*4.3. Environmental Changes to Improve Mealtime Habitat and Experience*

Environmental elements such as food accessibility (for example a glass door refrigerator with snack food easily visible), companions and furniture, smell, ambient sounds, lighting and temperature, size of the portion, eating location, and presentation of food play a crucial role during mealtimes, improving the patients' compliance to eat [25]. It is demonstrated that changes in mealtime habits and atmosphere, based on the personal needs of patients, could increase nutritional intake and reduce the malnutrition risk [25,29], especially among older people.

A great variety of environmental variables might have an influence on the nutritional intake of elderly inpatients as also reported in the review findings [25,30]. Wong, et al. have shown that appetite increased if those people needing more assistance were fed earlier than other patients; it is not the time of meal initiation that is important, but the longer duration [25]. To reduce the prevalence of malnutrition in these patients, it is useful to offer supplementary drinks, as they can improve oral intake and increase appetite [30]. Another environmental change to improve mealtime habitats is music. Wong et al. have shown that patients spent more time at the table when music was played, so it appears to be an effective strategy to lengthen mealtime and increase patients' appetite [25].

Family style meals, eating meals with caregivers, relaxing music during mealtime, patient education, protected mealtimes, and additional food assistance (implemented alone or in combination) were among the most promising interventions to improve mealtime experiences [25,29,30]. It is crucial that these fragile patients receive support from nurses or family members at mealtimes [25]. This relational strategy helps the patient to increase food intake during meals [29]. Receiving good mealtime assistance and increasing time spent by nurses or volunteers on feeding or helping during meals may positively affect eating behavior with a positive effect on the nutritional intake in older inpatients [27,29].

The physical presence of a caregiver helps the patient to be more focused on his or her meal [25,29]. Caregiver education is crucial to ensure proper weight maintenance for the patient who may go through weight loss even if they have a positive energy balance [26].
