Alongside the vast and growing knowledge and awareness of proper nutrition importance for both mental and physical health the overall human, the attitude towards food is still loaded and spiced up with various emotions, as well as personal and cultural context. Food is often associated with emotional experiences, memories of mom, grandma or aunt, bliss and sorrow, “barbeque” in a good company, restaurant indulgences and delightful culinary experiences, along beauty culture and current fashion.

With all this load, how can we clarify to a patient in a medical institution that nutrition is neither of these but an important, though not the sole component, of the ongoing illnesses healing, recovery and coping processes!?

Is there such a thing? In spite of deep scientific understanding of metabolism mechanics, the algorithm defining optimal personal nutritional composition is still to be deciphered. From the dawn of humanity, the pioneers (Maimonides and many others), followed by scientists, that employed progressive assumptions (Day2, veganism, genetic mapping of gut bacteria, etc.), have deployed multiple methods and approaches prior to us. Most of these methods have appealed to the general public (or age /blood type categories, etc.). Even so, the exact personal formula accepted and applied by the Western/ conventional medical community has not yet been found

In medical centers a multidisciplinary interaction with the patient takes place, which, combined with trial and error, allows us to define the nutritional profile, including its clear definitions (even if varying over time) that enable monitoring and correction. Nutrition guidelines (kosher, vegan, Mediterranean…), sensitivities (allergens), personal preferences (likes/ dislikes), food textures, fluid thickening, eating method (cutlery, nursing, interval, etc.), sex, age, background diseases, etc. – all these allow mapping of the personal profile and means of building a daily/weekly menu, and providing an individual estimation of essential nutritional values.

There are many profile components and some change over time. The patient’s preferences (taste and smell) also change over time and depend on the patient’s condition and recovery processes.

Assuming we have created a personal nutrition profile, is it possible to carefully and transparently manage the changing personal profile within the framework of a multi-diner institution!?

Even if we have compiled a personal nutrition profile and managed to create a suitable daily/weekly nutrition plan, which appeals to the patient, is it sufficient? We are changing, the weather is changing, the moods are changing, the physical activity, the medical condition, the recovery process varies or, God forbid, the disease exacerbates, these parameters are not static. Supervision and control are complex. Assessing the changing parameters, implementing profile changes and consequently updating the nutrition plans are complex and lengthy procedures. How do gut bacteria (our active partners…) react and what is the body’s reaction, in the meantime!?

The indices for nutritional status monitoring are known. There are tools for assessing nutritional integrity, but are these satisfactory or are they a “compromise”, provided the available information and data processing tools? How significant “eating observations” are and can they be performed, and data – collected and analyzed at effective response times?

The assessment of personal nutritional status is reviewed through several of main content aspects:

1) Medical indices (laboratory tests – sugar, hemoglobin, vitamins, minerals, etc.)

2) Physical parameters: BMI, eating independence, food textures and fluids, excreta frequency and more

3) Medical diagnoses

4) Medication

The relevant information for nutritional evaluation, gathered in patient’s medical file (EHR systems), is integrated with a variety of indices and medical evaluations rather than differentiated for nutritional control. In addition, it is doubtful whether it is collected in frequency and timing appropriate for a nutritional health assessment. The clinical dietitian has to “shovel up” vast amounts of medical information to extract the relevant data. Not to mention the challenge in comparing and translating the gaps versus personal nutrition profile and derived nutrition plans.

The difficulty of gaining relevant information (information collection and availability) forces dietitians to spend a lot of time assembling the nutritional “picture” and therefore there is usually a tendency to limit the information content (calories and carbohydrates), despite of possible lack of data (magnesium, sodium, minerals, etc.) When providing a complete dietary solution accuracy is crucial. We also note the challenge or estimating the gap between the nutritional values ​​provided in the menu versa actual food intake (what is left, or not, on a plate) and the ability to measure the nutritional values ​​actually eaten by the particular patient.

What is the origin of a gap between technological innovation (Digital HealthCare) in the various medical fields versa clinical nutrition and what does it mean in terms of importance and/or awareness of the nutrition contribution to quality of life in general and healing, rehabilitation and recovery in particular?

A glimpse into the daily/ weekly diet plan reveals daily consumption of large variety of dishes and meals. The personal plan includes characteristics that match the individual diet profile thus defining which food components are allowed, recommended and preferred alongside the forbidden and unadvisable ones, due to health reasons, sensitivities, nutritional art or personal preferences. Depending on this set of definitions, we can build a list of possible dishes categorized for meals and eating times. As far as institutional catering based on a weekly menu schedule is concerned, the meals available in the general menu needs to be customized to the personal plan, in hope that the menu will provide a satisfactory personal response to each consumer. Additionally, lacking an optimal solution or in case of special needs, we should offer individual supplements to “enrich” the menu, which are not included in the general menu (additional dishes, supplements or medical food).

Whether it is a kitchen functions inside the institution or as an outsource (catering), even if the menu offers a detailed choice of dishes (recipe book), in practice there are variations in the dishes and today’s chicken dish is not similar to the one served last week (season, ingredients availability in the market, the cook’s creativity, personal deviations alongside other influencing factors).

If we go back for a moment to the challenges of measuring nutritional health and learning the importance of nutritional values calculation ​​(counting calories, carbohydrates and other values, in the menu and individual nutrition observations), then the specifications of the dishes included in the meals and menu should include the nutritional values in addition to quantity parameters (have we already mentioned the cook book !?) In a way that enables assessing the “quality” of the planned menu and the estimate of the actual “consumption”, as a result of the “nutrition observations”.

In the reality of a dynamic menu, varying dishes and raw ingredients (used in food preparation) how can we track the planned nutritional composition, both at the institutional and the individual level?

How can we make sure that each patient consumes food according to his needs and personal plan based on the individual profile?

How quickly can gaps and unmet needs be identified and due adjustments made, to satisfy each individual patient?!

From the diner’s point of view, this is all about the serving cart and the full tray placed in front of him. Presumably he is also aware of kitchen existence and whatever happens there. However, as the screen goes down, it uncovers a whole space of planning and acting processes where each stage of the process may affect the outcome served on a plate. In professional language, the sequence of processes and steps required to serve the meal in accordance the current demands are referred to as: the supply chain. Although this chain ends at the point of submission (consumption), it begins somewhere in the raw ingredients production stage (in the farm or factory), which is called “Farm to Fork”.

The supply chain exists in all types of industries and in particular in those supplying sustainable products. In contrast, the food supply chain is the most complex of all, as it is measured in terms of food quality and safety alongside the availability index (the right product, in the right place, at the right time and quantity) and operates under conditions of uncertainty.

The food supply chain complexity stems from various factors such as: seasonality, expiration, regulation (veterinary supervision, food safety standards, etc.), manual production (cooking), difficulty in producing the same dish for the same recipe in each cooking round (consistency), Kashrut, temperature and more.

Another level of complexity – relevant in the context of “personal nutrition” – stems from the challenge of managing the ingredient data and the dish nutritional values. There are also several factors to this complexity:

1) In many cases there are substitute raw materials for food preparation which are not necessarily identical in terms of the value composition.

2) Identification and monitoring of the allergens found in raw materials and food components.

3) The ability to specify the amount of ingredients used to prepare a dish (consistency) (manual cooking, “creativity”)

As with any supply chain, the ability to optimize outputs, in terms of quality and availability, often depends on information availability level concerning the point of consumption (the diner’s plate). Transparency of information, from the point of consumption through chain link sequence, allows better planning of procurement processes, inventory reserves, production planning (timing, quantities, consistency) and also identify gaps (quantities, qualities, faults) in consumption point. Al this allows to “study” in the chain links, to prevent supply failure recurrence.

One can imagine what improvements could become possible if only the kitchen manager knew the differences in the nutritional integrity of each patient alongside supply failures, including “tastes bad this time”.

One can only assume what would have happened if the kitchen manager had known “what was left on the plate” of each diner, what was the actual consumption of each dish and especially what was the impact of this knowledge on the economic cost of the institution.

To which extent would the above information enable calculating the supply, at the individual diner level, increase the cooperation with the dietitian in the joint effort of improving nutritional health?

The clinical dietitian’s task is focused on adjusting the personal (dynamic) nutrition plan, supervising and controlling the diet over time (hospitalization period or continuous stay in a medical center) and making adjustments to the nutrition plan and its components. As we have previously reviewed in the article, nutrition is a complex task in general and in case of health deterioration (temporary or ongoing), in particular.

If so, are the dietitians equipped with appropriate tools to perform the task in the best way, for each patient under their supervision?

Well, there is no doubt there are multiple tools to accomplish the task. Tools that support each stage of the planning and control and enable supervision of both the individual’s nutrition and the medical institution functioning concerning food and catering. These tools, formulated by professionals under Ministry of Health guidance, include: menu planning (recipe book), personal and departmental observation questionnaires, kitchen control and supervision, nutritional health review tools (MUST and others), medical laboratory tests, various physical tests, and more.

Are these tools accessible by advanced digital means that reflect the volume of information (varying) on each portion and each patient?

Do they support the dietitians’ work processes?

Are they concentrated on a single digital platform?

Do they allow displaying information to support the decision and alerts in real time?

And in the absence of a dedicated digital system, to what extent do the existing tools contribute to the complexity of the task and supervision capacities both at the individual and at the institutional level?

The main digital system (probably the only one except “Tsameret”) available to dietitians is the medical file system (EHR).

Most of the existing EHR systems in the world are complex and, most importantly, inconvenient for the daily work of the end users – the medical staff. The main reason for this is that at the early stages of the EHR systems development, it was not mainly designed for medical staff. The main customers of the system were insurance companies and health organizations managers. Naturally, the emphases and issues important to the health organizations differ from medical staff preferences. For example: the meticulous and detailed documentation according to pre-defined codes intended to enable accurate collection or administrative follow-up. The more important the documentation is to the administrative management, the less interesting it is for the medical staff.

Beyond that, many EHR systems contain multiple details and options and do not always fit into the medical staff workflow who do not necessarily need all of these details, or use it for several patients only.

Though there was recent progress in these systems, making them more “user friendly” to medical staff, it is doubtful whether the aspects of catering and nutrition have received proper attention. As evidence, we can see a scope of forms and Office files used by the clinical dietitians in their daily work and in various reports to regulatory supervision representatives.

To what extent does the medical file system – EHR, support the dietitian’s day-to -day work?

Does the kitchen manager use the EHR system to check or update the menu quality/integrity?

The supply chain definition in Wikipedia says, among the rest: “The physical product chain begins with the raw material mining phase and includes a variety of processing, production, assembly, storage and transportation activities between a large number of companies and across a large geographical area until the product reaches the end customer.”

Two emphases in this definition:

• The chain starts with raw materials acquisition, which is contrary to the common insight of supply chain managers, assuming the chain starts with their supplier.
• The chain ends with the end customer. The pedants will even claim that the chain ends with the final removal of the product after the final customer has finished using it (disposal).

For example, let’s look at the cable that connects our computer to a router (of an internet provider). We are the end customers but the supply chain of the cable starts in a copper mine where ore is mined. Then it undergoes a primary and secondary refining process to a level of 99.5% after which a standard copper cable is produced to be stretched and woven into copper cables of different diameters, various weaving, sometimes – with different metal coating. Only then the cable is casted into plastic end fitted with various edge connectors. Afterwards certain copper cables are shipped to distribution networks and stores and eventually the required cable reaches our computer. There are at least eight to ten different business companies in this chain and sometimes even more. Every company, except the mine as the first company in the chain, buys raw material and sells a product to the next company and only at the end of the chain we can see a final product.

The copper cable is merely a single example because in most products we use the chain is long and complex. Even the garment we wear starts with sowing cotton in the field, goes through the yarn and fabric production, then shirts a sewed to go through and a complex and long distribution and sale system. By the way, the action of purchasing a particular model shirt of a certain size, as well as purchasing the other clothing items, by all buyers, creates a data set that rolls back [“upstream”], regarding the amount of clothing items the manufacturer has to produce and sales points to which the items must be delivered. This information rolls back, determining the amount of fabric of various kinds to be produced, which rolls back to establish the amount of yarn, another step back concerns the amounts of seeds for cotton farming. The products go downstream and the data-upstream. These are two opposite flow directions, both essential to get to the point where the final product purchaser will be satisfied and will willingly pay for the product. Consider another critical aspect:

1) Only high availability in the last chain link produces the money to sustains the entire chain. When we do not have the desirable shirt of the right size, no income is generated and there is a loss that rolls all the way back to the cotton farmer.

2) Only optimal availability in the last chain link produces “customer loyalty” and improves the chances of repurchase.

Have you ever pondered over the supply chain of the food we eat? Take potatoes for example. Let’s say we have just prepared some mashed potatoes and put it on a plate as a side-dish for a piece of meat. This is our lunch today. The cumulative data of buying potatoes of the necessary sort flows upstream to the network management center, and from there- to the market, the packing factory and refrigeration rooms, and further – to the farmer and seed producer, which is generally located in the Netherlands. By the way, the data should reach a farmer who produces the seed about two years before we sit down to eat mashed potatoes for lunch.

If you think it’s getting complicated then you’re right. Try looking at the plate a hospital patient receives. A diner for whom nutrition is an important component of his recovery process, the quality of daily life or preventing deterioration in his medical and functional condition. In this area there is an extra complexity dimension and these are the nutritional values ​​that the patient has to consume to accelerate recovery and avoid the risks of malnutrition. Not only do nutritional values ​​have to be quantified and tracked, it is quite possible that each patient needs a different composition, even if we speak of two patients dining together receiving food from the same source, or the forty dishes required for the same medical center division, which are all produced in the same kitchen and, by the same staff, under the supervision of the same chef. The same kitchen and the same staff must take into account additional data some of which is in the medical files, such as sensitivities (allergens), and some are known to the department dietitian and concerns food texture, eating independence, personal preferences and more. This way, thousands of personal dishes are prepared daily, or should be, to ensure each patient gets what he or she needs in the right time, and of sufficient quality. The unavailability of the right dish for the patient leads to the astonishing result: about 40% of people hospitalized in internal divisions of hospitals both around the country and around the world, suffer from malnutrition, though food waste rates (discarded food) reach 50%.

Preventing this undesirable phenomenon and achieving optimal availability in the sphere of personal catering under clinical nutritionist supervision, without a smart and intelligent management system, is nearly “mission impossible”.

Only a global view of the supply chain, from the initial raw materials production to the consumption by the end customer, can significantly reduce unavailability alongside the inventory surplus in the process. This way we can also limit the process losses. If we briefly return to the diner’s plate, by viewing the chain globally we can diminish food discarding (today over 30% of the produced food is discarded) and malnutrition rates in medical institutions.

In previous chapters we have described a supply chain that ends with the diner’s plate, especially when the diner is hospitalized or resides in a nursing home and needs specific food as part of due medical care. In this chapter we will focus on the plate itself and not on what precedes or follows the process. Yes, the story continues afterwards and it concerns disposal of food leftovers.

The food we consume is an important, and perhaps even critical component, of the patient’s recovery process and quality of life in general and for the elderly in particular. But let’s first try and understand the role of the food we consume. Food must comply several physiological, mental and social functions to ensure our survival:

Energy supply: The food we consume must provide the essential energy for the various cells’ functions, which is granted by chemical energy found in various food components.

• Body tissues generation: The food we consume must provide raw materials needed to rebuild worn-out body tissues and parts. The food provides “construction materials” when body structure changes: while growing up in childhood and adolescence, and also when increasing muscle mass by intentional training. This is crucial in situations of medical care, recovery and rehabilitation.
• Life sustenance processes: The food we consume replenishes various regulatory substances – hormones, enzymes, antibodies and more.
• Social needs: social and family pastime, events and holidays. Eating is related to communication/ connection with others.
• Mental needs: Eating helps in cases of boredom, nervousness, stress, joy and relief.

Proper nutrition is a balanced and diverse diet, which provides sufficient levels of all essential nutrients. That’s why the food we consume contains various ingredients, which are commonly divided into the following groups: water, carbohydrates, proteins, fats, vitamins and minerals. Even when we are healthy and active, we do not always know the right food composition, quantities and timing. As we grow old or ill or our ability to prepare our own food and especially decide for ourselves what should we eat is limited. Then we become dependent on the dietitian and the medical care staff. As food and its various components become more important to us in order to become stronger and overcome diseases, our ability to fulfill our needs by our own means decreases.

When the dietitian has to decide on composition of the meal for a hospitalized person, they consider multiple variables:

• Which nutrients are critical for a patient, at the current stage of the disease, to speed up recovery? The required data can be found in the patient’s medical file. As an example – dialysis patients require enhanced consumption of protein and calories.
• Which nutrients should not be present in food served to the patient, following test results? For example, foods rich in sodium (salt) should be removed from the menu for certain type of disease.
• What are the ingredients that the patient mustn’t consume due to various sensitivities and intolerance of certain ingredients? Example: gluten-containing foods for celiac patients. The required data is (hopefully) in the patient’s medical file
• Is the dish balanced correctly in terms of components and has both carbohydrates and proteins, etc.
• Does the dish account for food texture required for the patient? Not everyone can eat everything and some patients require soft food texture (for example), while for the others it does not matter
• Personal preferences – the” likes and dislikes” should also be considered. Someone hates cucumbers and the other – loathes onions. And we have not yet talked about color and smell.
• Has the patient consumed the appropriate amounts recently and is there a need to supplement certain nutrients?
• What about anesthetized and respirated patients that are fed through an enteral feeding tube?

When we look at all these variables then we can easily understand that there are no two patients whose food plate should be identical, even if they are hospitalized in the same room of the same department and receive their food from the same cart, after it was cooked in the same central kitchen of the institution. Each tray on the cart should be marked by department name, alongside patient’s name and ID.

You can probably assume what is required of the management and control system overseeing the supply chain, and I am talking just about one link in the chain – the diner’s plate. By the way, there are at least two conditions for such system to function properly, which is nearly impossible as long as there is no change in current state and functionality of hospital departments:

• The patient must not consume food that was brought from home and/or received from visitors and family members. Everything must be controlled by dietitians and the system managing the supply chain
• There must be a control, whether manual or automatic, reflecting the plate contents before and after eating to assess the actual consumption. A patient receives a plate of chicken and mashed potatoes. In practice he eats about a third of the chicken and doesn’t touch the This must be recorded and taken into account when preparing the next meal for the same patient and specifying his personal nutrition plan

When the above conditions are not met and there is no proper management and control, recovery as well as discharge from the hospital is delayed, the treatment costs grow and most importantly – the quality of for the patient care is impaired.

Just think- how can the kitchen function to serve patients properly without this information? If the kitchen is virtually blind, how will the rest of the supply chain links be able to properly plan their food production and distribution processes?