Ask a Dietitian > Evidence to show fortified foods are cost effective and feasible

Evidence to show fortified foods are cost effective and feasible

May 23, 2018

As health care professionals, having some hard evidence behind what we advise is key. In previous blogs we looked at how poor nutrition is associated with greater risk of pressure injuries, infections, poor recovery and increased length of hospital stay. Oral nutritional supplements (sip feeds) are frequently used in cases of poor nutrition, and certainly have their merits for short term rehabilitation and long term nutrition sport, however patients often dislike them.

Hot off the press, a systematic review (1) published January 2018  gives us a look into the evidence behind an alternative strategy – going back to basics and using food first to get enough energy and protein into our hospitalised older adults. Let’s take a look at the key findings from this review.

Food fortification (energy and protein dense meals)

Imagine you’re feeling sick, you’ve been admitted to hospital for an acute health issue, you’re nauseous, have no appetite and feeling worried about your health. Someone comes along and encouraged you eat something you’ve never tried before, and tastes a bit weird. You’re probably not going to eat it. Add delirium or confusion into the mix and it’s a recipe for inadequate oral intake.

Fortifying foods that are familiar and already accepted by the older person by adding ingredients such as margarine, cream, honey, cheese, skim milk powder, vegetable protein and healthy oils is a great way to boost the energy and protein content of meals.  Or there is the option of using pre prepared fortified foods that have already been fortified for you. Several studies highlighted in the systematic review showed the use of fortification was significant in supporting older people to increase their dietary energy intake. Better still, four studies found either positive or neutral feedback in the compliance and tolerance of fortified foods when compared with the non-fortified variety.

Snacks and portion sizes

Eating smaller, more frequent meals and snacks, can often help an older person get more nutrition in during the day.  One study found that including cakes, cheese sandwiches and Danish pastries in between meals increased a patient’s energy intake.  

Another study demonstrated success in increasing intake by using half portions but ensuring those smaller portions were adequately fortified (using the methods suggested above). Too often, older adults are overwhelmed with large portion sizes, meaning they ultimately eat very little. Having snacks in between meals can be very useful in this case, particularly if the older person is unwell, as nutrition plays an important role in recovery.


Another strong benefit of using fortified foods and snacks for  between meal snacks are their undeniable cost effectiveness. One study included in the review showed that these methods were more cost effective than giving patients sip feed drinks; even when accounting for the extra time it takes for staff to prepare such meals.

So, where to from here?

When identifying a patient is at risk of malnutrition or malnourished, instead of using oral nutrition supplements as the ‘go to’ or first port of call, let’s go back to the basics and start with food first. For older patients who are unwell and might be confused or delirious, fortifying ‘normal’ foods and including snacks that are already familiar and acceptable to that individual could encourage increased oral intake, support their recovery and promote  a better quality of life overall.

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Mills, S.R., et al., Can fortified foods and snacks increase the energy and protein intake of hospitalised older patients? A systematic review. J Hum Nutr Diet, 2018.

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