# A patient-centered nutritional intervention with a new fortified high-protein high-energy paste: an observational study to assess nutritional intakes in hospitalized older adults

Marie Blanquet, Candy Guiguet-Auclair, Pauline Berland, Véronique Neves, Jocelyn Aubert, Sabine Combes, Jérôme Bruel, Laurent Gerbaud, Yves Boirie

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Marie Blanquet, Candy Guiguet-Auclair, Pauline Berland, Véronique Neves, Jocelyn Aubert, et al. A patient-centered nutritional intervention with a new fortified high-protein high-energy paste: an observational study to assess nutritional intakes in hospitalized older adults. Age and Ageing, 2025, 54 (6), pp.afaf179. 10.1093/ageing/afaf179. hal-05138755

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# A patient-centered nutritional intervention with a new fortified high-protein high-energy paste: an observational study to assess nutritional intakes in hospitalized older adults

Blanquet Marie¹, Guiguet-Auclair Candy¹, Berland Pauline¹, Neves Véronique², Aubert Jocelyn², Combes Sabine², Bruel Jérôme³, Gerbaud Laurent¹, Boirie Yves⁴

¹ Université Clermont Auvergne, CNRS, CHU Clermont-Ferrand, Institut Pascal, F-63000 Clermont-Ferrand, France

² Centre Hospitalier de Mauriac, Mauriac, France

³ Centre Hospitalier Henri Mondor d'Aurillac, Aurillac, France

⁴ Nutrition Clinique, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France

Corresponding Author : Blanquet Marie (mblanquet@chu-clermontferrand.fr)
**Abstract**

**Background:** Protein-energy undernutrition in hospitalized older adults remains a major issue that warrants purposeful intervention.

**Objective:** To assess how a nutritional management process, using a fortified high-protein, high-energy paste, could help meet patient nutritional requirements.

**Methods:** An observational study was carried out between September 2021 and April 2022 in a community hospital's multidisciplinary care unit (MCU) and geriatric rehabilitation unit (GRU). Hospital stays of patients aged 75 years or older were included. Intakes were recorded for each component of each lunchtime and evening meal throughout the hospital stay. Daily energy and protein intakes were compared to patient recommended requirements, i.e. 30kcal/kg/day and 1.2g/kg/day.

**Results:** Analysis included 403 hospital stays (296 in the MCU, 107 in the GRU). Energy recommended requirements were met in 23.3% of MCU stays and 31.8% of GRU stays. Daily energy intakes were lower than the recommended level in both units (P<0.001): 25.2 ± 7.7 kcal/kg/day in the MCU and 27.0 ± 6.9 in the GRU. Protein recommended requirements were reached in 45.3% of MCU stays and 58.9% of GRU stays. Daily protein intakes were not significantly lower than the recommended level in both units: 1.17 ± 0.39 g/kg/day in the MCU (P=0.10) and 1.26 ± 0.35 in GRU (P=0.96).

**Conclusions:** The nutritional management process helped patients covering their protein requirements especially in the geriatric rehabilitation unit, but more efforts are still needed to reach energy requirements. Healthcare teams should be alert to the dependency in activities of daily living of patients.

**Keywords:** older adults, hospital, fortified high-protein and high energy paste, energy intake, protein intake, older people.
## Key points

* Early diagnosis and management for protein-energy undernutrition in hospitalized older adults are essential.

* A nutritional management process, based on a patient-centered approach combined with the use of a fortified high-protein, high-energy paste, was evaluated in a multidisciplinary care unit and a geriatric rehabilitation unit.

* Protein requirements were especially well covered throughout hospital stay, with low gaps between intakes and requirements.

* Dependency in activities of daily living was associated with likelihood of failing to cover requirements in both care settings.
**Introduction**

Protein-energy undernutrition in hospital remains a major issue, especially in older adults which have a 22% to 52% higher prevalence depending on definition used and healthcare settings studied [1–6]. Early diagnosis and management for protein-energy undernutrition are essential, because of a high risk of decline in nutritional status during the hospital stay. Malnutrition is associated with a number of critical adverse outcomes, including healthcare-associated infections, higher risk of pressure ulcer, longer hospital stay, more frequent readmission, and death [7–17]. A previous study has used the Global Leadership Initiative on Malnutrition (GLIM) criteria to diagnose malnutrition in hospitalized older adults and reported a high prevalence of malnutrition: 35.2% in a multidisciplinary care unit (MCU; median age: 86 years) and 30.6% in a geriatric rehabilitation unit (GRU; median age: 87 years), with large median gaps between both energy and protein intakes and requirements [6]. Similar studies have repeatedly found that most hospitalized older adults fail to get enough energy and protein [6,18–22]. Consequently, the European Society for Clinical Nutrition and Metabolism (ESPEN) produced guidelines on hospital nutrition and on clinical nutrition and hydration in geriatric care settings [17,23].

Our community hospital decided to improve its nutritional management process by implementing a new strategy based on a patient-centered approach per the ESPEN guidelines, including recommended requirements for acutely or chronically-ill older adults, provision of a protein- and energy-enriched diet for malnourished patients or patients at moderate or high nutritional risk, nutritional counselling, and food modification [17,23].

The aim of this study was to assess the effectiveness of this nutritional management process to meet patient energy and protein requirements, and to identify factors associated with an insufficient coverage of nutritional requirements.

**Methods**

**Study design and setting**

An observational study was carried out between September 2021 and April 2022 in the MCU and GRU of a community hospital in the south-central France.

All consecutive hospital admissions were screened for eligibility. The eligibility criteria were hospital stays of patients aged 75 years or older, and a consent to store medical data for research purposes. Hospital stays were not included if they went on for less than 24 hours, for end-of-life palliative care, or in patients under guardianship, or receiving only parenteral or enteral nutrition at admission.

All patients gave their informed consent to participate in the study.
## Nutritional management strategy

The patient-centered approach was based on four main actions. First, the hospital catering service offered only two diets for lunch and dinner, an enriched diet and a high-protein diet. The 'enriched diet' (providing 2000 kcal of energy and 75g of protein) and the 'high-protein diet' (providing 2500 kcal of energy and 100g of protein) were served in two different textures (normal and modified) and in three different portions (half, single or twice) to match to patient appetite. To elaborate these two kind of diet, a high-protein, high-energy paste (Appeti'mix™, Nutriset) was directly added to meals prepared. There was a higher number of meal components with high-protein, high-energy paste added in the high-protein diet than in the enriched diet. Second, nursing assistants screened for malnutrition early on in the hospital stay, wherever possible. A dietician calculated each patient's minimum nutritional requirements according to ESPEN guidelines [17]. Third, the healthcare team met to decide appropriate nutritional intervention for each patient (i.e., enriched or high-protein diet, and half, single or twice portions), based on its habits and characteristics. Patients were served the enriched diet at admission and up until the healthcare team decision. Fourth, daily intakes were recorded digitally and monitored to support appropriate ongoing decision making by the healthcare team.

## Intakes measurements and calculated requirements

Nursing assistants recorded in each computerized patient nutrition record the amount eaten as 0%, 25%, 50%, 75%, or 100% for each meal component of each lunchtime and evening meal served throughout the hospital stay. The energy and protein intakes of each meal were automatically calculated. Intakes of patients, either for those in palliative care or prescribed an oral nutritional supplement (ONS), were recorded only from the time of admission until the medical decision to initiate palliative care or ONS supplementation. Breakfast intake was estimated to provide an average of 324 kcal of energy and 7.2 g of protein per day in the MCU, and 338 kcal and 7.6 g in the GRU.

Inpatient requirements were calculated based on the recommended minimum level of 30kcal/kg/day for energy and 1.2g/kg/day for protein [17]. Adjusted weight was calculated for a body mass index (BMI) above 30 kg/m2 as: adjusted weight = ideal weight (kg) + 0.25 [measured weight (kg) - ideal weight (kg)], where ideal weight was calculated applying Lorentz equations: height (cm) - 100- (height (cm) - 150/4) for men and height (cm) - 100- (height (cm) - 150/2.5) for women. Energy and protein gaps were calculated as intakes minus calculated requirements. A negative gap value indicates intakes lower than required, and a positive gap value indicates intakes higher than required.
## Other measurements

Sociodemographic and medical characteristics were collected from the patient medical records: gender, age, living situation, medications at admission, usual weight (kg), weight at admission (kg), and height (m). Usual weight was the patient's regular weight when at home, and weight at admission was the weight measured on admission to care. Length of hospital stay in days and occurrence of death were recorded after discharge. The C-Reactive Protein (CRP) was recorded and inflammation was defined by $CRP > 5 mg/L$.

The Katz Activities of Daily Living (ADL) scale was used to measure inpatient functional ability at admission through six items: bathing, dressing, going to the toilet transferring, eating, and continence. Each item was scored 0 for unable/completely dependent, 0.5 for partially able/requiring assistance, or 1 for able/independent. The total ADL score, ranging from 0 to 6, was calculated by summing the item scores. A lower score indicated a higher level of dependency [24–26].

Comorbidity was measured using the age-adjusted Charlson comorbidity index [27] that took into account 18 pre-defined comorbid conditions, associated with different clinical weight on the basis of the adjusted risk of 1-year mortality, combined with age. Higher scores indicate a greater mortality risk and more severe comorbid conditions.

## Statistical analysis

Continuous variables were expressed as mean ± standard deviation (SD), median and interquartile range (IQR). Categorical variables were expressed as number and percentage. Analyses were performed separately for hospital stays in the MCU and the GRU.

Descriptive analyses were used to assess patient sociodemographic and clinical characteristics, daily intakes, daily gaps between intakes and requirements, and percentage of hospital stays where intakes were greater than requirements or greater than 90% of requirements. Daily energy and protein intakes in g/kg body weight were compared to the requirements of 30kcal/kg/day and 1.2g/kg/day using one-sided *t*-tests. Characteristics of patients who met 90% of their energy or protein requirements were compared against those who did not, using non-parametric Mann-Whitney tests for continuous variables or Chi-square tests (Fisher's exact tests) for categorical variables. Multivariate logistic regressions were used to identify which sociodemographic or clinical factors were associated with not meeting 90% of energy or protein requirements. If the linearity assumption between a continuous variable and the log odds was not respected, the continuous variable was categorized using quantiles. Adjusted odds-ratios (aOR) are reported with their 95% confidence intervals (95% CI).

Two-sided *P*-values<0.05 were considered statistically significant. All statistical analyses were performed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).
# Results

## Patient-population characteristics

During the study period, 486 hospital stays were screened for eligibility: 367 in the MCU and 119 in the GRU (Fig. 1). Among these hospital stays, 61 did not meet inclusion criteria and 22 were not included due to missing data on weight at admission making it impossible to calculate patient requirements, and due to prescription of ONS at admission. Finally, 296 MCU stays and 107 GRU stays were analyzed.

The patient population was a majority of women with a median age of 86 years (range 75-102), and low levels of dependency (median ADL score of 4) in both care ward units (Table 1). On admission to hospital, more than a third of patients were taking at least 10 medicines a day. Mean length of hospital stays was 13.3±9.0 days in the MCU (range 2–63) and 20.1±10.8 in the GRU (range 3–51). Death occurred in 5.4% of MCU stays and 6.5% GRU stays.

## Energy and protein intakes compared to recommended requirements

Energy and protein intakes were assessed daily and averaged over the hospital stay. Figure 2 shows the individual energy and protein intakes for each patient.

Daily energy intakes were above the minimum requirement of 30kcal/kg/day in 23.3% of MCU stays and 31.8% of GRU stays and met 90% of requirements in 37.8% of MCU stays and 50.5% of GRU stays (Table 2). The median of daily energy intakes in kcal/kg body weight was 24.5kcal (IQR: 20.0, 29.7) in the MCU and 27.1kcal (IQR: 22.1, 31.0) in the GRU. Daily energy intakes were significantly lower than the recommended level of 30 kcal/kg/day in both units (*P*<0.001).

Daily protein intakes were above the minimum requirement of 1.2g/kg/day in 45.3% of MCU stays and 58.9% of GRU stays and met 90% of the requirements in 59.5% of MCU stays and 71.0% of GRU stays (Table 2). The median of daily protein intakes in g/kg body weight was 1.16g (IQR: 0.90, 1.41) in the MCU and 1.26g (IQR: 1.00, 1.46) in the GRU. Daily protein intakes were not significantly lower than the recommended level of 1.2 g/kg/day in both units (*P*=0.10 in MCU and *P*=0.96 in GRU).

## Factors associated with not meeting 90% of requirements in the MCU

In the MCU, univariate analysis identified gender, age, living situation, BMI, ADL score, CRP, and inflammation as significantly associated with the likelihood of failing to meet 90% of energy requirement (See Appendix 1 in the Supplementary Data section for the full results). In the multivariate model, inflammation was included instead of CRP due to collinearity and high variance in CRP values. Male sex, a BMI between 22 and 29.9kg/m² (compared to BMI<22kg/m²), and greater
dependency (lower ADL score) were associated with a higher risk of not meeting 90% of energy requirements (Fig. 3).

For protein requirements, univariate analysis showed that living situation, BMI, ADL score, CRP, and inflammation were significantly associated with the likelihood of not meeting 90% of the recommended intakes (See Appendix 1 in the Supplementary Data section for the full results). In multivariate analysis, patients aged over 90 years (compared to those aged ≤80 years), with a BMI between 22 and 29.9kg/m² (vs. <22kg/m²), presenting inflammation (CRP > 5 mg/L), and those with greater dependency were more likely to fail to meet 90% of their protein requirements (Fig. 3).

## Factors associated with not meeting 90% of requirements in the GRU

In the GRU, univariate analysis identified gender, living situation, and ADL score as significantly associated with the likelihood of failing to meet 90% of energy requirements (See Appendix 2 in the Supplementary Data section for the full results). Not living alone and greater dependency were associated with a higher risk of not meeting 90% of energy requirements (Fig. 3).

For protein requirements, univariate analysis showed that gender and ADL score were significantly associated with the likelihood of not meeting 90% of the recommended intakes (See Appendix 2 in the Supplementary Data section for the full results). In multivariate analysis, patients with greater dependency were more likely to fail to meet 90% of their protein requirements (Fig. 3).

# Discussion

## Key findings

The nutritional management process based on a patient-centered approach and adding an energy and protein-enriched paste to regular meals contributed to cover patient protein requirements throughout hospital stay in both an acute care ward and a geriatric rehabilitation unit. Protein requirements were particularly well met in the GRU compared to the MCU, as patients in the GRU were further from the acute episode and generally had a better appetite. However, additional efforts are still needed to address energy requirements. Dependency in activities of daily living was associated with likelihood of failing to cover requirements in both care settings.

## Comparisons to other studies

To our knowledge, only three previous studies have assessed intakes brought by a protein enrichment adds to regular meals in older adults [28–30]. Stelten et al. performed a randomized controlled trial to evaluate the effect of protein-enriched regular foods (bread and drinking yoghurt) on protein intake in an acute care setting [28]. Their sample had a lower mean age (79.9±10.6 years in the intervention group) and a lower BMI (22.6±3.0 kg/m²) than in our study. Patients in the intervention group ate
16.6g more protein per day than the control group, enabling 36% to reach 1.2g of protein/kg/day vs. 8% in the control group, which was lower than our results (45.3% in the MCU).

Beelen et al. performed a randomized controlled trial that measured the efficacy of protein-enriched familiar foods and drinks on protein intakes at day 4 of hospitalization in acute care units [29]. Their sample had a lower mean age (78.5±7.4 years), a similar BMI (26.6±6.4 kg/m²), less comorbid patients compared to our study. Intakes were estimated based on ordering data rather than real consumption. The intervention group had significantly higher protein intakes, with 79% of the patients reaching the requirement of 1.2g/kg/day vs. 48% in the control group. However, all patients could order protein-enriched products in the morning, afternoon, or evening (representing nearly 30% of their total protein intake) in addition to the breakfast, lunch, and dinner meals, which was not the case in our study.

Trabal et al. conducted a review on the effects of dietary enrichment of regular food and/or powdered modules (high-protein powder) on intakes [30], and found that dietary enrichment led to significantly better energy intakes [31–34], although one of the studies reviewed found no significant improvement in protein intake [32] and only one study found significant body-weight gain [31].

The present study was conducted in the community hospital that had already participated in a study measuring energy and protein intakes [6]. This previous work was carried out in the MCU and the GRU of this hospital before the implementation of the new nutritional management process. In comparison to the present study, patients had comparable mean age (86.0 years in the MCU and 87.0 in the GRU) and BMI (25.3 kg/m² in the MCU and 28.4 kg/m² in the GRU) but intakes had been differently assessed, quantity eaten was only recorded during three days. This previous study showed median gaps between energy and protein intakes and requirements of 680kcal (IQR: 280.0–948.4) and 32.9g (IQR: 18.4–42.4) in the MCU and 536.5kcal (IQR: 261.5–765.0) and 20.4g (IQR: 9.9–31.8) in the GRU. In comparison, this study showed decreased gaps between intakes and requirements and an improved coverage of both energy requirements (from 10.5% to 23.3% in the MCU and from 7.3% to 31.8% in the GRU) and protein requirements (from 0% to 45.3% in the MCU and from 9.1% to 58.9% in the GRU),

A previous study performed in older adults (mean age 80 years old) identified higher BMI and dependency for eating as factors associated with insufficient energy intakes [35]. Another study performed in a younger population (68.9±14.3 years) also identified higher BMI as a factor associated with insufficient energy and protein intakes [36]. Most of the literature analyzing factors associated with malnutrition in older adults has also identified dependency measured by ADL or Barthel Index as a risk factor [37,38].
## Strengths and limitations

This study had some limitations. There was no control group of hospital stays by patients who did not benefit from the new nutritional management process, and no comparison with meals served without the fortified high-protein, high-energy paste. However, it would be very difficult to carry out a controlled study, because the hospital catering services add the paste directly to the meals as an ingredient in the hospital recipes. Second, malnutrition and sarcopenia status were not routinely assessed on all patients at admission, largely due to a lack of human resources in the hospital, which is a factor that needs to be addressed to support efforts to improve patient nutritional management. Lastly, the study was conducted at a single site. Consequently, further studies are needed to assess this nutritional management process in other settings before considering the generalizability of the results.

However, this study also has many strengths. To our knowledge, this was the first study to measure the daily energy and protein intakes of older patients throughout their hospital stay in routine medical practice. The detailed amounts eaten were recorded directly into computerized patient nutrition records, which were then used to automatically calculate the allied energy and protein intakes. In addition, as these measurements were produced for each component of both lunchtime and evening meals, we were able to very accurately estimate energy and protein intakes.

## Future research

Further studies are needed on larger samples and in different medical and surgical hospital settings to confirm our findings. Several strategies should be considered and evaluated to address the gap remaining between intakes and recommended requirements. One potential approach is to incorporate the fortified paste into a supplementary dish at lunch or dinner, in addition to provide a more enriched breakfast, which may be sufficient in better meeting nutritional requirements. Additional high-energy, high-protein snacks could also be offered in the morning, afternoon, and evening to help patients meet their needs. The ESPEN guidelines on hospital nutrition recommended "systematic between-meals snacks as a standard hospital food service" [23]. For instance, if patients were offered a dessert cream in the morning, a fruit compote in the afternoon, and a cake in the evening – each enriched with the high-protein high-energy paste – they would receive an additional 550kcal and 25g of protein per day. We estimated that energy intakes would increase to 34kcal/kg/day and protein intakes to 1.5g/kg/day in the MCU, and to 36kcal/kg/day and 1.6g/kg/day in the GRU. This would enable 64.9% and 78.7% of patients in the MCU, and 81.3% and 92.5% of patients in the GRU, to reach the recommended levels of energy and protein, respectively.

It would also be interesting to assess physical measures, such as hand grip strength, at both admission and discharge to identify whether any changes are associated with shifts in health status.
It would also be useful to examine whether nutritional behaviors follow distinct patterns over the course of the hospital stay.

**Conclusion**

The nutritional management process helped inpatients to reach their nutritional protein requirements, with only low gaps remaining between intakes and requirements. Additional efforts are still necessary to address energy requirements. Offering high-energy, high-protein breakfasts and snacks throughout the day long could help patients bridge the remaining gaps between intakes and needs. Dependency in activities of daily living was associated with inadequate intake in both hospital settings. Healthcare teams are encouraged to be vigilant on the issue, as dependency can be easily assessed early in the hospital stay.

**Acknowledgements**

The research team thanks all the medical and paramedical staff of the acute care ward and the geriatric rehabilitation unit, and their catering staff.

**Research data transparency and availability**

The data are available from the corresponding author on reasonable request.

**Declaration of Conflicts of Interest**

None

**Declaration of Sources of Funding**

This work was supported by Nutriset. The funders had no role in design of the study, in the collection, analysis, and interpretation of data, in the writing of the report, and in the decision to submit the article for publication.
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<table><caption>**Table 1.** Characteristics of patients at admission – included hospital stays</caption><thead><tr><th></th><th>Multidisciplinary<br>Care Unit<br>(MCU)<br>n=296</th><th>Geriatric<br>Rehabilitation Unit<br>(GRU)<br>n=107</th></tr><tr><th></th><th>Mean ± SD<br>or n (%)</th><th>Mean ± SD<br>or n (%)</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td></tr><tr><td>Men</td><td>117 (39.5)</td><td>39 (36.4)</td></tr><tr><td>Women</td><td>179 (60.5)</td><td>68 (63.6)</td></tr><tr><td>Age (years)</td><td>86.3 ± 5.8</td><td>86.2 ± 5.7</td></tr><tr><td>Living situation</td><td></td><td></td></tr><tr><td>Living alone</td><td>127 (49.2)</td><td>55 (53.4)</td></tr><tr><td>With partner or family members</td><td>131 (50.8)</td><td>48 (46.6)</td></tr><tr><td>BMI at admission (kg/m²)</td><td>27.4 ± 6.8</td><td>26.4 ± 6.0</td></tr><tr><td>Obesity <sup>a</sup></td><td>87 (29.6)</td><td>31 (29.0)</td></tr><tr><td>Charlson comorbidity index</td><td>7.8 ± 2.3</td><td>7.8 ± 2.3</td></tr><tr><td>Number of daily medicines at admission</td><td>8.4 ± 3.6</td><td>8.2 ± 3.7</td></tr><tr><td>Polypharmacy <sup>b</sup></td><td>100 (34.4)</td><td>38 (36.5)</td></tr><tr><td>ADL total score</td><td>3.7 ± 1.8</td><td>4.1 ± 1.4</td></tr><tr><td>CRP (mg/L)</td><td>56.2 ± 74.2</td><td>26.8 ± 36.9</td></tr><tr><td>Inflammation <sup>c</sup></td><td>240 (82.8)</td><td>71 (70.3)</td></tr></tbody></table>

Notes: ADL = Activities of Daily Living; BMI = Body Mass Index; CRP = C-Reactive Protein; SD = Standard Deviation.

<footnote><sup>a</sup> BMI > 30 kg/m² at admission</footnote>

<footnote><sup>b</sup> Number of daily medicines ≥ 10</footnote>

<footnote><sup>c</sup> CRP > 5 mg/L</footnote>
<table><caption>**Table 2.** Daily intakes and gaps between intakes and requirements (minimum level of 30 kcal/kg/day for energy and 1.2 g/kg/day for protein).</caption><thead><tr><th></th><th>Multidisciplinary Care<br>Unit<br>(MCU)<br>n=296</th><th>Geriatric Rehabilitation<br>Unit<br>(GRU)<br>n=107</th></tr><tr><th></th><th>Mean ± SD<br>or n (%)</th><th>Mean ± SD<br>or n (%)</th></tr></thead><tbody><tr><td><strong>Energy</strong></td><td></td><td></td></tr><tr><td>Daily intakes (kcal)</td><td>1574.3 ± 387.9</td><td>1634.1 ± 366.0</td></tr><tr><td>Daily intakes (kcal/kg))</td><td>25.2 ± 7.7</td><td>27.0 ± 6.9</td></tr><tr><td>Gap to meet requirements (kcal)</td><td>-357.5 ± 491.9</td><td>-217.1 ± 409.8</td></tr><tr><td>Intakes meeting requirements</td><td>69 (23.3)</td><td>34 (31.8)</td></tr><tr><td>Intakes meeting 90% of requirements</td><td>112 (37.8)</td><td>54 (50.5)</td></tr><tr><td><strong>Protein</strong></td><td></td><td></td></tr><tr><td>Daily intakes (g)</td><td>73.3 ± 20.5</td><td>76.5 ± 20.0</td></tr><tr><td>Daily intakes (g/kg)</td><td>1.17 ± 0.39</td><td>1.26 ± 0.35</td></tr><tr><td>Gap to meet requirements (g)</td><td>-4.0 ± 23.5</td><td>2.5 ± 20.2</td></tr><tr><td>Intakes meeting requirements</td><td>134 (45.3)</td><td>63 (58.9)</td></tr><tr><td>Intakes meeting 90% of requirements</td><td>176 (59.5)</td><td>76 (71.0)</td></tr></tbody></table>

Notes: SD = Standard Deviation. IQR = Interquartile range. Energy gap = energy intake - calculated requirement for a recommended minimum level of 30 kcal/kg/day. Protein gap = protein intake - calculated requirement for a recommended minimum level of 1.2 g/kg/day. A negative gap value indicates intakes lower than required, whereas a positive gap value indicates intakes higher than required.
<figure><img src="image_2.png" /><figcaption>**Figure 1.** Flow chart of hospital stays</figcaption></figure>
**Figure 2.** Distribution of daily individual energy and protein intakes (in kcal/kg body weight and g/kg) in the Multidisciplinary Care Unit and the Geriatric Rehabilitation Unit.

The horizontal red lines represent the minimum recommended level of 30 kcal/kg/day for energy and 1.2 g/kg/day for protein.

MCU: Multidisciplinary Care Unit; GRU: Geriatric Rehabilitation Unit.

<figure><img src="image_3.png" /></figure>

<figure><img src="image_4.png" /></figure>
**Figure 3.** Factors associated with not meeting 90% of energy and protein requirements in the Multidisciplinary Care Unit and in the Geriatric Rehabilitation Unit.

aOR, Adjusted odds-ratio; 95% CI: 95% confidence interval

<figure><img src="image_5.png" /></figure>
# A patient-centered nutritional intervention with a new fortified high-protein high-energy paste: an observational study to assess nutritional intakes in hospitalized older adults

## Supplementary Material

**Appendix 1.** Comparison of patients who met 90% of their requirements and those who did not during their hospital stays in the Multidisciplinary Care Unit (MCU).

**Appendix 2.** Comparison of patients who met 90% of their requirements and those who did not during their hospital stays in the Geriatric Rehabilitation Unit (GRU).
<table><caption>**Appendix 1.** Comparison of patients who met 90% of their requirements and those who did not during their hospital stays in the Multidisciplinary Care Unit (MCU).</caption><thead><tr><th rowspan="2"></th><th colspan="3">Energy intakes meeting 90% of requirements</th><th colspan="3">Protein intakes meeting 90% of requirements</th></tr><tr><th>Yes</th><th>No</th><th>P-Value</th><th>Yes</th><th>No</th><th>P-Value</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td>0.11</td></tr><tr><td>Men</td><td>30 (26.8)</td><td>87 (47.3)</td><td></td><td>63 (35.8)</td><td>54 (45.0)</td><td></td></tr><tr><td>Women</td><td>82 (73.2)</td><td>97 (52.7)</td><td></td><td>113 (64.2)</td><td>66 (55.0)</td><td></td></tr><tr><td>Age (years)</td><td>87.1 ± 6.1</td><td>85.7 ± 5.4</td><td>0.044</td><td>86.8 ± 5.9</td><td>85.5 ± 5.4</td><td>0.14</td></tr><tr><td>≤ 80</td><td>17 (15.2)</td><td>36 (19.6)</td><td>0.05</td><td>26 (14.8)</td><td>27 (22.5)</td><td>0.036</td></tr><tr><td>81 - 85</td><td>26 (23.2)</td><td>50 (27.2)</td><td></td><td>50 (28.4)</td><td>26 (21.7)</td><td></td></tr><tr><td>86 - 90</td><td>34 (30.4)</td><td>66 (35.9)</td><td></td><td>53 (30.1)</td><td>47 (39.2)</td><td></td></tr><tr><td>&gt; 90</td><td>35 (31.3)</td><td>32 (17.4)</td><td></td><td>47 (26.7)</td><td>20 (16.7)</td><td></td></tr><tr><td>Living situation</td><td></td><td></td><td>0.048</td><td></td><td></td><td>0.044</td></tr><tr><td>Living alone</td><td>61 (56.5)</td><td>66 (44.0)</td><td></td><td>89 (53.9)</td><td>38 (40.9)</td><td></td></tr><tr><td>With partner or family members</td><td>47 (43.5)</td><td>84 (56.0)</td><td></td><td>76 (46.1)</td><td>55 (59.1)</td><td></td></tr><tr><td>BMI at admission (kg/m²)</td><td>25.8 ± 5.7</td><td>28.4 ± 7.3</td><td>0.004</td><td>26.6 ± 6.1</td><td>28.7 ± 7.6</td><td>0.019</td></tr><tr><td>&lt; 22</td><td>31 (27.7)</td><td>26 (14.3)</td><td>0.009</td><td>44 (25.0)</td><td>13 (11.0)</td><td>0.004</td></tr><tr><td>22-29.9</td><td>47 (42.0)</td><td>103 (56.6)</td><td></td><td>78 (44.3)</td><td>72 (61.0)</td><td></td></tr><tr><td>≥ 30</td><td>34 (30.4)</td><td>53 (29.1)</td><td></td><td>54 (30.7)</td><td>33 (28.0)</td><td></td></tr><tr><td>Charlson comorbidity index</td><td>7.8 ± 2.3</td><td>7.8 ± 2.4</td><td>0.070</td><td>7.8 ± 2.4</td><td>7.8 ± 2.2</td><td>0.60</td></tr><tr><td>≤ 6</td><td>39 (34.8)</td><td>55 (30.1)</td><td>0.62</td><td>59 (33.5)</td><td>35 (29.4)</td><td>0.66</td></tr><tr><td>7-8</td><td>35 (31.3)</td><td>66 (36.1)</td><td></td><td>57 (32.4)</td><td>44 (37.0)</td><td></td></tr><tr><td>≥ 9</td><td>38 (33.9)</td><td>62 (33.9)</td><td></td><td>60 (34.1)</td><td>40 (33.6)</td><td></td></tr></tbody></table>
<table><tbody><tr><td>Polypharmacy <sup>a</sup></td><td>32 (29.4)</td><td>68 (37.4)</td><td>0.16</td><td>58 (33.5)</td><td>42 (35.6)</td><td>0.72</td></tr><tr><td>CRP (mg/l)</td><td>37.0 ± 49.6</td><td>67.9 ± 83.8</td><td>&lt;0.001</td><td>46.3 ± 63.0</td><td>70.8 ± 86.3</td><td>0.001</td></tr><tr><td>Inflammation <sup>b</sup></td><td>83 (75.5)</td><td>157 (87.2)</td><td>0.010</td><td>133 (76.9)</td><td>107 (91.5)</td><td>0.001</td></tr><tr><td>ADL total score</td><td>4.3 ± 1.5</td><td>3.4 ± 1.8</td><td>&lt;0.001</td><td>4.2 ± 1.6</td><td>3.0 ± 1.7</td><td>&lt;0.001</td></tr><tr><td>Bathing</td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>25 (22.3)</td><td>83 (45.4)</td><td></td><td>43 (24.4)</td><td>65 (54.6)</td><td></td></tr><tr><td>Requiring assistance</td><td>54 (48.2)</td><td>70 (38.3)</td><td></td><td>83 (47.2)</td><td>41 (34.5)</td><td></td></tr><tr><td>Independent</td><td>33 (29.5)</td><td>30 (16.4)</td><td></td><td>50 (28.4)</td><td>13 (10.9)</td><td></td></tr><tr><td>Dressing</td><td></td><td></td><td>0.001</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>19 (17.0)</td><td>60 (33.0)</td><td></td><td>33 (18.8)</td><td>46 (39.0)</td><td></td></tr><tr><td>Requiring assistance</td><td>54 (48.2)</td><td>87 (47.8)</td><td></td><td>83 (47.2)</td><td>58 (49.2)</td><td></td></tr><tr><td>Independent</td><td>39 (34.8)</td><td>35 (19.2)</td><td></td><td>60 (34.1)</td><td>14 (11.9)</td><td></td></tr><tr><td>Going to the toilet</td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>9 (8.0)</td><td>53 (29.0)</td><td></td><td>21 (11.9)</td><td>41 (34.5)</td><td></td></tr><tr><td>Requiring assistance</td><td>46 (41.1)</td><td>79 (43.2)</td><td></td><td>72 (40.9)</td><td>53 (44.5)</td><td></td></tr><tr><td>Independent</td><td>57 (50.9)</td><td>51 (27.9)</td><td></td><td>83 (47.2)</td><td>25 (21.0)</td><td></td></tr><tr><td>Transferring</td><td></td><td></td><td>0.001</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>3 (2.7)</td><td>13 (7.1)</td><td></td><td>7 (4.0)</td><td>9 (7.6)</td><td></td></tr><tr><td>Requiring assistance</td><td>45 (40.2)</td><td>104 (56.8)</td><td></td><td>72 (40.9)</td><td>77 (64.7)</td><td></td></tr><tr><td>Independent</td><td>64 (57.1)</td><td>66 (36.1)</td><td></td><td>97 (55.1)</td><td>33 (27.7)</td><td></td></tr><tr><td>Eating</td><td></td><td></td><td>0.003</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>2 (1.9)</td><td>13 (7.6)</td><td></td><td>4 (2.4)</td><td>11 (9.6)</td><td></td></tr><tr><td>Requiring assistance</td><td>11 (10.3)</td><td>37 (21.6)</td><td></td><td>17 (10.4)</td><td>31 (27.2)</td><td></td></tr></tbody></table>
<table><tr><td>Independent</td><td>94 (87.9)</td><td>121 (70.8)</td><td>143 (87.2)</td><td>72 (63.2)</td><td></td></tr><tr><td>Continence</td><td></td><td>&lt;0.001</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>9 (8.2)</td><td>46 (25.1)</td><td>18 (10.3)</td><td>37 (31.1)</td><td></td></tr><tr><td>Requiring assistance</td><td>32 (29.1)</td><td>56 (30.6)</td><td>49 (28.2)</td><td>39 (32.8)</td><td></td></tr><tr><td>Independent</td><td>69 (62.7)</td><td>81 (44.3)</td><td>107 (61.5)</td><td>43 (36.1)</td><td></td></tr></table>

Data are presented as mean ± SD or n (%).

ADL, Activity of Daily Living; BMI, Body Mass Index; CRP, C-reactive protein

<footnote>a Number of daily medicines ≥ 10</footnote>

<footnote>b CRP > 5 mg/L</footnote>
<table><caption>**Appendix 2.** Comparison of patients who met 90% of their requirements and those who did not during their hospital stays in the Geriatric Rehabilitation Unit (GRU).</caption><thead><tr><th rowspan="2"></th><th colspan="3">Energy intakes meeting 90% of requirements</th><th colspan="3">Protein intakes meeting 90% of requirements</th></tr><tr><th>Yes</th><th>No</th><th>P-Value</th><th>Yes</th><th>No</th><th>P-Value</th></tr></thead><tbody><tr><td>Gender</td><td></td><td></td><td>0.022</td><td></td><td></td><td>0.037</td></tr><tr><td>Men</td><td>14 (25.9)</td><td>25 (47.2)</td><td></td><td>23 (30.3)</td><td>16 (51.6)</td><td></td></tr><tr><td>Women</td><td>40 (74.1)</td><td>28 (52.8)</td><td></td><td>53 (69.7)</td><td>15 (48.4)</td><td></td></tr><tr><td>Age (years)</td><td>85.9 ± 5.8</td><td>86.5 ± 5.7</td><td>0.53</td><td>86.1 ± 5.8</td><td>86.5 ± 5.6</td><td>0.79</td></tr><tr><td>≤ 85</td><td>24 (44.4)</td><td>22 (41.5)</td><td>0.76</td><td>33 (43.4)</td><td>13 (41.9)</td><td>0.89</td></tr><tr><td>> 85</td><td>30 (55.6)</td><td>31 (58.5)</td><td></td><td>43 (56.6)</td><td>18 (58.1)</td><td></td></tr><tr><td>Living situation</td><td></td><td></td><td>0.008</td><td></td><td></td><td>0.19</td></tr><tr><td>Living alone</td><td>35 (66.0)</td><td>20 (40.0)</td><td></td><td>42 (57.5)</td><td>13 (43.3)</td><td></td></tr><tr><td>With partner or family members</td><td>18 (34.0)</td><td>30 (60.0)</td><td></td><td>31 (42.5)</td><td>17 (56.7)</td><td></td></tr><tr><td>BMI at admission (kg/m²)</td><td>25.7 ± 5.7</td><td>27.1 ± 6.1</td><td>0.24</td><td>26.3 ± 5.8</td><td>26.8 ± 6.4</td><td>0.94</td></tr><tr><td>&lt; 22</td><td>17 (31.5)</td><td>10 (18.9)</td><td>0.15</td><td>6 (19.4)</td><td>21 (27.6)</td><td>0.12</td></tr><tr><td>22-29.9</td><td>20 (37.0)</td><td>29 (54.7)</td><td></td><td>19 (61.3)</td><td>30 (39.5)</td><td></td></tr><tr><td>≥ 30</td><td>17 (31.5)</td><td>14 (26.4)</td><td></td><td>6 (19.4)</td><td>25 (32.9)</td><td></td></tr><tr><td>Charlson comorbidity index</td><td>7.6 ± 1.8</td><td>8.0 ± 2.8</td><td>0.93</td><td>7.8 ± 2.3</td><td>7.9 ± 2.5</td><td>0.97</td></tr><tr><td>≤ 6</td><td>17 (31.5)</td><td>17 (32.1)</td><td>0.99</td><td>23 (30.3)</td><td>11 (35.5)</td><td>0.60</td></tr><tr><td>7-8</td><td>20 (37.0)</td><td>19 (35.8)</td><td></td><td>30 (39.5)</td><td>9 (29.0)</td><td></td></tr><tr><td>≥ 9</td><td>17 (31.5)</td><td>17 (32.1)</td><td></td><td>23 (30.3)</td><td>11 (35.5)</td><td></td></tr><tr><td>Polypharmacy <sup>a</sup></td><td>16 (30.8)</td><td>22 (42.3)</td><td>0.22</td><td>28 (37.8)</td><td>10 (33.3)</td><td>0.67</td></tr><tr><td>CRP (mg/l)</td><td>24.7 ± 33.5</td><td>29.1 ± 40.3</td><td>0.28</td><td>23.3 ± 30.9</td><td>35.6 ± 48.3</td><td>0.07</td></tr></tbody></table>
<table><tbody><tr><td>Inflammation<sup>b</sup></td><td>34 (66.7)</td><td>37 (74.0)</td><td>0.42</td><td>47 (65.3)</td><td>24 (82.8)</td><td>0.08</td></tr><tr><td>ADL total score</td><td>4.6 ± 1.2</td><td>3.6 ± 1.5</td><td>0.001</td><td>4.4 ± 1.2</td><td>3.4 ± 1.6</td><td>0.005</td></tr><tr><td>Bathing</td><td></td><td></td><td>0.034</td><td></td><td></td><td>0.047</td></tr><tr><td>Completely dependent</td><td>5 (9.3)</td><td>12 (22.6)</td><td></td><td>8 (10.5)</td><td>9 (29.0)</td><td></td></tr><tr><td>Requiring assistance</td><td>31 (57.4)</td><td>33 (62.3)</td><td></td><td>47 (61.8)</td><td>17 (54.8)</td><td></td></tr><tr><td>Independent</td><td>18 (33.3)</td><td>8 (15.1)</td><td></td><td>21 (27.6)</td><td>5 (16.1)</td><td></td></tr><tr><td>Dressing</td><td></td><td></td><td>0.005</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>2 (3.7)</td><td>12 (22.6)</td><td></td><td>4 (5.3)</td><td>10 (32.3)</td><td></td></tr><tr><td>Requiring assistance</td><td>29 (53.7)</td><td>29 (54.7)</td><td></td><td>43 (56.6)</td><td>15 (48.4)</td><td></td></tr><tr><td>Independent</td><td>23 (42.6)</td><td>12 (22.6)</td><td></td><td>29 (38.2)</td><td>6 (19.4)</td><td></td></tr><tr><td>Going to the toilet</td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td>0.012</td></tr><tr><td>Completely dependent</td><td>1 (1.9)</td><td>10 (18.9)</td><td></td><td>5 (6.6)</td><td>6 (19.4)</td><td></td></tr><tr><td>Requiring assistance</td><td>21 (38.9)</td><td>29 (54.7)</td><td></td><td>32 (42.1)</td><td>18 (58.1)</td><td></td></tr><tr><td>Independent</td><td>32 (59.3)</td><td>14 (26.4)</td><td></td><td>39 (51.3)</td><td>7 (22.6)</td><td></td></tr><tr><td>Transferring</td><td></td><td></td><td>0.011</td><td></td><td></td><td>0.032</td></tr><tr><td>Completely dependent</td><td>0</td><td>2 (3.8)</td><td></td><td>1 (1.3)</td><td>1 (3.2)</td><td></td></tr><tr><td>Requiring assistance</td><td>20 (37.0)</td><td>31 (58.5)</td><td></td><td>31 (40.8)</td><td>20 (64.5)</td><td></td></tr><tr><td>Independent</td><td>34 (63.0)</td><td>20 (37.7)</td><td></td><td>44 (57.9)</td><td>10 (32.3)</td><td></td></tr><tr><td>Eating</td><td></td><td></td><td>0.002</td><td></td><td></td><td>&lt;0.001</td></tr><tr><td>Completely dependent</td><td>0</td><td>0</td><td></td><td>0</td><td>0</td><td></td></tr><tr><td>Requiring assistance</td><td>3 (5.8)</td><td>15 (28.8)</td><td></td><td>7 (9.5)</td><td>11 (36.7)</td><td></td></tr><tr><td>Independent</td><td>49 (94.2)</td><td>37 (71.2)</td><td></td><td>67 (90.5)</td><td>19 (63.3)</td><td></td></tr><tr><td>Continence</td><td></td><td></td><td>0.26</td><td></td><td></td><td>0.25</td></tr></tbody></table>
<table><tr><td>Completely dependent</td><td>4 (7.5)</td><td>9 (17.0)</td><td>7 (9.3)</td><td>6 (19.4)</td></tr><tr><td>Requiring assistance</td><td>22 (41.5)</td><td>23 (43.4)</td><td>31 (41.3)</td><td>14 (45.2)</td></tr><tr><td>Independent</td><td>27 (50.9)</td><td>21 (39.6)</td><td>37 (49.3)</td><td>11 (35.5)</td></tr></table>

Data are presented as mean ± SD or n (%).

ADL, Activity of Daily Living; BMI, Body Mass Index; CRP, C-reactive protein

<footnote>a Number of daily medicines ≥ 10</footnote>

<footnote>b CRP > 5 mg/L</footnote>