title: Protected Mealtimes in hospitals and nutritional intake: Systematic review and meta-analyses.
abstract: OBJECTIVE
  Protected Mealtimes is an intervention developed to address the problem of malnutrition, particularly in the hospital setting. The intervention aims to provide interruption-free time to eat during a hospital admission, thus supporting increased nutritional intake. This review aimed to determine the impact of Protected Mealtimes on the nutritional intake of hospitalised patients.
  
  
  METHODS
  The review was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42015023423) and followed the PRISMA guidelines. Meta-analyses were conducted of energy and protein intake.
  
  
  METHODS
  Seven databases were searched to identify relevant publications: Ovid MEDLINE, Embase, CINAHL Plus, PsycInfo, Scopus, Cochrane Library (including NHS economic evaluations), and NICE clinical guidelines. A supplementary internet search of Google and Google Scholar was undertaken. The search terms protect* AND (mealtime* OR "meal time*") were used for all searches.
  
  
  METHODS
  Eligible studies were original research where Protected Mealtimes was implemented in hospitals and nutritional intake measured. Studies were selected for inclusion following a systematic process of identification, screening and eligibility assessment. Two authors completed the screening and eligibility assessment, and quality assessment of included studies. The Quality Criteria Checklist for Primary Research was used to evaluate the quality of each study, whilst the overall body of evidence was assessed using the GRADE approach. One author extracted data and ran the meta-analyses, these were verified by a second author.
  
  
  RESULTS
  Database and hand searching yielded 150 papers for consideration; the final review library was seven studies where nutritional intake of patients had been evaluated before and after the introduction of Protected Mealtimes. No clinical trials of the intervention were identified. The meta-analyses of energy and protein intake in four observational studies found no effect in favour of Protected Mealtimes implementation. The GRADE of evidence was rated as very low.
  
  
  CONCLUSIONS
  Given the small number of observational studies and the quality of evidence on the effect of the intervention on nutritional intake, we conclude that there is insufficient evidence for widespread implementation of Protected Mealtimes in hospitals. More research including clinical trials, with subgroup reporting of patients' nutritional status and estimated energy requirements are needed to further understand the merits of this complex healthcare intervention.
authors.affiliation: Department of Nutrition & Dietetics, Monash University, Australia; Dietetics Department, Eastern Health, Australia. Electronic address: Judi.Porter@monash.edu.
authors.forename: Judi
authors.initials: J
authors.lastname: Porter
authors.affiliation: Department of Nutrition & Dietetics, Monash University, Australia; Dietetics Department, Eastern Health, Australia. Electronic address: Ella.Ottrey@monash.edu.
authors.forename: Ella
authors.initials: E
authors.lastname: Ottrey
authors.affiliation: Department of Nutrition & Dietetics, Monash University, Australia. Electronic address: Kate.Huggins@monash.edu.
authors.forename: Catherine E
authors.initials: CE
authors.lastname: Huggins
mesh_terms: D004044:Dietary Proteins / Q000378:metabolism; D002149:Energy Intake; D006801:Humans; D007297:Inpatients / Q000523:psychology*; D062407:Meals / Q000523:psychology*; D015596:Nutrition Assessment
chemical_list: D004044:Dietary Proteins
keywords: Diet therapy; Food services; Healthcare systems; Malnutrition; Mealtimes