“Older people” is defined as individuals aged 65 years or older who are deemed suitable to receive the national pension plan [1]. According to Orimo et al [1], the range of older persons can be divided into two categories. They are (1) “early elderly” (individuals aged 65-74 years) and (2) “late elderly” (individuals aged ≥75 years). In Malaysia, “elderly” is recognized as those aged 60 years and older, due to its policy and program development purposes [2]. The increasing trend of the aging population has shifted the world’s demographic patterns [3]. As a developing country, Malaysia is not spared from this phenomenon [4]. The recent National Health Morbidity Survey (2018) estimated that the country’s older population is at 2.3 million (6.3% of the total population) and is predicted to double within 23 years [2]. The aging process often relates to health complications [2]. Apart from the presence of comorbidities, malnutrition in older people is also common [5].

The reasons for having compromised nutritional status among older individuals are changes in physical, cognitive, psychological, and social factors (eg, living alone), as well as having limited income [6]. Other risk factors include the presence of comorbidities [7,8], poor dental status [9], and inadequate dietary intake [7,10,11]; moreover, those living in health care institutions often complain of having poor foodservice experience [12,13]. Older people with malnutrition often find themselves in a state of dependency, having prolonged hospital stays, an increase in infection rate that eventually diminishes their quality of life, and an increase in health care costs and mortality [6,7,14].

There are countless studies investigating malnutrition among hospitalized older individuals, and the prevalence is indisputable. The global prevalence of malnutrition in hospitalized older patients ranges from 12% to 75% [7]. Consistent with the worldwide trend, Malaysia also shows a prevalence of malnutrition that ranges from 21% to 55% among hospitalized geriatric patients, which appears to be a matter of concern [15].

Despite the interventions carried out thus far, the prevalence of malnutrition among geriatric patients is still appalling [16]. Most older people view themselves as healthy, in spite of their sociodemographic status (educational level, income status, and daily living activities) [17]. Despite their healthy self-image, older individuals are still vulnerable to malnutrition due to their frail condition [6]. In addition, of 52% of malnourished older patients, 18% were found to be nutritionally compromised even before admission [18]. Surprisingly, these older adults even believe that having inadequate nutritional intake is normal without realizing the consequences that malnutrition carries [6].

Hospital meal is considered as one of the important components of care. Hospital meals are served not only to facilitate well-being and recovery but also to contribute to the patients’ satisfactions on their overall treatment experiences [19]. Looking at the hospital foodservice system, oftentimes the patients’ nutritional status is impacted by it. For example, hospital-acquired malnutrition is believed to be caused by the poor quality and appearance of the food and its environment [20]. The same study reported that food quality is found to be the best predictor of patients’ overall satisfaction, followed by service quality given by staff. A study in Australia has proven this by introducing a room service model to hospitalized patients. The results showed good upturns in the patients’ nutritional intake and satisfaction as well as reduced plate waste and patient meal costs after the method was implemented [21].

Another study reported that patients found it tiring to order and eat their food at specific times [22]. On the contrary, these patients were also sensitive to delays and poor service. Further, the study documented that patients appreciated the presence of nonmedical foodservice staff, but at the same time felt pressured by them. According to a study conducted in a military hospital in Turkey, the patients’ satisfaction levels on the hospital’s foodservice system showed inconsistency. The results showed that 51.3% evaluated the foodservice quality to be adequate, while 32.4% deemed it was of inadequate quality. Accordingly, the remaining 16.3% stated that they were uncertain [23]. The different spectrum of thoughts by the patients only makes it hard to fathom, thus affecting the ways of intervention in many hospitals’ foodservice systems. Therefore, the redesigning of hospital foodservice models may be needed not only to drive toward the improvement of patient satisfaction and cost but also to influence clinical outcomes associated with nutritional intake.

Figure 1 shows the conceptual framework of the causes of malnutrition and its possible consequences. This study aims to develop, implement, and evaluate the effectiveness of a Malaysian Geriatric Patients’ Hospital Foodservice Protocol (MYGERYFS) in order to improve both the nutritional status of hospitalized geriatric patients and the quality of the foodservice.

Phase One of the protocol has already started. A total of 233 older respondents participated in this study. The mean age was 71.39 (SD 7.99) years, where most 51.5% (n=120) of the respondents were female and the rest 48.5% (n=113) were male.

The mean BMI of the older respondents was 24.84 (SD 6.05) kg/m². Based on the results showed, most (n=110, 47.2%) participants were classified as underweight, 37.8% (n=88) were normal, and 17.2% (n=40) were either overweight or obese.

The mean energy and protein intakes were 1026.82 kcal (SD 457.66 kcal) and 43.54 (SD 22.66) grams, respectively. The majority of the respondents 70.8% (n=165) had inadequate energy intake (<25-30 kcal/kg). The same trend was shown for their protein intake. Approximately 77.7% (n=181) of them consumed protein below 1.2 g/kg. It was also found that 84.5% (n=197) did not receive oral nutrition support in ward.

The percentage of older patients in hospitals in the Klang Valley who responded to the MNA-SF questionnaire—which was divided into 3 scores of “Normal” (12-14), “At Risk” (8-11), and “Malnutrition” (0-7)—was 27.9% (n=65) normal, 54.9% (n=128) at risk, and 17% (n=40) malnutrition, which is the lowest. Thus, most patients were at risk of malnutrition.

The mean Mealtime Audit Tool score was 3.27 (SD 1.89), showing that the respondents experienced at least 3 barriers during mealtimes. The most common barriers that these patients came across were as follows: (1) respondents were not paid any visits by health care staff midmeal to see if they need anything, (2) respondents were not asked or given other food if they refused to eat their meal, and (3) respondents were not offered to go to the washroom before mealtime. Most of the respondents 74.7% (n=119) experienced good foodservice satisfaction while the other 25.4% (n=59) did not.

Pearson correlation test was done to find the associations between BMI, dietary intake, mealtime barriers, and nutritional status with foodservice satisfaction. According to Table 1, there was no association found between BMI and foodservice satisfaction among hospitalized geriatric patients (r=–0.056, P=.39). As for the dietary intake, both energy (r=0.337, P<.001) and protein (r=0.255, P<.001) were significantly associated with foodservice satisfaction. A statistically significant result was also shown between mealtime barriers and foodservice satisfaction (r=–0.225, P<.01).

A chi-square test was also conducted between nutritional status with foodservice satisfaction. No significant association was found between malnutrition with foodservice satisfaction (χ²₈=12.778, P=.12).