Aged care nutrition: most vulnerable are also least well fed

WHEN you sit down to dinner tonight, what would you prefer: a delicious, aromatic and nutritiously balanced meal? Or a supplement?

If it is the meal, then don’t prescribe supplements to your patients. That default “magic bullet” nutrition supplement prescribed as a standalone treatment for unintentional weight loss is not solving the problem – it hasn’t been for years.

While aged care food budgets continue to dwindle ($6.08 per resident per day is the current national average spend – which is down 31c per day over the past year), the supplement budget is increasing (50c increase per resident per day in the past year). In addition to this trend, we are also seeing poor outcomes in terms of nutritional status with our elderly residents. More than half of the aged care resident population in Australia is malnourished, a shocking figure that seemingly hasn’t sparked enough attention, considering figures have remained this bad for over two decades. Research has demonstrated that low food budgets increase the odds of malnutrition in people in aged care by 66% and place significant economic burden on the health system; nevertheless, we continue down the reduced food budget path.

It’s clearly time to rethink how we manage malnutrition in the elderly. The Lantern Project Australia is a national collaboration designed specifically for just that – and we welcome doctors to join the conversation.

Lantern research has found that a food first approach effectively treats malnutrition and may offer cost savings. The key is supporting aged care homes to prioritise food as a foundation of care before considering supplement prescription. Too often, with budget restraints, this focus has been diminished, often resulting in less fresh foods on the menu, understaffed dining rooms and underqualified staff. With no wiggle room in the budget to make a difference, less than appealing meals and menus and less than optimal dietary intake can result.

A retired English schoolmaster residing at an aged care home said this of his small bowl of tinned spaghetti for dinner a few weeks back: “This place reminds me of something between Oliver … ‘Can I have some more please?’… and George Orwell’s Animal Farm, a place ruled by tyrannous leaders with many citizens dying as a result”.

How do we advocate a food first approach in aged care for our aged care residents nationwide? It starts with visiting physicians. By only ordering supplements, physicians are treating a problem without addressing the underlying food supply cause. Food is fundamental and food budgets have a direct impact on malnutrition risk. We need doctors’ support to help change the accepted food culture and the unacceptably low food budgets in aged care. In developed countries, increased total spend on food is associated with more nutritious dietary patterns (here and here).

Let’s put it in perspective – would you take the challenge and eat all meals next month at your local aged care home? Would you be happy to send your mum or dad there for the rest of their lives? Would you be happy, if mum and dad refused the meals on account of poor quality, to just give them a nutrition supplement with no discussion around actually organising foods that may tempt them and provide enjoyment? Would you like this to be you when you reach this stage of life?

Food is more than just a meal to residents. It’s the catalyst for conversations, triggers memories that can be enjoyed and impacts quality of life, and in addition, it should provide adequate nourishment. Supplements can’t replace the pivotal role food plays in our daily routine; however, more often than not, supplements are the default option provided when the aged care meal service isn’t enjoyed. Supplements can be the excuse – the “get out of jail free card” if you will – for aged care homes not to strive for an amazing meal service. A doctor’s prescription masks a sick underlying food system and it’s time to challenge this.

Dietitians can certainly help physicians make inroads using food first strategies; however, we have little impact if we are not part of the team. The doctor’s role in supporting food-based strategies over supplements via their decision to refer to allied health (ie, dietitian, exercise physiologist and physiotherapist) can be the much needed catalyst for change.

While there are some great aged care homes out there doing wonders with their meals and showcasing them through the Lantern Project, unfortunately, they are not yet the Australian norm.

Interventions that simply fortify existing standard resident meals with energy and protein may help prevent malnutrition, but a multitiered approach is more effective. Residents may not be eating enough for a myriad of reasons including lack of flavoursome meals, poor meal presentation (as in unshaped pureed foods), unfamiliar foods, culturally inappropriate foods, poor dentition and inadequate mealtime assistance when required. Care with the dining experience, including meal presentation, flavour, company at the table and acoustics can be integral. Even the healthiest meal presented is not nutritious unless it is actually eaten.

So, simply fortifying food is not enough. Emerging research shows that “environmental” interventions that improve the meal ambiance and delivery method, enhance choice over meals and promote overall diet liberalisation may significantly improve dietary intake. A Dutch randomised controlled trial found that by simply serving meals “family style”, there was a statistically and clinically significant improvement in global nutrition status. Our recent Lantern Nourish Study has demonstrated that food first strategies along with staff nutrition training improve dietary intake, malnutrition ratings and quality of life while offering a significant saving on supplement costs. Other successful strategies to improve meal ambiance are restaurant style seating and involving residents in the growing and preparation of meals.

Our research is also exploring the cost benefits of various nutrition interventions to help prove that for every dollar spent on the meal and dining experience, more can be saved in terms of malnutrition-related health outcomes, such as reduced wounds and pressure injuries, falls and hospital readmissions.

So, there are currently two main options for treating malnutrition in the aged care home: continue to order oral nutrition supplements without considering the dining experience (and see supplement budgets increase and encourage food budgets to drop below $6 a day), or ask for food first strategies and refer to your allied health team to provide strategies that have longer term benefits with malnutrition, savings in malnutrition-related health costs and most importantly, happier residents.

Cherie Hugo is an accredited practicing dietitian and director of My Nutrition Clinic. She is a founding member of the Lantern Project.

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