Intervention group
The intervention group is offered individualized dietary counseling delivered by a research dietitian affiliated with the hospital. The dietitian will perform a comprehensive individualized nutritional assessment to identify the cause of malnutrition, such as lack of appetite, nausea, swallowing problems, polypharmacy, mouth and dental problems, or obstipation. However, the focus is on the dietary intake, activity level, and weight of each participant as a basis for developing a nutrition plan consistent with estimated nutritional requirements and nutritional rehabilitation goals. Specific focus will be placed on optimizing the intake of protein during the day and on the importance of additional strength training. The individualized nutrition plan is delivered together with nutritional information provided on a handout sheet. The counseling will take place in connection with the discharge of the patient. The dietary counseling is standardized so that each session at least contains guidance for meal distribution and meal sizes, counseling in energy- and protein-rich meals and drinks, recommendations for ONSs, a recommendation of protein-rich drinks before bedtime to achieve the maximal anabolic response, the nutrition plan, and recommendation of daily intake of multivitamin tablet.
The individualized nutritional plan, which includes an assessment of nutritional problems, a description of the nutritional therapy started in the hospital, the dietary plan, and finally recommendations for handling the nutritional situation after discharge will be communicated to the municipality (i.e., the general practitioner and the home care if applicable). The purpose of this is that the municipality health care personnel should support the nutritional interventions initiated by the hospital dietitian. If the patient experiences a worsening that requires intervention (e.g., massive weight loss during the intervention period), the municipality will be contacted again.
On day 4 after discharge, the patient will be called by the hospital dietitian for the second individual dietary counseling. The purpose of this is to clarify any additional questions, provide further guidance in the handout nutritional information material, and adjust the nutritional plan if necessary. A need for adjustment of the nutritional plan is based on a questionnaire, where compliance with the nutritional plan, assessment of energy and protein intake in relation to needs, appetite (Simplified Nutritional Appetite Questionnaire [SNAQ]; see “Outcome assessments” section), frequency of strength training, experience of daily diet, use of ONSs, and eventual involvement of home care and startup of home-delivered meals are assessed. Thirty days after discharge, the patient is contacted again by the hospital dietitian for phone-based individual dietary counseling. Again, the purpose is to clarify any additional questions and eventually adjust the nutritional plan on the basis of a questionnaire. The participants and the participants’ relatives are encouraged to contact the hospital dietitian whenever needed and also after day 30.
The intervention group will receive a food package to cover the first 24 h after discharge. The food package is produced by the Nutritional Unit, Herlev Gentofte Hospital, and is based on recipes developed in former projects [
17,
22,
23].
The dishes in the food package will consist of energy- and protein-rich main and in-between meals as well as energy- and protein-rich drinks. The food is either naturally rich in energy and protein, enriched with naturally energy-tight ingredients, and/or industrially produced dairy protein powder, when enrichment with natural protein sources is not possible. The daily diet is available in three different energy and protein levels to best cover the patients’ individual needs. The levels of the daily diet start at 6500 kJ and 65 g of protein; the second level is 7500 kJ and 75 g of protein; and the third level is 8500 kJ and 85 g. If needed, the dietitians can further individualize the diet to increase either energy or protein or both.
Food and drink are provided for free to the patient. The first 50 patients in the intervention group will be provided with a questionnaire in which they are asked to note what they think about the food delivered, how the food has been to handle in the home, and what price they might possibly pay for the food delivered.
The intervention group will also receive a free “goodie bag” containing samples of energy- and protein-rich milk products for use in the week after admission. The purpose is for the patients to have the opportunity to taste different flavors. The intervention group will be recommended to take an energy- and protein-rich product just before bedtime for 16 weeks. The participants must purchase these at their own expense. After 16 weeks, the intervention group receives a home visit by research assistants to collect outcome data. A short dietetic counseling session is held if required.