Cited by 261Clinical Nutrition and GastroenterologyDietetics, Nutrition, and EducationNutrition and Health in Aging

The DOI matches its Crossref record; 240 of the 240 references it cites were found in a registry or an index; 78 of the 212 sources its claims cite were checked for support.

ESPEN guideline on hospital nutrition

Open access
Thibault, Ronan, Abbasoglu, Osman, Ioannou, Elina, Meija, Laila, Ottens-Oussoren, Karen, Pichard, Claude, Rothenberg, Elisabet, Rubin, Diana, Siljamäki-Ojansuu, Ulla, Vaillant, Marie-France, Bischoff, Stephan C.·2021·Clinical Nutrition

Abstract

In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This ESPEN guideline provides 56 recommendations on hospital nutrition, including hospital food organization, standard versus hospital diets, therapeutic diets, special patient groups, and monitoring of food intake. It emphasizes that therapeutic and restrictive diets can reduce energy delivery and increase malnutrition risk, so they should be used only when medically indicated.

Key findings

  • Hospitalized patients at moderate/high nutritional risk or malnourished shall receive the hospital diet, a protein-energy enriched diet; the standard diet should cover 25 kcal/kg actual BW/day and 0.8–1.0 g/kg actual BW/day protein, while the hospital diet should cover 30 kcal/kg actual BW/day and at least 1.2 g/kg actual BW/day protein.
  • Therapeutic diets should be used only if medically indicated; otherwise a regular diet should be used, because therapeutic diets such as low salt, gluten-free, or texture-modified diets are associated with decreased energy delivery and increased risk of malnutrition.
  • Systematic between-meals snacks shall be offered and consumed as a standard hospital food service to help reach nutritional requirements and prevent night fasting; a service with three meals and three snacks (7:30 am, 10 am, noon, 3 pm, 7 pm, 10 pm) is described as reaching this objective.
  • Neutropenic diets shall not be used, including in neutropenic patients with cancer and hematopoietic cell transplant patients; a systematic review and meta-analysis of six studies with 1,116 patients found no statistically significant difference in major infections or bacteremia/fungemia between neutropenic and usual diets.
  • Food intake should be monitored by semi-quantitative methods at hospital admission, at least weekly in patients with no nutritional risk, and daily in patients with nutritional risk or malnutrition; insufficient intake ≤50% of energy requirements over 3 days should trigger nutritional intervention.

Methods

  • ESPEN guideline developed according to standard operating procedures by an expert group of seven physicians and four dietitians; 24 PICO questions were created, and 57 recommendations were initially formulated, with a final guideline comprising 56 recommendations.
  • Literature search was performed separately for each PICO question in May 2019 using PubMed and Cochrane databases; existing guidelines were also considered, and evidence was graded using the Scottish Intercollegiate Guidelines Network (SIGN) system.
  • Recommendations were voted online between 13 February and 15 March 2020, then revised and voted again between 7 July and 31 August 2020; consensus was classified as strong (>90%), consensus (>75–90%), majority (>50–75%), or no consensus (<50%).

Limitations

  • Stated: 30 out of 56 recommendations are not based on evidence from literature but on extrapolations or expert knowledge, indicating gaps in research in hospital nutrition.
  • Stated: evidence is limited or lacking for several topics, including realimentation after lower gastrointestinal bleeding, endoscopy procedures, and some therapeutic diets; the authors call for stronger RCTs and more multicenter prospective studies.
  • Evident from text: some recommendations had lower agreement, including six recommendations with ≤75% agreement in the first voting and one final recommendation with >50% agreement; several evidence syntheses included heterogeneous, low-quality, or methodologically limited studies.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.clnu.2021.09.039

Cites

240 of 240 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Verification

Claims the paper makes

78 of 212 cited sources checked · 15 supported · 3 flagged · accuracy not yet measured

Show all 92 claims

  • Probably not a substantial claim. 63
  • It may state two separate claims as one. 58
  • The quote only partly states this claim. 15
112 of 112
  • The paper relies on this without support.

    In hospitals throughout Europe and worldwide, practices regarding hospital food are heterogeneous.

    “In hospitals throughout Europe and worldwide, the practices regarding hospital food are 63 heterogeneous.”
  • The paper relies on this without support.

    In many clinics, prescriptions of hospital diets are made independently from the evaluation of nutritional status, and without taking into account the nutritional status.

    “In many clinics, prescriptions of hospital 68 diets are made independently from the evaluation of nutritional status, and without taking into 69 account the nutritional status.”
  • The paper relies on this without support.

    The use, and if any, the prescriptions, of hospital diets are sometimes based on arbitrary non-scientific criteria or caregivers' personal beliefs.

    “The use, and if any, the prescriptions, of hospital diets are sometimes based on 64 arbitrary non-scientific criteria or caregivers' personal beliefs.”
  • The paper relies on this without support.

    Hospital diets are rarely prescribed by physicians.

    “Hospital diets are rarely prescribed by physicians, and sometimes the choices 34 of diets are based on arbitrary reasons.”
  • The paper relies on this without support.

    40-70% of hospitalized patients are at nutritional risk.

    “40-70% of hospitalized patients are at 542 nutritional risk.”
  • The paper relies on this without support.

    Malnutrition is associated with a prolonged length of stay and a higher complication risk, impaired wound healing, and an increased number of infections.

    “Malnutrition is associated with a prolonged length of stay and a higher complication risk, 554 impaired wound healing, and an increased number of infections.”
  • The paper relies on this without support.

    Hospitalized patients are frequently malnourished or at risk for malnutrition (e.g. older people, patients with acute or chronic diseases), and the risk increases with the length of hospital stay.

    “Hospitalized patients are frequently malnourished or at risk for malnutrition (e. g. older people, 589 patients with acute or chronic diseases), and the risk increases with the length of hospital stay.”
  • The paper relies on this without support.

    Food allergy can cause severe clinical manifestations including anaphylactic shock or death.

    “Even a tiny amount of the allergy-causing food can trigger signs and symptoms such as 694 digestive problems, hives, or swollen airways, going until the anaphylactic shock or death 695 (general ref to be included).”
  • The paper relies on this without support.

    There is absolutely no scientific rationale for a lactose-free diet in dysimmune diseases, inflammatory rheumatism, autism, irritable bowel syndrome, or atopic eczema in children.

    “However, there is absolutely no scientific rationale for a lactose-free diet in these indications.”
  • The paper relies on this without support.

    Lactase deficiency, which is common in adults, does not mean lactose intolerance.

    “Lactase deficiency, which is common in adults, does not mean lactose intolerance.”
  • The paper relies on this without support.

    There is no need for a therapeutic diet for acute care obese patients.

    “There is no need for a therapeutic diet for acute care obese patients.”
  • The paper relies on this without support.

    In-hospital patients are at high risk for malnutrition.

    “In-hospital patients are at high risk for malnutrition.”
  • The paper relies on this without support.

    In hospitalized patients, a too strict salt diet restriction worsens the risk of malnutrition.

    “At hospital, the risk for”
  • The paper relies on this without support.

    In systemic corticosteroid therapy, salt, sugar, fat, or calorie reduction has an unfavorable benefit-risk ratio toward a higher risk of malnutrition.

    “salt, sugar, fat, or calorie reduction”
  • The paper relies on this without support.

    Snacks containing mixed carbohydrate, protein, and fat induce better glycemic control than carbohydrate only.

    “Snacks containing mixed carbohydrate, protein, and fat intakes induce better glycemic control”
  • The paper relies on this without support.

    In hospitalized diabetic patients, a low carbohydrate diet (<40% of energy intake) is associated with lower energy intake and risk of malnutrition.

    “the low carbohydrate diet (<40% of energy intake)”
  • The paper relies on this without support.

    When hospitalized, diabetic patients could be more at risk of malnutrition, especially in case of diabetes disequilibrium.

    “When hospitalized, diabetic patients could be more at risk of malnutrition especially in case of”
  • The paper relies on this without support.

    Oral-pharyngeal dysphagia is associated with many medical conditions, including stroke, neurogenic and neuromuscular disorders, head and neck cancer, amyotrophic lateral sclerosis, hereditary ataxia, inflammatory bowel disease, and traumatic cervical spinal cord injury.

    “Oral-pharyngeal dysphagia is associated with many medical conditions, including stroke,”
  • The paper relies on this without support.

    Liver cirrhosis patients with arterial hypertension usually become normotensive, and patients with normal blood pressure before disease develop low blood pressure.

    “Liver cirrhosis patients with arterial hypertension usually become normotensive and patients”
  • The paper relies on this without support.

    In chronic cardiac failure, chronic renal failure, or cirrhosis, reducing sodium chloride below 6 g/day has an unfavorable benefit-risk ratio toward a higher risk of malnutrition.

    “reduction should not be decreased below 6 g/day, otherwise, the benefits-risk ratio is”
  • The paper relies on this without support.

    Reduction of dietary intake, together with the increase of energy requirements, is the main cause of hospital malnutrition.

    “Indeed, reduction of dietary intake, together with the increase of 1721 energy requirements, is the main cause of hospital malnutrition.”
  • The paper relies on this without support.

    Undernutrition is the main cause of malnutrition.

    “and that undernutrition is the main cause of malnutrition”
  • The paper relies on this without support.

    In some situations, patients are prescribed simultaneous therapeutic diets, thus reducing the variety of possible dishes and increasing the risk of low food intake and malnutrition.

    “In some situations, patients are prescribed simultaneous therapeutic diets (e.g., sugar-free, less 1689 salted, lipid-free…), thus. reducing the variety of possible dishes, increasing the risk of low 1690 food intake and malnutrition.”
  • The paper relies on this without support.

    These prescriptions often come from additional prescriptions made without knowing the previous ones.

    “These prescriptions often come from additional prescriptions 1691 made without knowing the previous ones.”
  • The paper relies on this without support.

    Most of the time a texture-modified diet corresponds to a low energy diet due to the absence of bread and a limited number of dishes.

    “Most of the 1699 time a texture-modified diet corresponds to a low energy diet due to the absence of bread and a 1700 limited number of dishes.”
25 of 25

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Hospital-diet protein percentage differs between recommendation and table

    Minor

    Recommendation 16 specifies 20% of energy from protein for the hospital diet, while Table 5 gives a range of 20-25%.

1 of 1

Cited works that were retracted

Works this paper cites that were later retracted, from the retraction notices publishers deposit. Major when the notice came out before this paper was published.

  • Cites a retracted work: 10.1016/j.clnu.2016.12.027

    Major

    The cited work was retracted on 2019-06-01 (notice 10.1016/j.clnu.2019.01.017), before this paper was published (2021-12). Its authors could have known.

    Cited work 10.1016/j.clnu.2016.12.027 · retracted 2019-06-01 · notice 10.1016/j.clnu.2019.01.017 · this paper published 2021-12

1 of 1

Citations

Cites

1 retracted

Flagged first, then by citations

Show all 238 references

Research works printed but not linked: 5

  1. Bischoff, 2015, Standard operating procedures for ESPEN guidelines and consensus papers, Clin Nutr, 34, 1043, 10.1016/j.clnu.2015.07.008 · DOI · Paper page
  2. Correa-Arruda, 2018, vol. 17
  3. Rumun, 2014, Influence of religious beliefs on healthcare practice, Int J Educ Res, 2, 37
  4. Laïcité, 2016, Un guide pour la gestion du fait religieux dans les hôpitaux, Histoire, monde et cultures religieuses, 37, 180
  5. National Clinical Guideline, 2014, vol. 2014

Cited by

Sorted by citations

Items 101–200 of 261

Metadata

Authors
Thibault, R., Abbasoglu, O., Ioannou, E., Meija, L., Ottens-Oussoren, K., Pichard, C., Rothenberg, E., Rubin, D., Siljamäki-Ojansuu, U., Vaillant, M.-F., & Bischoff, S. C.
Affiliations
  • Inserm (FR)
  • Limassol General Hospital (CY)
  • Pauls Stradiņš Clinical University Hospital (LV)
  • University Hospital of Geneva (CH)
  • Kristianstad University (SE)
  • Tampere University Hospital (FI)
  • Centre Hospitalier Universitaire de Grenoble (FR)
  • University of Hohenheim (DE)
Venue
Clinical Nutrition
Publisher
Elsevier BV
Published
2021-12
Volume
40
Issue
12
Pages
5684-5709
ISSN
0261-5614 (ISSN-L)
OpenAlex
W3206499007
Cited by
259
References
238
Citations by year
2026: 70 · 2025: 69 · 2024: 58 · 2023: 32 · 2022: 28 · 2021: 2
FWCI
15.95
Type
journal article
Language
en
Open access
Locations
  • Clinical Nutrition (acceptedVersion)
  • PubMed (publishedVersion)
  • Archive ouverte UNIGE (University of Geneva) (publishedVersion, cc-by)
  • HAL (Le Centre pour la Communication Scientifique Directe) (submittedVersion, cc-by-nc)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
Funders
European Society for Clinical Nutrition and Metabolism
Topics
  • Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
  • Health Sciences › Nursing › Nutrition and Dietetics › Dietetics, Nutrition, and Education
  • Health Sciences › Medicine › Physiology (medical) › Nutrition and Health in Aging
Keywords
hospital nutrition, dietary therapy, malnutrition prevention, nutritional assessment, dietary prescription, dysphagia, food allergy, food intolerance, sodium restriction, gluten-free diet, elderly patients, gastrointestinal diseases, diabetes mellitus, obesity, dietary monitoring, rehabilitation centers, nursing homes, patient safety
MeSH terms
Diet, Food Service, Hospital, Humans, Inpatients, Nutritional Requirements, Nutritional Status, Societies, Medical, Nutrition Assessment, Patient-Centered Care, Nutrition Therapy, Meals

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