While I spend a lot of my online time, as in, on my Youtube, Pinterest and Facebook channels, talking about healthy eating and healthy lifestyles – another half of my week is spent working in a large acute hospital here in Dublin. There I help people who are often sick and unwell to recover from, or preferably avoid, malnutrition.

Dietitians work in a wide range of settings, and with a large variety of people. Many dietitians in hospitals work only with people who are sick and are struggling to eat because they have no appetite.

Most people have heard of dietitians working with people to help them lose weight. Surprisingly however, the vast majority of dietitians in Ireland are found working in hospitals and health centres helping people to eat more!

Dietetics when working in a hospital is often quite different to working with people who are well and at home. Malnutrition is more common than we think. One in four people admitted to hospitals around Ireland are malnourished.

Let’s take a closer look at malnutrition before we go back to the differences between healthy eating when you are well and sick/unwell.

Please do be aware that the information is generalised. The treatment plan for you or your loved one may be different. When in doubt, you should speak to a dietitian in your hospital or linked to your GP.

Malnutrition is a condition where a person is not eating enough calories, protein or micronutrients. It often leads to weight loss, muscle loss, fatigue, delayed wound healing, increased risk of infection and falls.

In Ireland, people who are most at risk of not eating enough and malnutrition are:

• Older people over 65 years
• People with long-term conditions
• Those with cancer
• People who abuse alcohol or drugs
• People on low incomes

Common causes of malnutrition can be divided into three main factors:

• Inadequate intake (ie: not eating enough)
• Increased losses
• Increased requirements.

People can experience an inadequate intake of food, or specific nutrients, when they are unable to eat enough. This could be for a wide variety of reasons, such as having no appetite when they are sick or nauseous or being unable to eat or drink due to swallowing problems.

You can experience an increase in how much nutrition you are losing when you for example have very loose stools (diarrhoea) or an oozing wound. If this continues for a long time, it can be difficult for you to eat enough to catch up on these losses.

And then, some conditions increase how many calories your body needs. This can be due to inflammation or infection, for example in cancer or liver disease. Or it can be when your body needs to heal and build new tissues, for example after surgery. Again, if you are then unable to eat as many calories as you are burning, you are at risk of developing malnutrition.

Dietitians can diagnose malnutrition based on several pieces of information.

We will often ask you if you have lost any weight recently. We can check your current weight, and then calculate your body mass index. He/she will ask how you have been eating recently and compare this to your nutrition requirements. For example, we may talk about your appetite, whether you are nauseous or sick, if you have been vomiting. Often, we will ask you some questions about your living situation, and your ability to eat, cook and grocery shop. We will also ask you about your medical history, or we will examine your medical chart. This will help us to estimate whether you might be burning more energy because of any medical condition. Some dietitians are also trained in doing a physical assessment, where we can check your fat and muscle stores in your face, arms, back and legs.

The dietitian will then piece all this information together to assess if you may be at risk of/have developed malnutrition.

Based on this information then, the dietitian will work with you to decide on a treatment plan. They will help you to eat more, or may find other ways to help you get enough nutrition and/or gain weight.

For some people, enough food can simply not be taken by mouth. This may be due to a swallowing problem, or if you are too fatigued too eat. Then a feeding tube may be needed to help you get your nutrition. However, for many the treatment plan will involve a diet that is higher in energy and protein than usual. This may be in the form of foods that are more typically “comfort foods” or sometimes supplement drinks may be needed. We call this type of diet a “high protein, high calorie” diet.

And this is where the confusion kicks in for many people. Yes, your dietitian might recommend for you to eat more comfort foods such as sugary and fatty foods. He or she may ask for you to switch to full fat milk, add butter to food and indulge on cake. When I start discussed this treatment plan with my patients, I am often met with both sighs of relief and gasps of disbelief!

Dietitian recommending us to eat more cake or fast food? What about our 5-a-day of fruit and veg, and a healthy portion of wholegrains? Why does your typical healthy eating recommendation go out the window when you’re malnourished?

Well this is because when you are malnourished and have no appetite, you often need to eat more calories. Our goal is to help you stop losing weight or even to gain weight again! Healthy eating advice is very much focused around losing excess weight for those who are overweight.

Doing this when you are feeling unwell, have a poor appetite and are in pain is even more challenging. To get that increase in calories from typically healthy foods such as fruits, veggies, whole carbs and lean proteins would mean that you would likely need to double your portion sizes. And you’d be tiring yourself out chewing through all that!

Now imagine trying to get those calories in from high-energy foods such as slices of cake, butter on your potatoes and nutritious drinks such as hot chocolate… a little easier isn’t it? Especially when you are feeling sick, nauseous and unwell.

We often recommend for someone to eat “little and often”. This means to continue eating three small meals a day, but to focus on having three snacks a day also. This way you are taking in more calories without curbing your appetite for your meals.

Taking nourishing drinks such as juice, milk and milk-based drinks rather than water is another useful strategy to help you take in more calories each day.

But what about all those risks that eating sugary foods and saturated fats pose on our health? Are there risks to eating a “high protein, high calorie” diet?

Well this is definitely something we consider. Our first thought here is that the risks linked to becoming or remaining malnourished are high. These risks are higher than your chances of developing cardiovascular disease in the time it takes to regain your strengths. 

Another thought is that we would of course recommend for someone, if they feel able, to focus on adding calories through healthy oils, larger portions of lean meats, and regular cups of low-fat milk. However, for many people who feel sick and have no appetite, this is more difficult than eating “traditional comfort foods” such as cake and fast food. And really, our primary goal is to help you back to health and prevent malnutrition.

So now, looking at the main differences between healthy eating when you are well and unwell/ sick (in other words, malnourished):

Meals:

When well, we recommend that you focus your meals around plenty of vegetables, some wholegrain carbs and lean protein. We recommend that you use oils sparingly.

When you are malnourished, sick or have no appetite, a more suitable meal might be focusing more on a larger portion of meat, some carbohydrate of choice (potatoes, pasta, rice etc) and a small amount of vegetables. We recommend that you add butter for example to your carbs and vegetables. We suggest that you could fry your meat and choose creamy sauces with your pasta.

Fluids:

When we are well, our drink of choice is recommended to be water. However, when we are malnourished or feeling unwell, our fluids provide us with a great opportunity to take in more calories. Juice, milk and milk based drinks such as hot chocolate, milkshakes and cappuccinos are high calorie options.

And finally, snacks:

Healthy eating when well does not mean avoiding snacks. Snacks are important to keep our energy levels balanced and can be a great way to squeeze in those fruits and veggies. We do recommend to aim to keep snacks below 150kcal.

When you are malnourished and have no appetite, snacking is an important way to beat that poor appetite. Choose high calorie snacks such as crackers and cheese, a sandwich, cakes, biscuits, eggs on toast – the list goes on.

So this Nutrition and hydration week, help us raise awareness about the differences between healthy eating: When well and unwell. Feel free to share this post  or the accompanying video with your loved ones! I have also dedicated a separate section of this blog to people looking to gain weight, which you can find HERE.