By Harriet Smith of HRS Communications, Registered Dietitian

Dietitians often talk about the importance of using a food first approach with their patients. To coincide with Nutrition and Hydration Week (16th - 22nd March 2020), a global initiative that seeks to raise awareness of the importance of good nutrition and hydration care, this article will explore what a food first approach is and how it can be used with patients.

What is a food first approach?

As the name suggests, a food first approach is a simple way to address poor dietary intake and unintentional weight loss using food-based strategies.

These strategies may include:

• Food fortification
• Offering high energy snacks
• Encouraging patients to eat little and often
• Offering nourishing drinks
• Providing education about food choices
• Altering the mealtime environment

Food Fortification

Food fortification is an ideal way of adding additional calories (energy) and/or protein to meals and snacks without increasing the volume of food consumed. This can be especially useful in patients with reduced appetite. 

The following foods are commonly used to fortify meals and snacks in people with or at risk of malnutrition. Using a combination of the foods below will ensure that the patient receives additional protein and energy.

 

Food	Portion size	Energy (kcal)	Protein (g)
Butter	1 tbsp	104	0.1
Cheese	30g	121	8
Mayonnaise	1 tbsp	94	0.1
Skimmed Milk powder	25g	124	7
Double cream	1 tbsp	67	0.25
Olive oil	1 tbsp	119	0
Peanut butter	1 tbsp	94	4
Honey/sugar	1 tbsp	48	0

If your patient requires food fortification, you could suggest that they try the following: 

1. Add grated cheese and butter to potato, egg or pasta dishes
2. Spread butter and honey/jam on toast, crumpets, and scones
3. Add milk powder to cooked dishes such as porridge and scrambled eggs
4. Mix sandwich or jacket potato fillings with mayonnaise (i.e. chicken/tuna/cheese and chive)
5. Drizzle olive oil on salads and vegetable dishes
6. Add peanut butter or ice cream to milkshakes and smoothies
7. Add sugar to tea or coffee

High energy snacks

Offering a choice of energy-dense snacks between meals is a useful way of increasing calorie intake in those with reduced appetite. Suitable options may include biscuits, cakes, scones, crumpets, cheese and crackers, crisps, nuts, full-fat yoghurts, custard pots, and mini sausages.  

For patients living alone, individually packaged snacks may be useful for reducing food waste. For more inspiration on sweet and savoury snack ideas, click here.

Little and often

Eating large volumes of food at mealtimes may be unrealistic and overwhelming for patients with reduced appetite. These patients may benefit from eating three meals per day with several small snacks in between meals.

For hospital patients, smaller portions of meals and additional snacks can usually be arranged. For patients living in the community, pre-prepared supermarket meals are often available in smaller, individual portions. Patients could also store some of their leftovers in the fridge for when they next feel hungry.

Nourishing drinks

Drinking nourishing drinks such as smoothies, enriched soups, milkshakes, malted milk drinks, fruit juice drinks, and hot chocolate is an easy way of boosting nutritional intake. Encouraging patients to choose full-fat dairy (or dairy alternatives) is a good way of delivering extra calories. Patients could also fortify their drinks with skimmed milk powder for additional protein.

If you’d like some inspiration for simple and easy recipes for nourishing drinks, click here.

Education about food choices

It’s important to remember that typical healthy eating guidelines encourage people to reduce their intake of sugary, energy-dense and high-fat foods. Therefore, making dietary changes may be difficult for people if they go against deeply ingrained food behaviors.

It’s important that dietitians provide an evidence-based rationale for their recommendations - for example, by explaining that energy-dense meals help to improve energy intake (2).

Similarly, nutrition misinformation may need to be addressed or corrected in a supportive and non-judgmental way.

For more information on engaging with relatives and carers about nutrition support, read our article here.

Mealtime environment

Some hospitals and care homes implement protected mealtimes in a bid to minimise interruptions to patients or residents. However, further evidence is required to determine whether this healthcare initiative increases energy intake and improves nutritional status (3).

Interestingly, a small interventional study of 48 hospital inpatients on an acute ward for the elderly found that eating in a supervised communal dining room significantly increased energy intake by 129 calories when compared with the unsupervised control group (4). Another study found that eating with companions increases caloric intake in older, house-bound individuals (5).

Oral nutritional supplements (ONS)

Oral nutritional supplements (ONS) are used in those who are struggling to meet their nutrition and hydration needs through an oral diet alone and have been deemed to be at nutritional risk using a validated malnutrition screening tool. 

ONS products are used for medical purposes in patients who meet the Advisory Committee on Borderline Substances (ACBS) prescribing criteria.

There are a variety of ONS products available such as powdered products, pre-made drinks, high protein products, juice-style drinks, and semi-solid dessert-style supplements. To view our full range of ONS products, click here.

A systematic review found that dietary counselling with or without ONS is effective at increasing nutritional intake and body weight in those deemed to be at nutritional risk (6). Therefore, implementing a food first approach with patients is a simple and effective way to address poor dietary intake and unintentional weight loss in patients.