Meeting the nutritional needs of elderly residents in aged-care: are we doing enough?

Food, nutrition and the dining experience in aged care settings: Findings of a nationwide survey

OBJECTIVE

Previous research on food, nutrition and dining practices in Australian residential aged care (RAC) homes has been based on a limited sample of single-home or multiple-home providers, but a nationwide study has not been conducted. The aim of this study was to provide a preliminary overview of current food, nutrition and dining practices across Australian RAC facilities using a nationwide survey.

METHODS

A survey was distributed to Australian RAC homes in August-September 2020, as part of the National Congress on Food, Nutrition and the Dining Experience in Aged Care (February 2021). The survey, administered via an online portal, consisted of 38 semistructured questions including yes/no or multiple-choice responses, free text, frequency scales and number entry. Six key topics were explored, including 'food service system and environment', 'catering style', 'menu planning and evaluation', 'nutrition planning and requirements', 'nutrition-related screening and assessment' and 'training and additional information', which were informed by the Australian Government Department of Health and reflected the interests of the Congress.

RESULTS

The final sample included 292 respondents (204 individual homes and 88 multiple-home proprietors) representing 1152 homes and 125,393 residents, encompassing approximately 43% of RAC homes (of a possible 2671) and 57% of residents (of a possible 219,965) in Australia. Survey respondents representing RAC homes included service managers, catering managers, Chief Executive Officers, cooks, chefs, dietitians or staff from other roles within homes. A number of potential areas of need were identified, included increasing the autonomy of residents to select the foods they desire, increasing the variety and choice (including timing) of meals, enhancing the dining environments in homes to stimulate food intake and increasing staff training and the number of trained chefs in homes, so that meals are prepared which address diverse nutritional needs of residents.

CONCLUSIONS

This study provides insight into the food service and mealtime practices of over a third of Australian RAC homes. The findings of this survey may help to identify key targets for intervention to improve the food, nutrition and quality of life of aged care residents.

Food provision in Australian aged care homes does not meet protein needs of residents: A call for reform

AIM

Malnutrition is common in older adults in aged care homes, partly due to inadequate protein intake. Menu planning guidelines are available however, adherence to guidelines is unknown. This study aimed to determine; (i) what are the average serving sizes of menu items provided and do they meet recommended portion sizes? (ii) does consumption from a 'typical' menu provide sufficient protein? and (iii) can substituting a 'typical' menu with high-protein options enable residents to achieve protein adequacy?

METHODS

This study involved 572 residents (73% female; aged 86.4 ± 7.3 years) from 60 aged-care homes in Australia involved in a 2-year cluster-randomised trial. During the trial, food intake was recorded quarterly using visual estimation of plate-waste and 42 061 foods analysed. As part of a secondary analysis of these data, portion sizes of foods were compared to guidelines by calculating the mean (95% confidence interval). Items were deemed inadequate if the upper 95% confidence interval remained below recommended portion sizes.

RESULTS

On average 47% of breakfast and 80% of lunch/dinner items were below recommended portion sizes. Relative protein intakes, from a typical menu (most consumed foods), was 0.9 g and 0.8 g/kg body weight/day for females and males; both below recommendations. Substituting regular items with higher protein equivalents increased protein intake to 1.3 g and 1.2 g/kg body weight/day, for females and males, respectively.

CONCLUSION

Aged care homes in Australia are not meeting menu planning guidelines resulting in insufficient protein being provided. Reform to menu guidelines including provision of high-protein foods, will ensure protein adequacy in older adults in aged-care homes.

Depression level, nutritional status, and dietary nutrient intake of the older adult at the community level in a selected area of Bangladesh

Malnutrition is associated with higher rates of morbidity and death in the older population. Depression or mental health is a major component of older adult malnutrition. The aim of the study was to measure the level of malnutrition and depression in older adults, as well as their correlated factors, such as dietary energy and nutrient consumption. A cross-sectional study was conducted among 108 older individuals living in two areas of Faridpur, Bangladesh. The Mini Nutritional Assessment-Short Form (MNA-SF), Geriatric Depression (GD) Scale, and 24-h dietary recall were used to measure the nutritional status, depression level, and dietary nutrients, respectively. A total of 20.4% and 55.6% were malnourished or at risk of malnutrition, respectively. Around 81.5% of the study subjects exhibited a different degree of depression and 9.3% were identified as having severe depression. There was a significant inverse association between the MNA-SF score and the GD score (r = -0.684, p=<0.001). The average energy and protein consumption was 1387 kcal and 45.52 g, respectively; and energy and protein intake were significantly lower in the depressed group (1353 Kcal, 43.8 g) than in the non-depressed group (1530 Kcal, 52.4 g). An extremely low energy consumption (<20 kcal/kg body weight/day) was noted in 27.1% of the older adults. None of the participants in this study were able to meet the requirements for dietary fiber, calcium, vitamin B6, folate, vitamin D, and vitamin E. Specific nutrition-related intervention programs as well as social and familial support are recommended to improve the nutritional status of older adults.

Can fortified, nutrient-dense and enriched foods and drink-based nutrition interventions increase energy and protein intake in residential aged care residents? A systematic review with meta-analyses

BACKGROUND

Food fortification as part of the food-first approach in nursing homes is a strategy that may increase energy and protein intake.

OBJECTIVES

This review aimed to determine the effect of nutrition interventions using fortification, nutrient-dense or enriched food and/or drinks on energy and protein intake in residents living in nursing homes, compared to the standard menu with or without oral nutritional support products. The secondary aim was to identify and synthesise outcomes of these interventions on weight change, nutritional status, acceptability, cost-effectiveness, and cost-benefit.

METHODS

A systematic search of seven databases was undertaken. After reviewing all titles/abstracts then full-text papers, key data were extracted and synthesised narratively and through meta-analysis. The quality of included studies was assessed using the Quality Criteria Checklist for Primary Research.

RESULTS

Of 3,098 articles retrieved, 16 were included, 13 in the meta-analysis. There were 891 participants, with the study duration ranging from four to 26 weeks. The groups receiving the fortified diet had a significantly higher energy intake (Hedges' g = 0.69 (CI 0.36-1.03), p < 0.0001) and protein intake (Hedges' g = 0.46 (CI 0.17-0.74), p = 0.003) compared with the groups receiving the standard menu +/- ONS. The meta-analysis revealed I² values of 77% for energy (p < 0.0001) and 60% for protein (p = 0.003), indicating considerable statistical heterogeneity across included studies. Benefits to weight and nutritional status of residents were recorded in some studies. Where reported, cost-effectiveness and cost-benefit of menu fortification/supplementation were variable.

CONCLUSIONS

This systematic review with meta-analyses has shown that fortified menus may significantly increase energy and protein intakes compared with standard menus in nursing homes. As such, the findings of this review support further use of fortified diets in this setting. Further research is warranted comparing food fortification to standard menus, with a particular focus on evaluating the effect on weight, nutritional status and cost-effectiveness of the intervention.

STUDY REGISTRATION

PROSPERO no. CRD42020162796.

Effect of dietary sources of calcium and protein on hip fractures and falls in older adults in residential care: cluster randomised controlled trial

OBJECTIVE

To assess the antifracture efficacy and safety of a nutritional intervention in institutionalised older adults replete in vitamin D but with mean intakes of 600 mg/day calcium and <1 g/kg body weight protein/day.

DESIGN

Two year cluster randomised controlled trial.

SETTING

60 accredited residential aged care facilities in Australia housing predominantly ambulant residents.

PARTICIPANTS

7195 permanent residents (4920 (68%) female; mean age 86.0 (SD 8.2) years).

INTERVENTION

Facilities were stratified by location and organisation, with 30 facilities randomised to provide residents with additional milk, yoghurt, and cheese that contained 562 (166) mg/day calcium and 12 (6) g/day protein achieving a total intake of 1142 (353) mg calcium/day and 69 (15) g/day protein (1.1 g/kg body weight). The 30 control facilities maintained their usual menus, with residents consuming 700 (247) mg/day calcium and 58 (14) g/day protein (0.9 g/kg body weight).

MAIN OUTCOME MEASURES

Group differences in incidence of fractures, falls, and all cause mortality.

RESULTS

Data from 27 intervention facilities and 29 control facilities were analysed. A total of 324 fractures (135 hip fractures), 4302 falls, and 1974 deaths were observed. The intervention was associated with risk reductions of 33% for all fractures (121 v 203; hazard ratio 0.67, 95% confidence interval 0.48 to 0.93; P=0.02), 46% for hip fractures (42 v 93; 0.54, 0.35 to 0.83; P=0.005), and 11% for falls (1879 v 2423; 0.89, 0.78 to 0.98; P=0.04). The risk reduction for hip fractures and falls achieved significance at five months (P=0.02) and three months (P=0.004), respectively. Mortality was unchanged (900 v 1074; hazard ratio 1.01, 0.43 to 3.08).

CONCLUSIONS

Improving calcium and protein intakes by using dairy foods is a readily accessible intervention that reduces the risk of falls and fractures commonly occurring in aged care residents.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000228785.

The effects of cardiovascular and orthopaedic surgery on vitamin concentrations: a narrative review of the literature and mechanisms of action

Given the rise in worldwide chronic diseases, supplemented by an aging population, the volume of global major surgeries, encompassing cardiac and orthopedic procedures is anticipated to surge significantly. Surgical trauma can be accompanied by numerous postoperative complications and metabolic changes. The present review summarized the results from studies assessing the effects of orthopedic and cardiovascular surgery on vitamin concentrations, in addition to exploring the possible mechanisms associated with changes in concentrations. Studies have revealed a potentially severe depletion in plasma/serum concentrations of numerous vitamins following these surgeries acutely. Vitamins C, D and B1 appear particularly vulnerable to significant depletions, with vitamin C and D depletions consistently transpiring into inadequate and deficient concentrations, respectively. The possible multifactorial mechanisms impacting postoperative vitamin concentrations include changes in hemodilution and vitamin utilization, redistribution, circulatory transport and absorption. For a majority of vitamins, there has been a lack of investigation into the effects of both, cardiac and orthopedic surgery. Additionally, studies were predominantly restricted to short-term postoperative investigations, primarily performed within the first postoperative week of surgery. Overall, results indicated that further examination is necessary to determine the severity and clinical significance of the possible depletions in vitamin concentrations that ensue cardiovascular and orthopedic surgery.

Factors associated with inflamm-aging in institutionalized older people

The increase in inflammatory cytokines associated with a reduction in the bioavailability of zinc has been used as a marker for inflammation. Despite the high inflammatory state found in institutionalized older individuals, few studies have proposed verifying the factors associated with this condition in this population. To verify the factors associated with inflamm-aging in institutionalized older people. A total of 178 older people (≥ 60 years old) living in nursing homes in Natal/RN were included in the study. Cluster analysis was used to identify three groups according to their inflammatory state. Analysis anthropometric, biochemical, sociodemographic, and health-related variables was carried out. In sequence, an ordinal logistic regression was performed for a confidence level of 95% in those variables with p < 0.20 in the bivariate analysis. IL-6, TNF-α, zinc, low-density lipids (LDL), high-density lipids (HDL), and triglycerides were associated with inflamm-aging. The increase of 1 unit of measurement of LDL, HDL, and triglycerides increased the chance of inflammation-aging by 1.5%, 4.1%, and 0.9%, respectively, while the oldest old (≥ 80 years old) had an 84.9% chance of presenting inflamm-aging in relation to non-long-lived older people (< 80 years). The association between biochemical markers and inflamm-aging demonstrates a relationship between endothelial injury and the inflammatory state. In addition, the presence of a greater amount of fat in the blood may present a higher relative risk of death.

Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.

Dietary Advice in Hemodialysis Patients: Impact of a Telehealth Approach During the COVID-19 Pandemic

Objective

The purpose of this study was to assess the effect of a telehealth-delivered nutritional intervention via telephone in maintenance hemodialysis (HD) patients during the coronavirus outbreak.

Methods

This was a multicenter, observational, prospective, and longitudinal study of 156 patients undergoing maintenance HD from 15 dialysis units conducted during the COVID-19 pandemic. We assigned patients to receive dietary counseling through a phone call, according to their biochemical and nutritional parameters. Dry weight, intradialytic weight gain percentage (%IDWG), body mass index, potassium, phosphorus, calcium, calcium/phosphorus product, normalized protein catabolic rate, albumin, and hemoglobin were recorded at baseline and 1 month after nutrition counseling.

Results

The prevalence of hyperkalemia and hyperphosphatemia decreased significantly after dietary advice. A statistically significant reduction in serum potassium and phosphorus levels was observed in patients receiving counseling for hyperkalemia and hyperphosphatemia. In addition, there was a statistically significant decrease in the prevalence of hypophosphatemia. We also observed a significant decrease in %IDWG, although no statistically significant differences were detected in patients with high %IDWG. The data demonstrated statistically significant differences in potassium and phosphorus values when the person receiving the phone contact was the patient or the caregiver. The main statistically significant differences in hypophosphatemia %IDWG were only observed when contact was made directly with the patient. No differences were observed when the contact was made through nursing homes.

Conclusion

Our results suggest that telehealth-delivered dietary interventions can improve the clinical and nutritional parameters of HD patients. Consequently, this strategy may be effective for promoting continuous nutritional monitoring in these patients, in particular when conducting a face-to-face option is not crucial.

Magnesium and Hypertension in Old Age

Hypertension is a complex condition in which various actors and mechanisms combine, resulting in cardiovascular and cerebrovascular complications that today represent the most frequent causes of mortality, morbidity, disability, and health expenses worldwide. In the last decades, there has been an exceptional amount of experimental, epidemiological, and clinical studies confirming a close relationship between magnesium deficit and high blood pressure. Multiple mechanisms may help to explain the bulk of evidence supporting a protective effect of magnesium against hypertension and its complications. Hypertension increases sharply with advancing age, hence older persons are those most affected by its negative consequences. They are also more frequently at risk of magnesium deficiency by multiple mechanisms, which may, at least in part, explain the higher frequency of hypertension and its long-term complications. The evidence for a favorable effect of magnesium on hypertension risk emphasizes the importance of broadly encouraging the intake of foods such as vegetables, nuts, whole cereals and legumes, optimal dietary sources of magnesium, avoiding processed food, which are very poor in magnesium and other fundamental nutrients, in order to prevent hypertension. In some cases, when diet is not enough to maintain an adequate magnesium status, magnesium supplementation may be of benefit and has been shown to be well tolerated.

Trace Mineral Intake and Deficiencies in Older Adults Living in the Community and Institutions: A Systematic Review

The global population is ageing with many older adults suffering from age-related malnutrition, including micronutrient deficiencies. Adequate nutrient intake is vital to enable older adults to continue living independently and delay their institutionalisation, as well as to prevent deterioration of health status in those living in institutions. This systematic review investigated the insufficiency of trace minerals in older adults living independently and in institutions. We examined 28 studies following a cross-sectional or cohort design, including 7203 older adults (≥60) living independently in 13 Western countries and 2036 living in institutions in seven Western countries. The estimated average requirement (EAR) cut-off point method was used to calculate percentage insufficiency for eight trace minerals using extracted mean and standard deviation values. Zinc deficiency was observed in 31% of community-based women and 49% of men. This was higher for those in institutional care (50% and 66%, respectively). Selenium intakes were similarly compromised with deficiency in 49% women and 37% men in the community and 44% women and 27% men in institutions. We additionally found significant proportions of both populations showing insufficiency for iron, iodine and copper. This paper identifies consistent nutritional insufficiency for selenium, zinc, iodine and copper in older adults.

Provincial Differences in Long-Term Care Menu Variety and Food Intake for Residents who Consume a Regular Texture

Purpose: To determine regular-texture menu variety offered in Canadian long-term care (LTC) homes and its association with residents' food intake. Methods: Twenty-nine LTC menus from Alberta, Manitoba, New Brunswick, and Ontario were analyzed. Items offered during the regular-texture menu cycle were categorized according to Eating Well with Canada's Food Guide food groups and variety scores were calculated per day and per week. Residents' food intake was assessed by weighing and observing intake over 3 nonconsecutive days. Diet quality was determined using a mean adequacy ratio score (MAR) for regular and soft and bite-sized consumers (n = 394). Results: Average daily and weekly menu variety scores were 24 ± 5.8 and 78 ± 17.2, respectively, with significantly higher scores in Ontario (29 ± 2.7 and 102 ± 11.7). Of all the food groups, only the variety score for the "Other" food category was positively associated with protein intake. No associations were observed between variety and energy intake or MAR score. Conclusion: This study is the first in Canada to assess LTC menu variety. Although there was variability between provinces in menu variety, this was not associated with resident diet quality or intake.

From menu to mouth: the decay pathway of nutrient intake from planned menu to consumed and characteristics of residents in an aged care facility with greater nutrient decay rates: a cross-sectional study

OBJECTIVES

To observe the cascade of nutrient loss from meals planned to those provided and subsequently consumed by older people in residential care. A secondary aim was to determine the characteristics of residents with higher nutrient loss resulting in lower intake of key nutrients.

DESIGN

A single-centre cross-sectional study.

SETTING

An aged residential care facility in Christchurch, New Zealand.

PARTICIPANTS

All low and high level of care residents except those who are end of life, enterally fed or on short-term stay were invited to participate in the study. 54 of 60 selected residents who consumed all three main meals (breakfast, lunch and dinner) for three non-consecutive days were included in the analyses.

MAIN OUTCOME MEASURES

Nutrient contents of planned menu; nutrient contents of meals served and consumed using modified 3-day diet records; and percentage of planned nutrients served and consumed.

RESULTS

Vitamins C, B12 and folate had the greatest total decay rates of 50% or more from that planned to be consumed to what was actually consumed, while unsaturated fats, beta carotene, iodine and zinc had the lowest decay rates of 25% or less. Male participants and lower care level residents consumed significantly more nutrients, compared with female participants and those receiving higher level care. Increased age, female gender, higher level of care, smaller meal size, pureed diet and lower body mass index were associated with larger decay rates and lower nutrient intakes.

CONCLUSIONS

Not all planned and served food and beverages are consumed, contributing to potential multiple nutrient deficiencies including energy and protein in the majority of aged-care residents. As a consequence, some nutrients may need to be oversupplied if consumption is to match planned intakes.

Can foodservices in aged care homes deliver sustainable food fortification strategies? A review

Food fortification is used as a nutrition support strategy in aged care homes, for residents who are malnourished or at risk of malnutrition. The aim of this review was to determine the scope and strength of published works exploring relationships between food fortification strategies, mode of delivery and sustainability in aged care homes. Literature from four databases and grey literature was searched. A total of 3152 articles were screened. Seventeen studies were included. Results showed that the majority of studies used pre-made food fortification, rather than fortifying foods on-site. There was heterogeneity across studies, including the mode of delivery and ingredients used for food fortification. Only two studies measured any aspect of costs. No clear sustainable strategies for implementing food fortification in this setting could be identified. Research is required to provide further insight into the acceptability and sustainability of food fortification interventions.

Plasma Vitamin C Concentrations and Cognitive Function: A Cross-Sectional Study

Vitamin-C is a water soluble molecule that humans have lost the ability to produce. Vitamin-C plays a role in CNS functions such as neuronal differentiation, maturation, myelin formation and modulation of the catecholaminergic systems. A recent systematic review by our team indicated the need for further research into the relationship between plasma vitamin C and cognition in cognitively intact participants using plasma vitamin C concentrations instead of estimates derived from food-frequency-questionnaires (FFQ), and more sensitive cognitive assessments suitable for cognitive abilities vulnerable to aging. It was hypothesized that higher plasma vitamin C concentrations would be linked with higher cognitive performance. This cross-sectional trial was conducted on healthy adults (n = 80, Female = 52, Male = 28, 24-96 years) with a range of plasma Vitamin C concentrations. Cognitive assessments included The Swinburne-University-Computerized-Cognitive-Assessment-Battery (SUCCAB) and two pen and paper tests, the Symbol-Digits-Modalities-Test (SDMT) and Hopkins-Verbal-Learning-Test-Revised (HVLT-R). The pen and paper assessments were conducted to establish whether their scores would correlate with the computerized tasks. Plasma-Vitamin C concentrations were measured using two biochemical analyses. Participants were grouped into those with plasma vitamin-C concentrations of adequate level (≥28 μmol/L) and deficient level (<28 μmol/L). The SUCCAB identified a significantly higher performance ratio (accuracy/reaction-time) in the group with adequate vitamin-C levels vs. deficient vitamin-C on the choice reaction time (M = 188 ± 4 vs. 167 ± 9, p = 0.039), immediate recognition memory (M = 81 ± 3 vs. 68 ± 6, p = 0.03), congruent Stroop (M = 134 ± 3 vs. 116 ± 7, p = 0.024), and delayed recognition tasks (M = 72 ± 2 vs. 62 ± 4, p = 0.049), after adjusting for age (p < 0.05). Significantly higher scores in immediate recall on the HVLT-R (M = 10.64 ± 0.16 vs. 9.17 ± 0.37, p = 0.001), delayed recall (M = 9.74 ± 0.22 vs. 7.64 ± 0.51, p < 0.001), total recall (M = 27.93 ± 0.48 vs. 24.19 ± 1.11, p = 0.003) were shown in participants with adequate plasma Vitamin-C concentrations, after adjusting for vitamin-C supplementation dose (p < 0.05). Similarly, higher SDMT scores were observed in participants with adequate plasma Vitamin-C concentrations (M = 49.73 ± 10.34 vs. 41.38 ± 5.06, p = 0.039), after adjusting for age (p < 0.05). In conclusion there was a significant association between vitamin-C plasma concentrations and performance on tasks involving attention, focus, working memory, decision speed, delayed and total recall, and recognition. Plasma vitamin C concentrations obtained through vitamin C supplementation did not affect cognitive performance differently to adequate concentrations obtained through dietary intake. Clinicaltrials.gov Unique Identifier: ACTRN 12615001140549, URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369440.

Fat from dairy foods and 'meat' consumed within recommended levels is associated with favourable serum cholesterol levels in institutionalised older adults

CVD is common in older adults. Consumption of ‘meat’ (beef, pork, lamb, game, poultry, seafood, eggs) and dairy foods (milk, cheese, yoghurt) is encouraged in older adults as these foods provide protein and nutrients such as essential fatty acids, Ca, Fe, Zn and vitamins A, D and B₁₂ required for healthy ageing. However, these foods also contain saturated fats considered detrimental to cardiovascular health. To determine the effect of their consumption on CVD risk we assessed associations between fat intake from ‘meat’ and dairy foods and serum cholesterol levels in 226 aged-care residents (mean age 85·5 years, 70 % female). Dietary intake was determined over 2 d using visual estimation of plate waste. Fat content of foods was determined using nutrition analysis software (Xyris, Australia). Fasting serum total cholesterol (TC), LDL-cholesterol and HDL-cholesterol were measured, and the TC:HDL-cholesterol ratio calculated. Associations were determined using random-effect models adjusted for CVD risk factors using STATA/IC 13.0. Total fat and saturated fat from ‘meat’ and dairy foods were associated with higher serum HDL-cholesterol levels, and dairy fat intake and number of servings were associated with a lower TC:HDL-cholesterol ratio. Every 10 g higher intake of fat and saturated fat from dairy products, and each additional serving was associated with a −0·375 (95 % CI −0·574, −0·175; P = 0·0002), a −0·525 (95 % CI −0·834, −0·213; P = 0·001) and a −0·245 (95 % CI −0·458, −0·033; P = 0·024) lower TC:HDL-cholesterol ratio, respectively. Provision of dairy foods and ‘meat’ in recommended amounts to institutionalised older adults potentially improves intakes of key nutrients with limited detriment to cardiovascular health.

Dietary Intake and Associated Factors in Long-Term Care Homes in Southeast Spain

Diet is a key modifiable factor in the management of malnutrition and age-related diseases such as sarcopenia, an important issue in long-term care homes. The objectives of this study were to evaluate the dietary intake of residents, define dietary patterns, and analyze their association with sex, diet texture, nutritional status, and the presence of sarcopenia. Intake was assessed by the precise weighing method, dietary patterns were defined a posteriori by cluster analysis, and nutritional status and sarcopenia were evaluated by applying the MNA-SF test and EWGSOP algorithm, respectively. A regular diet was consumed by 63% of participants; 56% were at risk of malnutrition and 63% were diagnosed with sarcopenia. Intake of potassium, magnesium, zinc, iodine, vitamin D, E, folic acid, and fiber was low in >80% of participants. Protein intake was <1 g/kg/day in 56% of participants and <25 g/meal in 100%. Two dietary patterns were identified, but neither fully met recommendations. The risk of a poorer diet was higher in females and residents with sarcopenia and was lower in those consuming regular diets. In conclusion, action is required to improve the inadequate nutritional intake of long-term care residents.

Engaging food service providers to change food service practices in aged care facilities

AIM

The present study describes the impact of a novel education program for food service staff from Australian aged care facilities (ACF) to facilitate improvements in food service practices. The purpose was to explore; (i) the impact of the intervention (ii) barriers and facilitators of the program from food service providers' perspectives and (iii) make program planning and practice recommendations.

METHODS

Participants completed pre- and post-program questionnaires, attended two focus groups on program process and impact and 4 months later reported through individual interviews on changes they had implemented. Results were triangulated between the questionnaires, focus groups and interviews and impacts and outcomes identified through directed content analysis.

RESULTS

Thirty senior-level chefs and a cook participated from 27 ACF from Victoria, Australia. Participation impacted on the menu, dining experiences and food service practices. All of the participants were enacting changes in their workplace 4 months later as change agents. A focus on skilling the participants as 'change agents', brokering ongoing peer-support and the celebrity and/or expert status of the facilitators were attributed to the success of the intervention.

CONCLUSIONS

This novel intervention empowered Victorian food service providers to make positive changes in ACF. Further research is required to measure if these self-reported changes are sustainable and relevant to other facilities and to establish the effect on food experience, satisfaction and well-being of residents.

Prevalence of inadequate micronutrient intakes of Canadian long-term care residents

This study determines the prevalence of inadequate micronutrient intakes consumed by long-term care (LTC) residents. This cross-sectional study was completed in thirty-two LTC homes in four Canadian provinces. Weighed and estimated food and beverage intake were collected over 3 non-consecutive days from 632 randomly selected residents. Nutrient intakes were adjusted for intra-individual variation and compared with the Dietary Reference Intakes. Proportion of participants, stratified by sex and use of modified (MTF) or regular texture foods, with intakes below the Estimated Average Requirement (EAR) or Adequate Intake (AI), were identified. Numbers of participants that met these adequacy values with use of micronutrient supplements was determined. Mean age of males (n 197) was 85·2 (sd 7·6) years and females (n 435) was 87·4 (sd 7·8) years. In all, 33 % consumed MTF; 78·2 % (males) and 76·1 % (females) took at least one micronutrient pill. Participants on a MTF had lower intake for some nutrients (males=4; females=8), but also consumed a few nutrients in larger amounts than regular texture consumers (males=4; females =1). More than 50 % of participants in both sexes and texture groups consumed inadequate amounts of folate, vitamins B6, Ca, Mg and Zn (males only), with >90 % consuming amounts below the EAR/AI for vitamin D, E, K, Mg (males only) and K. Vitamin D supplements resolved inadequate intakes for 50-70 % of participants. High proportions of LTC residents have intakes for nine of twenty nutrients examined below the EAR or AI. Strategies to improve intake specific to these nutrients are needed.

An Even Distribution of Protein Intake Daily Promotes Protein Adequacy but Does Not Influence Nutritional Status in Institutionalized Elderly

OBJECTIVE

Although it has been established that sufficient protein is required to maintain good nutritional status and support healthy aging, it is not clear if the pattern of protein consumption may also influence nutritional status, especially in institutionalized elderly who are at risk of malnutrition. Therefore, we aim to determine the association between protein intake distribution and nutritional status in institutionalized elderly people.

DESIGN

Cross-sectional study among 481 institutionalized older adults.

METHODS

Dietary data from 481 ambulant elderly people (68.8% female, mean age 87.5 ± 6.3 years) residing in 52 aged-care facilities in Victoria, Australia, were assessed over 2 days using plate waste analysis. Nutritional status was determined using the Mini-Nutritional Assessment tool and serum (n = 208) analyzed for albumin, hemoglobin, and IGF-1. Protein intake distribution was classified as: spread (even distribution across 3 meals, n = 65), pulse (most protein consumed in one meal, n = 72) or intermediate (n = 344). Regression analysis was used to investigate associations.

RESULTS

Mean protein intakes were higher in the spread (60.5 ± 2.0 g/d) than intermediate group (56.0 ± 0.8 g/d, P = .037), and tended to be higher than those in the pulse group (55.9 ± 1.9 g/d, P = .097). Residents with an even distribution of protein intake achieved a higher level of the recommended daily intake for protein (96.2 ± 30.0%) than the intermediate (86.3 ± 26.2%, P = .008) and pulse (87.4 ± 30.5%, P = .06) groups, and also achieved a greater level of their estimated energy requirements (intermediate; P = .039, pulse; P = .001). Nutritional status (Mini-Nutritional Assessment score) did not differ between groups (pulse; 20.5 ± 4.5, intermediate; 21.0 ± 2.5, spread; 20.5 ± 3.5), nor did any other indices of nutritional status.

CONCLUSIONS

Meeting protein requirements is required before protein distribution may influence nutritional status in institutionalized elderly. Achieving adequate protein and energy intakes is more likely when protein is distributed evenly throughout the day. Provision of high protein foods especially at breakfast, and in the evening, may support protein adequacy and healthy aging, especially for institutionalized elderly.

Commercial Mineral Enhanced Dairy By-Products as Sodium Replacers, Antioxidants and Calcium Fortifiers in Sausages

Sausages are perceived as high in Na and with a too high Na:K ratio. Frankfurter type sausages are regarded as important contributors of sodium in the diet and thereby of health risks. Surplus products from the dairy industry are various mineral powders enriched in either potassium, calcium, or phosphate and include various amounts of lactose. Sausages were produced at 3 sodium levels (equivalent to 13, 15, and 17 g NaCl/kg sausage) using 4 different milk ingredients (a dried skimmed milk powder, a calcium enriched milk powder, a potassium enriched powder, and a lactose enriched powder). The sausages with added calcium and potassium enriched milk powders resulted in the hardest sausages when compared at the same sodium level. Milk mineral addition also produced whiter and less red sausages. No effect on rancidity after 6 wk at chill (4 °C) storage was observed by adding milk minerals, when compared with adding dried skimmed milk powder. A significant advantage of using these milk minerals in sausages is that the Na:K ratio can be reduced from an unhealthy (in this study 36) to a far healthier ratio ( ̴ 2) with limited or no taste changes. High additions of milk calcium (6 g/kg), where Ca-phosphates prevail, added as milk mineral, had no influence on sensory bitterness or aftertaste as typically observed for CaCl₂ additions. Ca additions to sausages are presently presumed to be an advantage with respect to human nutrition.

Dairy food supplementation may reduce malnutrition risk in institutionalised elderly

Malnutrition in institutionalised elderly increases morbidity and care costs. Meat and dairy foods are high-quality protein sources so adequate intakes may reduce malnutrition risk. We aimed to determine whether inadequate intakes of meat and dairy foods contribute to malnutrition in institutionalised elderly. This cross-sectional study involved 215 elderly residents (70·2 % females, mean age 85·8 years) from twenty-one aged-care facilities in Melbourne, Australia. Dietary intake was assessed using observed plate waste. Food groups and serving sizes were based on the Australian Guide to Healthy Eating. Nutrient content was analysed using a computerised nutrient analysis software (Xyris). Malnutrition risk was assessed using the Mini Nutrition Assessment (MNA) tool; a score between 24 and 30 indicates normal nutritional status. Data were analysed using robust regression. Mean MNA score was 21·6 (sd 2·7). In total, 68 % of residents were malnourished or at risk of malnutrition (MNA score≤23·5). Protein intake was 87 (sd 28) % of the Australian recommended dietary intake (RDI). Consumption averaged 1 serving each of dairy foods and meat daily. Number of dairy and meat servings related to proportion of protein RDI (both P<0·001), with the former contributing 13 % and the latter 12 % to protein RDI. Number of dairy servings (P<0·001), but not meat servings increased MNA score; each dairy serving was associated with a 1 point increase in MNA score so based on current intakes, on average if residents consumed the recommend four dairy servings (addition of 3 points to MNA score) they would achieve normal nutrition status (>24 points). Provision of meat and dairy foods did not meet recommended levels. On the basis of current dietary intakes in aged-care residents, increasing consumption of dairy foods to the recommended four servings daily ensures protein adequacy and may reduce malnutrition risk in institutionalised elderly, and so reduce risk of comorbidities and costs associated with malnutrition.

Novel insights on nutrient management of sarcopenia in elderly

Sarcopenia is defined as a syndrome characterized by progressive and generalized loss of muscle mass and strength. The more rationale approach to delay the progression of sarcopenia is based on the combination of proper nutrition, possibly associated with the use of dietary supplements and a regular exercise program. We performed a narrative literature review to evaluate the till-now evidence regarding (1) the metabolic and nutritional correlates of sarcopenia; (2) the optimum diet therapy for the treatment of these abnormalities. This review included 67 eligible studies. In addition to the well recognized link between adequate intake of proteins/amino acids and sarcopenia, the recent literature underlines that in sarcopenic elderly subjects there is an unbalance in vitamin D synthesis and in omega-6/omega-3 PUFA ratio. Given the detrimental effect of these metabolic abnormalities, a change in the lifestyle must be the cornerstone in the treatment of sarcopenia. The optimum diet therapy for the sarcopenia treatment must aim at achieving specific metabolic goals, which must be reached through accession of the elderly to specific personalized dietary program aimed at achieving and/or maintaining muscle mass; increasing their intake of fish (4 times/week) or taking omega-3 PUFA supplements; taking vitamin D supplementation, if there are low serum levels.

Food security: who is being excluded? A case of older people with dementia in long-term care homes

OBJECTIVES

PURPOSE

To explore the extent of food security among older people, particularly those with cognitive impairments residing in Canadian long-term care homes (LTCHs) through a focused review of literature.

METHOD

Databases including Medline, Nursing and Health Sciences (SAGE), Psych Info, Social Sciences Abstract, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and HealthSTAR were searched for peer-reviewed articles related to food experiences of older individuals in industrialized countries including Canada. Only articles that were published in English between 1997-2012 were included.

RESULTS

Sixty two studies met the inclusion criteria. Of those 17 focused on older adults in LTCHs. The review found that food security has rarely been examined among older persons living in LTCHs, and has never been examined within the context of cognitive impairment. While a few studies have focused on residents' satisfaction with foods that are provided to them in LTCHs, none have explored the extent of food security in this population. Furthermore, food satisfaction surveys in the LTCH are limited to the assessment of foods that are served to residents, and do not capture residents' food accessibility beyond the food dispensing routines of the organization. Thus, food quality, food preferences, and the traditional meanings and rituals associated with food consumption are not purposefully evaluated. In addition, LTCHs are not required to monitor residents' food satisfaction using a consistent, regular, and standardized approach and there is no regulation in the LTCH Act that requires LTCHs to assess their residents' food security.

CONCLUSIONS

The findings highlight the need for: 1) expansion of food security research to non-community-based settings including LTCHs; 2) re-conceptualization of food security and modification of measurement tools to assess the extent and determinants of food security among older adults in LTCHs; 3) mandatory monitoring of food security via standardized and regular surveys tailored to meet the unique preferences and needs of the older population, particularly those with dementia; and 4) education of healthcare professionals regarding food security and its assessment in LTCHs.