Think of malnutrition and you don't picture a hospital ward in Australia, but around one hospital patient in four is suffering from it. In Queensland, at RBWH. It took Merrilyn Banks to recognise that, put a number on it and make it a priority. These patients arrive in nutritional deficit because their illness or injury has affected their appetite or their ability to eat or to prepare meals. This can have a big impact on their prospects of recovery.

In the early 2000s, hospitals were facing what was starting to be seen as an epidemic of pressure ulcers – sores developing on immobile patients in beds, often long-stay frail elderly patients. Nursing researchers were setting out to investigate, and Merrilyn thought it likely that same group was at high risk of malnutrition. With support from the RBWH Foundation in 2007, Merrilyn did the research that demonstrated malnourished patients were twice as likely to have pressure ulcers. With severely malnourished patients, that rose to five times as likely. The association was clear but, beyond that, what the study brought to light was the staggering prevalence of malnutrition in patients across Queensland hospitals.

Hospitals were funnelling in people who were sick and needed treatment and, ‘Not only were a large number of people malnourished,’ Merrilyn says, ‘they actually were becoming more malnourished while they were in hospital.’

The traditional approach to hospital catering followed the idea that 80% of people can eat the standard diet and dietitians can have input into the other 20% who have particular needs, so there are special meals, for example, for people with diabetes or coeliac disease, or who need soft foods. Beyond that, the principle was that everyone should eat healthy food and healthy food is the same for all of us. And patients are mostly lying in bed, so don’t feed them too much.

But that’s not right for sick people. They’ve come in eating less. They’re already suffering from the effects of that. And their appetites don’t pick up the moment they’re admitted. And yet hospital food, like airline food, had a reputation for being a turn-off rather than a turn-on.

Our approach to malnutrition and to hospital food had to change.

It’s standard now to screen new patients for malnutrition risk. Expect to hear questions like ‘Have you been eating less recently?’ and ‘Have you lost weight?’, with anyone at risk going on to be assessed in detail. Weight loss quantified, diet reviewed looking at deficit of calories and protein, activity level assessed, physical assessment of fat stores, muscle stores, pressure sores and risk of pressure sores.

Dietitians and the food services team got together, with a determination to make food that patients would want to eat and would eat and that gives them what they need. Hospital food is now more ‘normal’, but a high-energy high-protein version of normal. You might be 90 and not moving much, but expect to be offered a high-protein popper of the kind usually marketed to young folk about to cycle 20k before breakfast.

At 25%, the prevalence of malnutrition in RBWH patients is down from the levels Merrilyn first recorded and severe malnutrition is much less common. But it’s an ever-present issue, since patients will keep coming in malnourished.

Hospital food has adapted to anticipate that, and that’s created an opportunity to reframe the role that food plays in the hospital experience. A patient’s experience of the food service makes a big difference to their level of satisfaction with their hospital experience overall and to their engagement with their care.

Food is fuel, but it’s not just fuel. And it’s not just fuel plus nutrition to help with healing. Food is the one thing in their day that patients get to choose. It can be something to look forward to. It’s social. Food can be talked about, complained about. And that can bring to the surface issues that need to be dealt with. More than anything else in the hospital day, meals create routine. For patients in hospital, it’s easy to lose track of time. Meals allow a re-set and stop one part of the day merging into the next. In hospital, food can offer the prospect of something normal, in a very abnormal environment. Breakfast, lunch, dinner – we do them in the outside world and we do them in hospital too.

Food is a priority at RBWH because patients need it to be and, nudged along by work led by Merrilyn, the hospital realises its importance. Food service keeps evolving to improve its fit with patients’ needs. The latest development is an app for patients to give instant meal feedback. Let’s see an airline dare to do that.