that valid comparisons can be
made between different systems and institutions.

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