To: Hospital administrators, medical superintendents and care-home owners
From: A geriatrician who has spent too many ward rounds looking at lunch trays
Re: The cheapest clinical upgrade you are not making
I’ll keep this short, because I know how many proposals land on your desk.
In most Indian hospitals, the kitchen sits in the budget beside laundry and housekeeping. It’s a hotel service: a cost to be contained, judged by complaints. I’d like to persuade you to move it, at least in your head, to the column where you keep pharmacy and physiotherapy. Food is a clinical intervention. For your older patients especially, it is one of the few you give every single day, to every single patient.
The case, in four points
1. Many of your older patients arrive at nutritional risk, and more leave that way. A study of older inpatients in five private Indian hospitals found about 31% at malnutrition risk on admission, rising to 44% during the stay (Wright et al., 2021). Your hospital likely has a similar pattern. You just haven’t counted it.
2. Malnourished patients cost more. Across health systems, malnutrition in hospital is consistently linked to longer stays, more complications, more readmissions and higher mortality. Each of these lands on your bed occupancy, your insurance claim disputes and your reputation.
3. Fixing it works, and it is not a drug. In the EFFORT trial, 2,088 medical inpatients at nutritional risk were given individualised nutrition support. They had fewer serious adverse outcomes and lower 30-day mortality than those on standard hospital food (Schuetz et al., Lancet, 2019). The intervention was a protocol, a target and follow-up: things a well-run hospital already knows how to do.
4. Your patients notice. Food is one of the few parts of care that patients and families can judge for themselves. A hospital that feeds people well earns trust that no billboard can buy.
What I am not asking for
I’m not asking for a five-star kitchen, an imported menu or a large new budget line. Some of the best hospital food I’ve eaten in Kerala was in modest mission hospitals that simply cared about it.
What I am asking for: a 90-day plan
Days 1–30: Measure.
- Screen every patient over 65 for nutrition risk within 48 hours of admission, using a validated tool such as the MNA-SF or MUST. It takes minutes.
- For one week, have ward staff estimate plate waste for each tray: none, a quarter, half, three-quarters, all. Write it down.
- Count dietitian hours per occupied bed.
Days 31–60: Fix the obvious.
- Make sure every at-risk patient has an energy and protein target and a written plan, reviewed by a dietitian.
- Add protein at breakfast and dinner, where hospital menus are usually weakest. An egg, a cup of milk, a bowl of payar.
- Offer snacks between meals for patients who can’t manage full plates.
- Introduce protected mealtimes on at least one ward: no non-urgent rounds, tests or cleaning during meals, and help for those who need it to eat.
- Standardise texture-modified diets to the IDDSI framework, so “soft” means the same thing to the cook and the nurse.
Days 61–90: Make it stick.
- Add nutrition-risk screening and intake to the ward handover template.
- Report three numbers monthly to the quality committee: % screened, % at risk with a plan, average plate waste.
- Bring the head of dietetics and the head chef into the same monthly meeting. They have often never sat together.
For care homes in particular
In a residential home, food is not part of the care. Food is much of the care. It structures the day, gives people something to look forward to and keeps the body working. Weigh residents monthly. Act on unplanned loss of more than a few percent. Ask residents what they want to eat. You will be surprised by how much better people eat when the menu includes their food.
One last thought
Your accreditation surveyors may not ask about plate waste. Your patients’ families won’t use the word “malnutrition”. But both will notice, in time, the hospital where grandmothers go home stronger than they came in.
That can be your hospital, and it costs less than the MRI you are planning to buy.
With respect,
Dr. Praveen G Pai
References
- Wright C, et al. Prevalence of malnutrition risk and poor food intake in older adults in Indian hospitals. Nutrition & Dietetics. 2021;78(2):135–144.
- Schuetz P, et al. Individualised nutritional support in medical inpatients at nutritional risk (EFFORT). Lancet. 2019;393:2312–2321.