•Biomedical gastronomy in management of patients.•Physiological cues lost in smell and taste alterations.•Value of the eating environment in altered eating.•Extrinsic cues and psychosocial factors could ameliorate ‘altered eating’. Altered eating represents a deviation from ‘normal eating’ and often leads to malnutrition and loss of quality of life. Cues derived from smell and taste direct the cephalic phase responses in the complex process of eating and digestion. Other cues derived from psychosocial aspects of the eating process combined with extrinsic cues derived from the eating environment could compensate partially in providing an environment which is conducive to encourage the meaningful and purposeful consumption of food and beverages when the pleasures of smell and taste are lost or altered. Biomedical gastronomy has the potential to promote a conducive environment in which eating problems can be managed and which in many cases provides purpose and pride; it employs many of the well-recognized practices on which hospitality and restaurant professions are assumed and founded; studies of gastrophysics provide a scientific basis. Altered eating represents a deviation from ‘normal eating’ and often leads to malnutrition and loss of quality of life. Cues derived from smell and taste direct the cephalic phase responses in the complex process of eating and digestion. Other cues derived from psychosocial aspects of the eating process combined with extrinsic cues derived from the eating environment could compensate partially in providing an environment which is conducive to encourage the meaningful and purposeful consumption of food and beverages when the pleasures of smell and taste are lost or altered. Biomedical gastronomy has the potential to promote a conducive environment in which eating problems can be managed and which in many cases provides purpose and pride; it employs many of the well-recognized practices on which hospitality and restaurant professions are assumed and founded; studies of gastrophysics provide a scientific basis. Regardless of a person's philosophy of food is ‘to eat to live’, or ‘to live to eat’, the consumption, ingestion and digestion of foods and beverages comprise a complex system of intertwined signals and rituals [[1]Woods S. Begg D. Regulation of the motivation to eat.in: Simpson E.H. Balsam P.D. Behavioral neuroscience of motivation. Current topics in behavioral neurosciences. 27 ed. Springer, 2015: 15-34Crossref Scopus (26) Google Scholar]. These signals arise from visceral and sensory sources, modulated by psychological, psychosocial and cultural influences, and by external (extrinsic) influences. The phenomenon of appetite which dictates food choice, pleasure and quality of life is largely dependent on these cues. Food choice and food intake are guided by both sensory and metabolic processes with taste and smell playing key roles in influencing choice, intake and appetite in which gustation senses nutrients and palatability along with texture influences eating rate, whereas olfaction induces appetite [[2]Boesveldt S. de Graaf K. The differential role of smell and taste for eating behavior.Perception. 2017; 46: 307-319Crossref PubMed Scopus (107) Google Scholar]. Food intake is under the joint control of internal signals and external cues [[3]Bilman E. van Kleef E. van Trijp H. External cues challenging the internal appetite control system—Overview and practical implications.Crit Rev Food Sc Nutr. 2017; 57: 2825-2834https://doi.org/10.1080/10408398.2015.1073140Crossref PubMed Scopus (42) Google Scholar], with psychological and psychosocial aspects influencing cues and evoking cephalic phase responses [[4]Nederkoorn C. Smulders F.T. Jansen A. Cephalic phase responses, craving and food intake in normal subjects.Appetite. 2000; 35: 45-55Crossref PubMed Scopus (202) Google Scholar]. Gastronomy has a significant potential, albeit unrecognized role, when taste and smell alterations occur through physiological changes of aging, iatrogenesis of treatment and psychological perturbation. Before reflecting on ‘altered taste’, the physiological role of gastronomy in ‘normal taste’ needs considering. Flavour is generated on the ‘backbone’ of physiological taste (gustation) [[5]]Spence C. Just how much of what we taste derives from the sense of smell?.Flavour. 2015; 4: 30-39Crossref Google Scholar] integrated with smell (olfaction) and inputs of the somatosenses; olfaction contributes between 75 and 95% of the flavour percept [[5]]Spence C. Just how much of what we taste derives from the sense of smell?.Flavour. 2015; 4: 30-39Crossref Google Scholar]. This becomes modulated by extrinsic and psychosocial factors to generate a neural picture (image) of flavour. This neural image is referred to the mouth where it is recognized as the illusion that is commonly referred to as ‘taste’ [[6]Breslin P.A.S. Human gustation and flavour.Flavour Fragr J. 2001; 16: 439-456Crossref Scopus (31) Google Scholar]. With some diseases and treatments, the physiological balance becomes perturbed with appetite becoming diminished. Homeostatic and allostatic mechanisms prevail in mild situations, but when they become exceeded ‘altered eating’ prevails [[7]Watson D. Lewis S. Bryant V. Patterson J. Kelly C. Edwards-Stuart R. et al.Altered eating: a definition and framework for assessment and intervention.BMC Nutr. 2018; 4: 14-23https://doi.org/10.1186/s40795-018-0221-3Crossref PubMed Scopus (13) Google Scholar]. Altered eating represents a deviation form ‘normal eating’, but little formal or theoretical attention is paid to normal eating, and surmises that ‘everybody knows what normal eating is’ [[8]Herman C. Polivy J. Pliner P. Normal Eating.in: Meiselman H. Handbook of eating and drinking. Springer Nature, Switzerland, AG2020: 219-234Crossref Google Scholar]. Given the complexity of eating, normal eating is difficult to define and depends on the situation, culture, social situations, psychosocial aspects and myriad other factors. Taste and smell alterations (TSAs) commonly occur in the pathosis and in the management of diseases and are side effects of a variety of therapeutic agents [[9]Brondel L.B.M. Jacquin-Piques A. Mouillot T. Pénicaud L. Taste disorders in disease.in: Etieveant P. Flavor: from food to behaviors, wellbeing and health: Elsevier. Woodhead Publishing., 2016: 337-361Crossref Scopus (4) Google Scholar]; significant are those employed in cancer chemotherapy. Appetite loss in altered eating is further compounded with nausea and vomiting in cancer therapies. Management of chemotherapy induced nausea and vomiting are difficult to prevent completely [[10]Natale J.J. Reviewing current and emerging antiemetics for chemotherapy-induced nausea and vomiting prophylaxis.Hosp Prac. 2015; 43: 226-234Crossref Scopus (14) Google Scholar]; use of pleasant and cold stimuli can mask adverse taste [[11]Gonella S. Dimonte V. Potential effects of pleasant and cold stimuli on nausea and vomiting induced by disgusting tastes.J Neurosci Res. 2016; 94: 366-377Crossref PubMed Scopus (3) Google Scholar]. Intrinsic cues comprise both the mechanisms relating to hunger and the satiety cascade and to the intrinsic properties of the food conferring taste, smell and somatosenses [[12]Drareni K. Dougkas A. Giboreau A. Laville M. Souquet P.-J. Bensafi M. Relationship between food behavior and taste and smell alterations in cancer patients undergoing chemotherapy: A structured review.Semin Oncol. 2019; 46: 160-172Crossref PubMed Scopus (23) Google Scholar]. The flavour of food is perceived through the senses of taste, smell and somatosensory (texture and chemesthesis), along with oral function, as the composite neural ‘image’ which is perceived in the mouth [[13]Shepherd G.M. Neurogastronomy: how the brain creates flavor and why it matters. Columbia University Press, NY2012Google Scholar]. Psychosocial factors, influence the perception, represent cues independent of food and comprise social interactions, accessibility and atmospherics of the manner in which food is presented or provided [[14]Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers.Annu Rev Nutr. 2004; 24: 455-479Crossref PubMed Scopus (698) Google Scholar]. Extrinsic factors and cues are considered to be those involving food behaviour with a focus on the context and process in which food and beverages are consumed. They include the ambience, place, sound, company, presentation and related factors. A significant body of information, recognised as gastronomy, is available from hospitality, restaurateurs and related industries, but its application to the ‘healing environment’ is wanting with currently no clear definitions [[15]DuBose J. MacAllister L. Khatereh H. Exploring the concept of healing spaces.HERD: Health Environ Res Des J. 2018; 11: 43-56Crossref Scopus (32) Google Scholar], and when considered with enhanced food presentation food acceptance is enhanced [[16]Navarro D.A. Boaz M. Krause I. Elis A. Chernov K. Giabra M. et al.Improved meal presentation increases food intake and decreases readmission rate in hospitalized patients.Clin Nutr. 2016; 35: 1153-1158Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar]. An extrinsic approach conjoins the senses of the ambience, purpose of meals, and is a tool to evoke multisensory embodied experiences [[7]Watson D. Lewis S. Bryant V. Patterson J. Kelly C. Edwards-Stuart R. et al.Altered eating: a definition and framework for assessment and intervention.BMC Nutr. 2018; 4: 14-23https://doi.org/10.1186/s40795-018-0221-3Crossref PubMed Scopus (13) Google Scholar]. It combines culture, and identity and beliefs in eating, and the role of the ‘meal and the table’. Gastronomy potentially has a valuable place in health care establishments [[17]Giboreau A. Dougkas A. Gastronomy as an Aid to Increasing people's Food Intake at Healthcare Institutions.in: Encyclopedia of Food Security and Sustainability. 1. Elsevier, 2018: 540-545Google Scholar]; it is regarded as biomedical gastronomy. The senses of taste smell and somatosenses, have an important physiological role in eliciting the cephalic phase response (CPRs) [[18]Kershaw J.C. Mattes R.D. Nutrition and taste and smell dysfunction.World J Otorhinolaryngol-Head Neck Sur. 2018; 4: 3-10Crossref PubMed Google Scholar]. Currently, few associations between the cephalic phase responses (CPRs) and ‘altered eating’ in diseases are made or proffered; much of the research available has centered around obesity studies. These senses confer a vital physiological role on the CPRs in the feeding process in promoting appetite, and preparing the gastrointestinal tract and brain related systems for the consumption and digestion of food, and a lesser extent beverages [[19]Woods S.C. Strubbe J.H. The psychobiology of meals.Psychon Bull Rev. 1994; 1: 141-155Crossref PubMed Scopus (88) Google Scholar,[20]Pribic T. Azpiroz F. Biogastronomy: Factors that determine the biological response to meal ingestion.Neurogastroenterol Motil. 2018; 30e13309Crossref Scopus (10) Google Scholar]. Anticipatory cues from extrinsic sources relate to Pavlov's classic research [[21]Pavlov I. Physiology of digestion.in: Nobel lectures: physiology or medicine. Elsevier, 1904: 141-155Google Scholar]. A link between extrinsic cues of consumption influencing appetite with the cephalic phase responses is rarely considered let alone in those with ‘altered eating’; neuromodulation is induced by extrinsic factors [[22]Lizbinski K.M.D.A. Intrinsic and extrinsic neuromodulation of olfactory processing.Front Cell Neurosci. 2018; 9: 424-434Crossref Scopus (30) Google Scholar]. Although CPRs are the direct result of sensory stimulation of intrinsic cues, conditioned processes do play a role [[4]Nederkoorn C. Smulders F.T. Jansen A. Cephalic phase responses, craving and food intake in normal subjects.Appetite. 2000; 35: 45-55Crossref PubMed Scopus (202) Google Scholar,[23]Mattes R.D. Physiologic responses to sensory stimulation by food: nutritional implications.J Am Diet Assoc. 1997; 97: 406Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar]. When a subject has learned that a cue predicts food intake, cephalic phase responses are elicited by exposure to that cue; an association with extrinsic properties evoking CPRs although not researched is highly probable. The hospitality and restaurant professions have relied on this proffered physiological response. Cognitive factors play an important role in food anticipation in humans. The mere discussion about food triggers insulin release as a component of anticipation [[24]Feldman M. Richardson C.T. Role of thought, sight, smell, and taste of food in the cephalic phase of gastric acid secretion in humans.Gastroenterology. 1986 Feb 1; 90: 428-433Abstract Full Text PDF PubMed Scopus (174) Google Scholar] and expected food palatability influences cephalic response [[25]Rigamonti A.E. Piscitelli F. Aveta T. Agosti F. De Col A. Bini S. et al.Anticipatory and consummatory effects of (hedonic) chocolate intake are associated with increased circulating levels of the orexigenic peptide ghrelin and endocannabinoids in obese adults.Food Nutr Res. 2015; 5929678Crossref PubMed Scopus (32) Google Scholar]. An understanding of cognitive capacities in food anticipatory responses is lacking [[26]Skvortsova A. Veldhuijzen D.S. Kloosterman I.E.M. Pacheco-Lopez G. Evers A.W.M. Food anticipatory hormonal responses: A systematic review of animal and human studies.Neurosci Biobehav Rev. 2021; 126: 447-464Crossref PubMed Scopus (8) Google Scholar], and are likely influenced by rituals, ambience, presentation, and other aspects to enhance pleasure and flavor. Ambience markedly influences food choice [[27]Stroebele-Benschop N. Depa J. de Castro J.M. Environmental strategies to promote food intake in older adults: a narrative review.J Nutr Gerontol Geriatr. 2016; 35: 95-112Crossref PubMed Scopus (22) Google Scholar] and impacts flavor [[28]Spence C. Multisensory flavour perception.Curr Biol. 2013; 23: R365-R369Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar]. A recent literature review considering the role of interventions of patients with taste and smell alterations resulting from cancer chemotherapy [[29]Ellender G. Coveney J. Flavor alterations in cancer treatment: extrinsic factors as a means of augmentation.Clin Nutr ESPEN. 2021; 43: 76-89Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar] found a confusing picture with a lack of consistent data. They suggested that by introducing a gastronomic extrinsic approach in conjunction with psychological and sociological management as an intervention may facilitate the potential for other interventions of intrinsic natures to ameliorate the ‘ravages’ of malnutrition which may not be influenced significantly with the vagaries of heterogeneities of treatments and alterations. Intrinsic approaches based on flavour enhancements, often in conjunction with nutrient enhancement and textural changes, use of therapeutics and other avenues were generally unsuccessful in encouraging eating and preventing the patient from developing malnutrition; few clinical trials were reported. Psychosocial approaches comprised diverse interventions ranging from direct counselling and education to personal involvement in coping strategies. Some encouraging reports indicated improvement when the patient was counselled prior to treatment, became involved in their own care, and were involved with others such as family and carers [[29]Ellender G. Coveney J. Flavor alterations in cancer treatment: extrinsic factors as a means of augmentation.Clin Nutr ESPEN. 2021; 43: 76-89Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. Extrinsic approaches represent those involving food behaviour and focusing on the context of the food and the eating process represent a largely unexplored field in respect to the biomedical environment. The role of extrinsic factors is poorly considered in interventions of altered eating. Extrinsic factors are considered to be the eating environment in which the eating process is undertaken and is independent of the food itself [[14]Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers.Annu Rev Nutr. 2004; 24: 455-479Crossref PubMed Scopus (698) Google Scholar]. The environment in which consumption occurs can be considered as an ‘eating environment’ and a ‘food environment’. The former represents the ambient characteristics of the atmosphere such as temperature, lighting, odour and noise, whereas the latter directly relates to the tablescape and the manner in which food is presented. Both influence the meaningfulness of the consumption of food [[12]Drareni K. Dougkas A. Giboreau A. Laville M. Souquet P.-J. Bensafi M. Relationship between food behavior and taste and smell alterations in cancer patients undergoing chemotherapy: A structured review.Semin Oncol. 2019; 46: 160-172Crossref PubMed Scopus (23) Google Scholar]. Their value is well recognized in the restaurant and hospitality professions, in influencing the psychology of the consumer, but are rarely considered in interventions of ‘altered eating’ whether in hospitals or in domestic settings. A significant component involves with whom the process of consumption occurs. Food and meals are seldom eaten in isolation and are, therefore, influenced by myriad social factors which compound with whom the meal is consumed [[7]Watson D. Lewis S. Bryant V. Patterson J. Kelly C. Edwards-Stuart R. et al.Altered eating: a definition and framework for assessment and intervention.BMC Nutr. 2018; 4: 14-23https://doi.org/10.1186/s40795-018-0221-3Crossref PubMed Scopus (13) Google Scholar], with the surroundings and prevailing conditions in which the meal is eaten, notably the environment [[30]Edwards J.S. Meiselman H.L. Edwards A. Lesher L. The influence of eating location on the acceptability of identically prepared foods.Food Qual Prefer. 2003; https://doi.org/10.1016/S0950-3293(02)00189-1Crossref Scopus (146) Google Scholar,[31]Edwards J.S. Hartwell H.J. Giboreau A. Emotions studied in context: the role of the eating environment.in: Meiselman H.A. Emotion measurement. Elsevier, 2016: 377-403https://doi.org/10.1016/B978-0-08-100508-8.00015-1Crossref Scopus (7) Google Scholar] and location [[32]Plaza A.G. Saulais L. Blumenthal D. Delarue J. Eating location as a reference point: Differences in hedonic evaluation of dishes according to consumption situation.Food Qual Prefer. 2019; 78103738Google Scholar]. In summary, interventions based on intrinsic cues and factors are poorly accepted, and are confused by inconsistent research, diversity of treatments, staging of diseases, and primary lesions. Interpretations can be confounded by therapies for other comorbidities such as antihypertensive pharmaceuticals, leading to unreliable estimates of incidences and outcomes. Psychosocial and psychological techniques have provided some success with psychoeducation having significant value. Extrinsic approaches based on gastronomy are lacking. Several publications concluded that further research of taste and smell alterations and interventions are needed. Currently studies are based on data from patients, ranging from self-reporting and surveys, and diverse assays. Considered here is the potential provide interventions directed at alterations of taste and smell, so lessening the impact of malnutrition by employing principles derived from gastrophysics and psychophysiology [[33]Spence C. Gastrophysics: a new scientific approach to eating. Viking, Penguin, NY2017Google Scholar,[34]Mouritsen O.G. Gastrophysics of the oral cavity.Curr Pharm Des. 2016; 22: 2195-2203Crossref PubMed Scopus (8) Google Scholar] to the medical and healing environment as Biomedical Gastronomy. Food selection and the motivation to eat is complex and represents physiological (intrinsic), psychosociological and environment (extrinsic) influences and cues. Numerous papers refer to factors influencing the motivation to eat but limit their scope to suggestions, not applications. Many of the currently used interventions directed towards enhancing intrinsic factors of food were considered to be ineffective [[29]Ellender G. Coveney J. Flavor alterations in cancer treatment: extrinsic factors as a means of augmentation.Clin Nutr ESPEN. 2021; 43: 76-89Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. Significant advances have been made in the early diagnosis and the treatment of malignant diseases, but at the same time the side effects of cancer chemotherapy remain significant especially in relationship to taste and smell alterations. Loss of flavor perception, distressing to the patient for the loss of appetite and the enjoyment of food, presents a serious problem leading to the development of malnutrition, wasting and malignant cachexia. It contributes to morbidity, is associated with diminished treatment outcomes [[35]Boltong A. Campbell K. ‘Taste’ changes: A problem for patients and their dietitians.Nutri Diet. 2013; 70: 262-269Crossref Scopus (13) Google Scholar,[36]Arends J. Baracos V. Bertz H. Bozzetti F. Calder P. et al.ESPEN expert group recommendations for action against cancer-related malnutrition.Clin Nutr. 2017; 36: 1187-1196Abstract Full Text Full Text PDF PubMed Scopus (520) Google Scholar] and compounds with psychological and psychosociological problems [[37]Bernhardson B.M. Tishelman C. Rutqvist L.E. Taste and smell changes in patients receiving cancer chemotherapy: distress, impact on daily life, and self-care strategies.Cancer Nurs. 2009; 32: 45-54Crossref PubMed Scopus (46) Google Scholar,[38]Munankarmi D. Management of Dysgeusia related to Cancer: A Systematic Review.J Lumbini Med Coll. 2017; 5: 3-12Crossref Google Scholar]. The value of cues based on extrinsic factors is considered rarely in the management of patients with taste and smell alterations with studies affording potential significant applications in the emerging interdisciplinary field of gastrophysics [[33]Spence C. Gastrophysics: a new scientific approach to eating. Viking, Penguin, NY2017Google Scholar] pertaining to the physical and physicochemical nature of the empirical world of gastronomy having a focus on the sensory perception of the oral cavity [[34]Mouritsen O.G. Gastrophysics of the oral cavity.Curr Pharm Des. 2016; 22: 2195-2203Crossref PubMed Scopus (8) Google Scholar]. Secular rituals, as well as religious and cultural eating rituals are known to make the eating process meaningful. These rituals often provide an understanding and consideration of the production and procurement of food, leading to its preparation and presentation [[39]Vohs K.D. Wang Y. Gino F. Norton M.I. Rituals enhance consumption.Psychol Sci. 2013; 24: 1714-1721Crossref PubMed Scopus (72) Google Scholar]. Rituals provide structure and purpose and in relation to the process of eating have become downplayed in recent decades. Rituals can have the psychological effect of changing one's taste preferences, through ‘evaluative preferences’ [[40]Prescott J. Multisensory processes in flavour perception and their influence on food choice.Curr Opin Food Sci. 2015; 3: 47-52Crossref Scopus (78) Google Scholar], and the application of a fixed meal pattern can influence ghrelin secretion as a learned response independent of nutrient status [[41]Drazen D.L. Vahl T.P. D’Alessio D.A. Seeley R.J. Woods S.C. Effects of a fixed meal pattern on ghrelin secretion: evidence for a learned response independent of nutrient status.Endocrinology. 2006; 147: 23-30Crossref PubMed Scopus (260) Google Scholar]. Rituals, as “symbolic activity that often include repeated and unusual behaviors occurring in fixed, episodic sequences,” can make food actually taste better [[39]Vohs K.D. Wang Y. Gino F. Norton M.I. Rituals enhance consumption.Psychol Sci. 2013; 24: 1714-1721Crossref PubMed Scopus (72) Google Scholar]; singing ‘happy birthday’ is such a ritual that enhances the flavor of a birthday cake. Gastrophysics has potential applications in conjunction with interventions of an extrinsic nature. It is the scientific study of those factors that influence our multisensory experience when tasting food and drink [[33]Spence C. Gastrophysics: a new scientific approach to eating. Viking, Penguin, NY2017Google Scholar], and includes psychological, psychophysical and neuroscientific considerations which can address fundamental problems related to human consumption of foods, no matter whether these are related to questions of pleasure and satisfaction or are more concerned with health issues [[42]Moller P. Gastrophysics in the brain and body.Flavour. 2013; 2: 8-9Crossref Google Scholar]. In ‘altered eating’ when sensory perception of food is deranged any aspect that can enhance (improve) perception of food is considered positive. The close association between CPRs and the control of eating and digestive behaviours is multifaceted and are strongly associated with both anticipation [[26]Skvortsova A. Veldhuijzen D.S. Kloosterman I.E.M. Pacheco-Lopez G. Evers A.W.M. Food anticipatory hormonal responses: A systematic review of animal and human studies.Neurosci Biobehav Rev. 2021; 126: 447-464Crossref PubMed Scopus (8) Google Scholar,[43]Power M.L. Schulkin J. Anticipatory physiological regulation in feeding biology.Appetite. 2008; 50: 194-206Crossref PubMed Scopus (154) Google Scholar] and the chemical senses of smell and taste [[44]Fine L.G. Riera C.E. Sense of smell as the central driver of pavlovian appetite behavior in mammals.Front Physiol. 2019; 10: 1151Crossref PubMed Scopus (16) Google Scholar]. When the influences of taste and smell are diminished other contributing factors guiding CPRs, currently under researched, may compensate this deficit. The complexity of eating behaviour necessitates a greater focus on multidisciplinary research [[45]Emilien C. Hollis J.H. A brief review of salient factors influencing adult eating behaviour.Nutr Res Rev. 2017; 30: 233-246Crossref PubMed Scopus (23) Google Scholar] between physiology, environment, psychology, culture, socioeconomics, and genetics. Extrinsic cues are within the remit of the scope of gastronomy, especially those elements of the eating process, including the venue, the setting, the ambience, which provide an opportunity by implementing aspects based on the principles and practices of multisensory technology for flavor augmentation [[46]Velasco C. Obrist M. Petit O. Spence C. Multisensory technology for flavor augmentation: a mini review.Front Psychol. 2018; 9: 26Crossref PubMed Scopus (57) Google Scholar]. These are coupled with social and sociological aspects of culture, education and involvement and an understanding of the feeding process. The role of the eating environment has received only cursory considerations in the management of TSAs and their outcomes. Myriad factors comprise the ‘eating environment’ [[31]Edwards J.S. Hartwell H.J. Giboreau A. Emotions studied in context: the role of the eating environment.in: Meiselman H.A. Emotion measurement. Elsevier, 2016: 377-403https://doi.org/10.1016/B978-0-08-100508-8.00015-1Crossref Scopus (7) Google Scholar], and how and what is consumed. A recent trend has seen the exploration of healing spaces and healing environments [[15]DuBose J. MacAllister L. Khatereh H. Exploring the concept of healing spaces.HERD: Health Environ Res Des J. 2018; 11: 43-56Crossref Scopus (32) Google Scholar]; these environments do not cause healing but facilitate engagement in behaviours and emotions that support healing and represent extrinsic influences. The environment can induce physical and emotional responses such as happiness and joy (reduced distress) and promote relaxation, and the build environment can enhance individual control and functionality – all of which are antecedent to healing [[47]Olsen T.D. Healing Architecture: how hospital food environments can help improve patient recovery-an integrative literary review.2010: 101-121https://vbn.aau.dk/en/publications/healing-architecture-how-hospital-food-environments-can-help-imprGoogle Scholar,[48]Justesen L. Gyimothy S. Mikkelsen B.E. Hospitality within hospital meals—Socio-material assemblages.J Foodser Bus Res. 2016; 19: 255-271Crossref Scopus (9) Google Scholar]. Despite a wealth of information concerning extrinsic multimodal and cross sensory influences in food it seldom finds application in health sciences, taking a place secondary to active disease management. By introducing a gastronomic extrinsic approach in conjunction with psychological and sociologic management as an intervention for TSAs may enable intrinsic approaches to ameliorate the ‘ravages’ of malnutrition, and may assist in countering some heterogeneities of treatment regimes. There is a potential role for gastronomy to encourage patients with TSAs to obtain pride, purpose and potential pleasure in the consumption of food and beverages in an enhanced gastronomic environment. This could be achieve through the recognition of biomedical gastronomy. It is not just when, what and how much is eaten, but the manner and the environment in which, one eats. Directions of research worthy of investigation: Extrinsic approaches based on knowledge gained from gastronomy conjoined with psychoeducation need to be explored by a dedicated team liaising with clinical support. Studies of the potential influence as an extrinsic approach for interventions having a focus on CPRs. Psychosocial investigation of the value of extrinsic factors on healing and prevention of malnutrition and potential economic values in cost of treatment with respect to aspects of patient stay time and food wastage. Value to the mental health of the patients and to those caring as health professional, and families of patients. An extrinsic biomedical gastronomic approach, integrating the concepts of gastrophysics applied to altered eating, has the potential to enable a person to eat to live and hopefully enable them to live to eat by regaining pleasure and purpose in the eating process. Biomedical gastronomy can learn much from the hospitality profession. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.