Issue 44 / 14 November 2016

YOU have to admit that, at first glance, it seems oxymoronic and quite ridiculous that in spite of 50 years of research, advocacy and the implementation of nutrition standards, the prevalence of malnutrition in residential aged care (RAC) is still at 50% in Australia.

What have we done wrong?

Despite being provided with “adequate meals”, residents are still becoming malnourished. And when that happens, they are usually given standardised oral nutritional supplements.

What does the evidence say about this approach? In early 2016, my colleagues and I had the same question, so we conducted a review of the literature.

Are supplements the answer?

Yes, supplements can be one method to improve the nutrition status of residents who are malnourished. But, if supplements are used to help treat residents who are already malnourished, they are going to do nothing at all to stop residents from becoming malnourished in the first place. In addition, outside of the research setting, residents get tired of supplements quickly.

If we rely on supplements as a Band-Aid treatment for residents, malnutrition in RAC will stay on the same trajectory it has been on for the past few decades. Residents will continue to become malnourished at alarming rates.

The good news

Supplements are not the only solution. We found research showing that a “fortified” and “food first” approach can be used to treat malnutrition. In addition, it can also be used prophylactically to prevent residents from becoming malnourished in the first place.

But this food-first approach isn’t as easy as adding extra protein and energy into existing meals. Research shows that unless the quality of the meals and dining experience is improved, food fortification won’t make much difference.

Why is food fortification not enough?

A quote from a recent qualitative study read:

“I’d rather die than go into aged care. You can’t walk into one of those places without wanting to vomit. The quality of the food is disgusting. One of the very last pleasures in life is something nice to eat and you’re served up slop.”

Studies in our review found that residents simply don’t eat enough of most RAC standard food to treat malnutrition because, as the quote above suggests, the food in most Australian RAC facilities is … not awesome. If a meal smells like nothing (or worse) and looks like “slop”, simply adding some protein into it is not going to encourage the resident to eat enough protein, as they can only tolerate two mouthfuls.

Emerging research shows that “environmental” interventions which improve the meal ambiance and delivery method, enhance choice over meals and, overall, liberalise diet can significantly improve dietary intake. A Dutch randomised control trial found that by simply serving meals “family style”, there was a statistically and clinically significant improvement in global nutrition status. Other successful strategies to improve meal ambiance are restaurant style dining and involving residents in the growing and preparation of meals.

There is likely to be increasing research in this area thanks to organisations such as the Lantern Project and the Maggie Beer Foundation, which have been advocating for respecting the dignity of our elders by vastly improving the quality of meals and the meal environment in RAC.

Until there are strong studies demonstrating the cost-effectiveness of this approach, there won’t be a major shift in Australian RAC facilities. My team and I are currently conducting a systematic review and meta-analysis, which we are hoping to publish soon.

Implications for RAC, medical and allied health professionals

If nutrition policies and strategies want to decrease both the incidence and prevalence of malnutrition in RAC, there is only one option – we must respect older Australians and provide them with high quality nutrient rich food that meets their psychological, social and environmental needs.

If medical and allied health professionals advocate for high quality meals, appropriate food choices and a dining experience that you would create for your own grandmother, we may see, for the first time, the incidence of malnutrition going down in RAC.

Dr Skye Marshall, an Accredited Practising Dietitian, is a teaching fellow at Bond University on the Gold Coast, Queensland. Her early career as a clinical dietitian in the Northern Rivers, NSW, inspired her doctoral and post-doctoral research to build evidence for the role of dietitians to support happy and healthy ageing.


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I don't visit patients in residential aged care facilities because:
  • All of the above (67%, 30 Votes)
  • There is inadequate financial incentive to do so (24%, 11 Votes)
  • It's too hard to find staff and patients (4%, 2 Votes)
  • It takes too much time away from my walk-in patients (2%, 1 Votes)
  • It's too difficult to get a comprehensive patient history (2%, 1 Votes)

Total Voters: 45

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5 thoughts on “No food is nutritious unless it is eaten

  1. Anonymous says:

    A similar pattern occurred as in the comment above, it is very sad to see one’s mother slowly slipping away malnourished and dehydrated. It was understood that feeding was a problem as there are never enough staff to assist, but there could well be volunteer programs set up or at least a roster system where one good meal a day could be enjoyed.

  2. Anonymous says:

    I couldn’t agree more with Sue and Rosemary. In a supposedly excellent facility, we watched our mother diminish into a skeleton because she so disliked thickened ‘slops’, which we discovered were blended from the previous day’s leftovers. They were served in large drab coloured mounds and sat in salty, brown gravy. The visual appearance was enough to put anyone off eating. Her once much enjoyed tea was also thickened beyond having any taste. Every time this diet was discussed, we were tacitly threatened by staff who asked if we wanted our mother to choke to death. What are the statistics for death from aspiration in nursing homes?

  3. Dr Rosemary Stanton says:


    I totally agree that if someone of advanced years wants more fat or sugar or salt added to foods that are basically nutritious, surely that should be their right.Note too that the Australian Dietary Guidelines state (page 2) that they do not apply to frail elderly people.

  4. Sue Ieraci says:

    Thanks for a very relevant article. Apart from the mastication and safe-swallowing aspects that limit the palatability and texture of foods that are offered to the frail elderly, we also seem to assume that the preventive principles of moderating salt, sugar and fat should continue to operate towards the end of life. We should all do our best to maintain healthy lifestyles to get us into our nineties, but, once we get there, why not live our last few years enjoying the foods that we like best? If that means eating more fat or sugar, so long as we are getting all our nutrients and fibre, why no do so.

    In my view, the ability to accept risk on one’s own behalf is a key part of human dignity. If the cost of preventing aspiration is “thinkened fluids” for the rest of one’s life, many of us would choose a shorter life. Seeing those sealed containers of “thickened water” can only invoke a horror of potential things to come.

  5. Anne Malatt says:

    Great article, Skye, it’s not rocket science…if the food looks and tastes disgusting, no-one will want to eat it. It would be a lot cheaper in the long run to provide good quality food than to implement all the bandaid measures that have been attempted. Not to mention the fact that our elderly deserve and enjoy a good meal just as much as the rest of us!

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