A Logical Framework for Tailor-made Paradigm Shift Hospital Foodservice to Prevent Malnutrition Among Geriatric Patients in Hospitals

Medical background of the patients will be obtained through patients' medical records and interviewing method. The medical history of the patients includes reasons of admission, date of admission, date of discharge, days of hospitalisation, types and numbers of comorbidities, numbers of drugs prescription, previous hospitalisation and whether the patient has encountered a dietitian visit during hospitalisation. All of these data will be recorded in the self-developed questionnaire.

Anthropometry measurements of the patients include current and previous body weight, percentage of body weight change, height, body mass index (BMI), mid upper arm circumference (MUAC), calf circumference, triceps skin fold (TSF) and body fat percentage. The body weight of hospitalised patients will be measured using Digital Weighing Scale OMRON HBF-357 and recorded in kilogram (kg) to the nearest 0.1 kg Weight estimation is done to geriatric patients who are unable to stand without assistance or non-ambulatory. The outcome measured will be in Body Mass Index (kg/The Body Mass Index classification will be used as stated in WHO (2004) which is underweight (<18.5kg/m1), normal weight (18.5 to 24.9kg/m2), overweight (25.0 to 29.9kg/m2) and obesity (>30.0kg/m2).

The hand-grip strength test used Jamar Plus+Digital Handgrip Dynamometer as tools of assessment to evaluate muscle strength. The cut-off point recommended for the hadgrip strength is < 26kg/force (men) and <18kg/force (women) consider low strength. While, > 26kg/force (men) and >18kg/force (women) consider normal strength.

The respondents' level of feeding assistance will be acquired directly from the patients or caregivers via interviewing method using self-developed questionnaire. The researchers are required to assess the respondents' feeding assistance level during main meals. The level of feeding assistance is classified into four. The level of feeding assistance is classified into dependent, moderate dependent (≥5 minutes), minimal dependent (<5 minutes), and independent.

The respondents' information on visual ability will be acquired via self- reported. The researchers are required to observe if the respondents wear glasses during mealtimes.

The dental status will be assessed using Geriatric Oral Health Assessement Index (GOHAI) instrument) 12 questions were developed to evaluate three dimensions of oral health-related quality of life (QoL). These include physical function during eating, psychosocial function including worry or concern about oral health, dissatisfaction with appearance, self-consciousness about oral health an avoidance of social contacts because of oral problems and pain or discomfort including the use of medication to relieve pain or discomfort from the mouth. Each question is given a score 1 to 5. A higher GOHAI score (≥57) indicates better self-reported oral health status and high perception towards oral health, 51 and 56 (average), 12 - 50 (low perception) towards oral health.

Dietary intake will be obtained by using 24-hour dietary recall for 2 days in the hospital. The dietary intake will be taken among patients who are admitted for ≥ 48 hours and have taken at least two hospital meals. The estimated amount of food will then be converted into grams and later finalised into subject's total energy, macronutrients (protein, carbohydrates and fat) , micronutrients (fat-soluble vitamins, water-soluble vitamins, potassium, sodium, calcium, phosphate, zinc and iron) as well as fibre. The respondents' energy and protein requirements will be estimated above 70% energy and 80% protein consider adequate. This will be done by Nutritionist Pro software.

Mealtime Audit Tool (MAT) instrument is used to measure the respondents' mealtime barriers/issues. This instrument consists of two distinct parts which are Part 1: observation of the time of meal tray arrival (completed by the researcher) and Part 2: list of key challenges or barriers individual patients may experience (completed by the patients). MAT scoring is based on the total of 'NO' responses. The higher the score, the more barriers experienced by the patient.

The Acute Care Hospital Foodservice Patient Satisfaction (ACHFPSQ) questionnaire will be used. Other than that, the statements were grouped into four main dimensions (food quality, meal service quality, staff/service issues, and physical environment) to know the factor scores of the dimensions. The questionnaire uses a 5-point Likert scale (Always = 5, Often = 4, Sometimes = 3, Rarely = 2, and Never =1). This grouping was to measure the highest and lowest score factors affecting satisfaction with hospital foodservice. The relationship between foodservice dimensions with overall satisfaction was assessed with Multiple Linear Regression Analysis. Statements that were worded negatively were scored using the reverse scoring method. The higher the mean score, the better the results were.