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To the Editor: Hospitalized elderly patients have a relatively high risk for malnutrition.¹ While some of this problem may be related to factors such as preexisting malnutrition, lack of appetite, or inability to eat, it is not known to what degree clinically indicated restricted diets contribute to such deficiencies.

Methods
We analyzed commonly prescribed diets served in 2 US hospitals. One was a large private not-for-profit academic research-oriented medical center serviced by a well-known commercially contracted hospital food service and the other was a large metropolitan Veterans Affairs medical center with an in-house dietary department. Amounts of ingredients for recipes for every item served in the 7 prescribed meal plans in both hospitals were recorded in a comprehensive database that allowed precise nutritional analyses by weight of food serving. The data included ingredients used in literally thousands of recipes; for instance, 1 hospital had more than 50 different recipes for green beans. Nutritional information supplied by the manufacturer of prepackaged foods was used when available.

To analyze these meals, we weighed each item with an electronic scale accurate to the nearest 0.1 g. Two weeks of breakfast, lunch, and dinner meals made up of standardized portion sizes for each prescribed diet were analyzed for daily nutrient content using the United States Department of Agriculture Database, 1997. The Nutritionist V nutrition analysis software package (First Databank Inc, San Bruno, Calif) was used for data analysis.

Results
Figure 1 displays the amount of nutrients supplied each day by the different diets in relation to published age-specific minimum daily intake requirements. Although most diets supply adequate energy, protein, and vitamin A, they are generally deficient in terms of a number of additional vitamins and minerals.

View larger version (110K): [in this window] [in a new window] Figure. Nutrient Availability in Prescribed Diets Horizontal lines within boxes indicate the median; boxes indicate the interquartile range (IQR); upper limits of error bars, values 75th percentile plus 1.5 times the IQR; lower limits of error bars, values 25th percentile minus 1.5 times the IQR. Open-circle outliers are >1.5 times the IQR above or below the upper or lower hinge, respectively. Closed-circle extreme outliers are >3 times the IQR above or below the upper or lower hinge, respectively. DRI indicates daily reference intake.

Conclusion
Hospital-prescribed diets, especially the restricted diets, may often lack important nutrients. Nutrient deficits in hospital meals could have serious consequences for elderly patients, especially those hospitalized for extended periods. Older patients frequently present with advanced nutritional deficiencies and, when hospitalized, rarely eat everything they are served. Moreover, age-, disease-, or treatment-related changes in digestion, absorption, and metabolism further increase demand and decrease utilization of critical nutrients. When restricted diets are necessary, alternative methods of delivering essential nutrients should be considered.

Funding/Support: This research was funded by National VA Merit Award #E2117, the Retirement Research Foundation, and the National VA Center for Healthy Aging with Disabilities. It was supported by grants M01 RR02719 and MO1 RR-14467 from the National Institutes of Health, National Center for Research Resources, General Clinical Research Center.

Acknowledgment: Biostatistical assistance was provided by Donald E. Parker, PhD, and Christie E. Burgin, PhD, of Applied Research Consultants and the Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City. We also thank Ji H. Park, BS, for her help with organizing the data and constructing Figure 1.

Jonelle E. Wright, PhD
jonelle-wright{at}ouhsc.edu
Donald W. Reynolds Department of Geriatric Medicine

Garth J. Willis, MHS
University of Oklahoma College of Medicine
Oklahoma City

Marilyn S. Edwards, PhD, RD
Department of Internal Medicine
University of Texas Medical School
Houston

1. Sullivan DH. The role of nutrition in increasing morbidity and mortality. Clin Geriatr Med. 1995;11:661-674. ISI | PUBMED 2. McGee M, Jensen GL. Nutrition in the elderly. J Clin Gastroenterol. 2000;30:372-380. FULL TEXT | ISI | PUBMED 3. Panel on Micronutrients, Subcommittees on Upper Reference Levels of Nutrients and of Interpretation and Use of Dietary Reference Intakes, Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academies Press; 2002. 4. Levine M, Dhariwal KR, Welch RW, Wang Y, Park JB. Determination of optimal vitamin C requirements in humans. Am J Clin Nutr. 1995;62:1347S-1356S. FREE FULL TEXT

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2004;291:2194-2196.

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