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THE UNIVERSITY OF COPENHAGEN

Gourmet

Good, Nutritious Meals for All

Older People

Whitepaper on providing

nutritious, high-quality meals

for older people

January 2015

Table of contents

FOREWORD ...................................................................................................................... 11

1. INTRODUCTION ....................................................................................................... 13

2. METHODOLOGY AND READING GUIDE .............................................................. 15

2.1. Methodology ............................................................................................................ 16

2.2. Links to other initiatives ........................................................................................... 16

2.3. Scope ........................................................................................................................ 16

2.4 Concepts .................................................................................................................... 17

2.5 References ................................................................................................................. 18

3. BACKGROUND ......................................................................................................... 19

3.1 PHYSIOLOGICAL FACTORS AFFECTING FOOD INTAKE, NUTRITIONAL

STATUS, PHYSICAL FUNCTION AND QUALITY OF LIFE ...................................... 19

3.1.1 Appetite regulation and intestinal function .......................................................... 20

3.1.2 Changes in large intestine and intestinal flora ...................................................... 20

3.1.3 Sight and dental health ........................................................................................ 20

3.1.4 Cognitive function .............................................................................................. 21

3.1.5 Chronic diseases ................................................................................................. 21

3.1.6 Dietary recommendations for frail older people with low appetites ..................... 21

3.1.7 Macronutrients .................................................................................................... 21

3.1.8 Micronutrients .................................................................................................... 22

3.1.9 References .......................................................................................................... 23

3.2 NUTRITIONAL STATUS OF OLDER PEOPLE IN HOME CARE, NURSING

HOMES AND HOSPITALS ........................................................................................... 25

In home care ............................................................................................................ 26

In nursing homes ..................................................................................................... 27

In hospitals .............................................................................................................. 28

Summary ................................................................................................................. 29

3.2.1 Proportion of older people and the extent of public meal services for the older .... 29

3.2.2 References .......................................................................................................... 32

4. MEAL QUALITY ....................................................................................................... 34

4.1 RECOMMENDATIONS FOR FOOD AND LIQUIDS FOR OLDER PEOPLE IN

NURSING HOMES, HOME CARE AND HOSPITALS ................................................. 34

4.1.1 Normal menu ...................................................................................................... 34

4.1.2 Menu for older people with low appetites ............................................................ 34

4.1.3 Food that is easy to chew and swallow ................................................................ 35

4.1.4 Diet ..................................................................................................................... 35

4.1.5 Specifically for nursing homes ............................................................................ 35

4.1.6 Specifically for delivery meal services ................................................................ 36

4.1.7 References .......................................................................................................... 36

4.2 SENSORY CHANGES AND TASTE PREFERENCES ............................................ 37

4.2.1 Why it is important ............................................................................................. 37

4.2.2 Sensory changes .................................................................................................. 37

4.2.3 Food preferences and desire to eat ....................................................................... 39

4.2.4 Official Danish Recommendations……………………………………………….40

4.2.5 Barriers ............................................................................................................... 40

4.2.6 Areas where more research is needed .................................................................. 41

4.2.7 Next steps ........................................................................................................... 41

4.2.8 References .......................................................................................................... 42

4.3 DIETS FOR OLDER PEOPLE IN NURSING HOMES, HOME CARE AND

HOSPITALS ................................................................................................................... 43

4.3.1 Why it is important ............................................................................................. 43

4.3.2 Use of disease-specific diets ................................................................................ 43

In nursing homes and home care .............................................................................. 43

In hospitals .............................................................................................................. 43

4.3.3 Dietary interventions ........................................................................................... 43

In nursing homes ..................................................................................................... 43

In home care ............................................................................................................ 44

In hospitals .............................................................................................................. 44

4.3.4 Official Danish recommendations ....................................................................... 44

4.3.6 Areas where more research is needed .................................................................. 45

4.3.7 Next steps ........................................................................................................... 45

4.3.8 References .......................................................................................................... 45

5. MEAL ACCESS .......................................................................................................... 46

5.1 EATING ASSISTANCE IN NURSING HOMES, HOME CARE AND HOSPITALS

........................................................................................................................................ 46

5.1.1 Why it is important ............................................................................................. 46

5.1.2 The importance of eating assistance to ensure intake of food and liquid .............. 46

In nursing homes and home care .............................................................................. 46

In hospitals .............................................................................................................. 47

5.1.3 Interventions regarding eating assistance ............................................................. 47

In nursing homes ..................................................................................................... 47

In home care ............................................................................................................ 47

In hospitals .............................................................................................................. 47

5.1.4 Official Danish recommendations ....................................................................... 48

5.1.5 Barriers ............................................................................................................... 48

5.1.6 Areas where more research is needed .................................................................. 48

5.1.7 Next steps ........................................................................................................... 49

5.1.8 References .......................................................................................................... 49

5.2 DYSPHAGIA IN OLDER PEOPLE IN HOME CARE, NURSING HOMES AND

HOSPITALS ................................................................................................................... 50

5.2.1 Why it is important ............................................................................................. 50

5.2.2 The significance of dysphagia to the intake of food and liquids ........................... 50

All three settings ...................................................................................................... 50

In nursing homes and home care .............................................................................. 50

In hospitals .............................................................................................................. 51

5.2.3 Interventions regarding dysphagia and the intake of food and liquids .................. 51

In nursing homes ..................................................................................................... 51

In home care and hospitals ....................................................................................... 52

5.2.4 Good examples ................................................................................................... 52

5.2.5 Official Danish recommendations ....................................................................... 53

5.2.6 Barriers ............................................................................................................... 53

5.2.7 Areas where more research is needed .................................................................. 54

5.2.8 Next steps ........................................................................................................... 54

5.2.9 References .......................................................................................................... 54

5.3 CHEWING PROBLEMS IN OLDER PEOPLE IN HOME CARE, NURSING

HOMES AND HOSPITALS ........................................................................................... 56

5.3.1 Why it is important ............................................................................................. 56

5.3.2 The importance of chewing problems to the intake of food and liquids ................ 56

In nursing homes and home care .............................................................................. 56

In hospitals .............................................................................................................. 57

5.3.3 Interventions regarding poor dental health and intake of food and liquids ............ 57

All three settings ...................................................................................................... 57

In nursing homes ..................................................................................................... 57

In home care and hospitals ....................................................................................... 57

5.3.4 Official Danish Recommendations………………………………………………..57

5.3.5 Barriers ............................................................................................................... 58

5.3.6 Areas where more research is needed .................................................................. 58

5.3.7 Next steps ........................................................................................................... 58

5.3.8 References .......................................................................................................... 58

6. MEALTIME EXPERIENCE ....................................................................................... 60

6.1 REDUCED APPETITE AND INTAKE OF FOOD AND LIQUIDS IN OLDER

PEOPLE IN NURSING HOMES AND HOME CARE ................................................... 60

6.1.1 Why it is important ............................................................................................. 60

6.1.2 Knowledge about intake of food and liquids ........................................................ 60

6.1.3 Interventions to increase intake of food and liquids ............................................. 61

6.1.4 Good examples ................................................................................................... 62

6.1.5 Official Danish recommendations ....................................................................... 62

6.1.6 Barriers ............................................................................................................... 63

6.1.7 Areas where more research is needed .................................................................. 63

6.1.8 Next steps ........................................................................................................... 64

6.1.9 References .......................................................................................................... 64

6.2 THE SOCIAL INTERACTION AND THE IMPORTANCE OF THE MEAL

AMBIENCE FOR THE DESIRE TO EAT ...................................................................... 66

6.2.1 Why it is important ............................................................................................. 66

6.2.2 The significance of the meal's social interaction ................................................. 66

All three settings ...................................................................................................... 66

In nursing homes ..................................................................................................... 67

In home care ............................................................................................................ 68

In hospitals .............................................................................................................. 68

6.2.3 Interventions regarding the meal's social interaction ........................................... 69

In nursing homes ..................................................................................................... 69

In home care and hospitals ....................................................................................... 69

6.2.4 Good examples ................................................................................................... 69

6.2.5 The significance of the meal ambience ................................................................ 70

In nursing homes ..................................................................................................... 70

In home care ............................................................................................................ 70

In hospitals .............................................................................................................. 70

6.2.6 Interventions regarding the meal ambience.......................................................... 70

In home care ............................................................................................................ 70

In hospitals .............................................................................................................. 71

6.2.7 Good examples ................................................................................................... 71

6.2.8 Summary of the significance of the meal ambience ............................................. 71

6.2.9 Official Danish recommendations regarding the meal ambience and the social

framework of the meals ............................................................................................... 72

6.2.10 Barriers ............................................................................................................. 73

6.2.11 Areas where more research is needed ................................................................ 74

6.2.12 Next steps ......................................................................................................... 74

6.2.13 References ........................................................................................................ 75

7. THE RESIDENT ......................................................................................................... 77

7.1 THE EFFECT OF NUTRITION ON THE PHYSICAL FUNCTION OF OLDER

PEOPLE IN NURSING HOMES AND HOME CARE ................................................... 77

7.1.1 Why it is important ............................................................................................. 77

7.1.2 The significance of food and liquids on physical function ................................... 77

In nursing homes and home care .............................................................................. 77

7.1.3 Interventions to improve the intake of food and liquids as well as physical function

.................................................................................................................................... 78

All three settings ...................................................................................................... 78

In nursing homes and home care .............................................................................. 79

7.1.4 Good examples ................................................................................................... 81

7.1.5 Official Danish recommendations ....................................................................... 81

7.1.6 Barriers ............................................................................................................... 82

7.1.7 Areas where more research is needed .................................................................. 83

7.1.8 Next steps ........................................................................................................... 84

7.1.9 References .......................................................................................................... 84

7.2 DEMENTIA IN OLDER PEOPLE IN NURSING HOMES, HOME CARE AND

HOSPITALS ................................................................................................................... 86

7.2.1 Why it is important ............................................................................................. 86

7.2.2 The significance of dementia for food intake and mealtimes................................ 86

All three settings ...................................................................................................... 86

7.2.3 Interventions with food and liquid in older people with dementia ........................ 87

All three settings ...................................................................................................... 87

In nursing homes ..................................................................................................... 87

7.2.4 Official Danish recommendations ....................................................................... 88

7.2.5 Barriers ............................................................................................................... 88

7.2.6 Areas where more research is needed .................................................................. 88

7.2.7 Moving forward .................................................................................................. 88

7.2.8 References .......................................................................................................... 89

7.3 REDUCED INTAKE OF FOOD AND LIQUIDS DURING HOSPITALISATION ... 90

7.3.1 Why it is important ............................................................................................. 90

7.3.2 Intake of food and liquids during hospitalisation ................................................. 90

7.3.3 Interventions to increase intake of food and liquids during hospitalisation ........... 92

7.3.4 Good examples ................................................................................................... 93

7.3.5 Official recommendations ................................................................................... 93

7.3.6 Barriers ............................................................................................................... 93

7.3.7 Areas where more research is needed .................................................................. 94

7.3.8 Next steps ........................................................................................................... 94

7.3.9 References .......................................................................................................... 94

7.4 THE IMPORTANCE OF LIFE SKILLS FOR OLDER PEOPLE'S DESIRE TO EAT

........................................................................................................................................ 97

7.4.1 Why it is important ............................................................................................. 97

7.4.2 General comments on life skills and rehabilitation .............................................. 97

In home care ............................................................................................................ 98

In nursing homes ..................................................................................................... 98

In hospitals .............................................................................................................. 99

7.4.3 Assessing older people for municipal care services ............................................. 99

7.4.4 The significance of life skills for older people's desire to eat and prioritise meals

.................................................................................................................................. 101

In home care .......................................................................................................... 101

In nursing homes ................................................................................................... 102

In hospitals ............................................................................................................ 102

7.4.5 Interventions to give older people better life skills and more desire to eat and

prioritise meals .......................................................................................................... 103

In hospitals ............................................................................................................ 103

In nursing homes and home care ............................................................................ 103

7.4.6 Good examples ................................................................................................. 103

7.4.7 Official Danish recommendations ..................................................................... 104

7.4.8 Barriers ............................................................................................................. 104

7.4.9 Areas where more research is needed ................................................................ 104

7.4.10 Next step ......................................................................................................... 105

7.4.11 References ...................................................................................................... 105

8. THE STAFF'S SKILLS ............................................................................................. 107

8.1 THE SIGNIFICANCE OF THE STAFF'S SKILLS FOR PRIORITISING AND

PROVIDING MEALS ................................................................................................... 107

8.1.1 Why it is important ........................................................................................... 107

8.1.2 The significance of the staff's skills for prioritising and providing meals .......... 107

All three settings .................................................................................................... 108

In home care .......................................................................................................... 108

In nursing homes ................................................................................................... 108

In hospitals ............................................................................................................ 109

8.1.3 Interventions regarding the staff's skills ............................................................ 109

In home care .......................................................................................................... 109

In nursing homes ................................................................................................... 109

In hospitals ............................................................................................................ 110

8.1.4 Good examples ................................................................................................. 110

In nursing homes ................................................................................................... 110

In hospitals ............................................................................................................ 110

8.1.5 Official Danish recommendations ..................................................................... 111

8.1.6 Barriers ............................................................................................................. 112

8.1.7 Areas where more research is needed ................................................................ 112

8.1.8 References ........................................................................................................ 112

9. POLICY (GOVERNMENT) ...................................................................................... 114

9.1 THE SIGNIFICANCE OF THE FINANCIAL AND ORGANISATIONAL

FRAMEWORK FOR FOOD AND MEALTIMES ........................................................ 114

9.2 THE IMPORTANCE OF OLDER PEOPLE'S NUTRITIONAL STATUS TO THE

COSTS OF OLDER CARE ........................................................................................... 114

9.2.1 Why it is important ........................................................................................... 114

9.2.2 The significance of inadequate intake of food and liquids for the costs of older

services ...................................................................................................................... 115

All three settings .................................................................................................... 115

In nursing homes ................................................................................................... 115

In home care .......................................................................................................... 115

9.2.3 Interventions to increase the intake of food and drink, and their significance in

terms of the costs for older care and services ............................................................. 116

All three settings .................................................................................................... 116

In nursing homes and home care ............................................................................ 116

In hospitals ............................................................................................................ 117

9.2.4 Good examples ................................................................................................. 118

9.2.5 Barriers ............................................................................................................. 118

9.2.6 Areas where more research is needed ................................................................ 118

9.2.7 Moving forward ................................................................................................ 119

9.2.8 References ........................................................................................................ 119

9.3 THE SIGNIFICANCE OF HOW THE MUNICIPALITIES USE THEIR BUDGETS

FOR OLDER MEAL SERVICES .................................................................................. 120

9.3.1 Why it is important ........................................................................................... 120

9.3.2 The financial significance of the organisation .................................................... 120

In nursing homes ................................................................................................... 120

In home care .......................................................................................................... 120

Quality control and optimising sensory quality ...................................................... 121

In hospitals ............................................................................................................ 122

9.3.3 Interventions for cost-efficient food ordering and meal services ........................ 122

In home care .......................................................................................................... 122

In nursing homes ................................................................................................... 124

In hospitals ............................................................................................................ 125

General financial challenges regarding interventions .............................................. 125

9.3.4 Good examples ................................................................................................. 126

9.3.5 Barriers ............................................................................................................. 126

9.3.6 Areas where more research is needed ................................................................ 127

9.3.7 Moving forward ................................................................................................ 128

9.3.8 References (for sections 9.2 and 9.3) ................................................................. 128

9.4 FOOD AND MEALTIME POLICY ........................................................................ 131

9.4.1 Why it is important ........................................................................................... 131

9.4.2 The importance of a food and mealtime policy for older people's nutrition ....... 131

All three settings .................................................................................................... 131

In hospitals ............................................................................................................ 132

In nursing homes and home care ............................................................................ 133

9.4.3 Interventions regarding food and mealtime policies ........................................... 135

All three settings .................................................................................................... 135

In hospitals ............................................................................................................ 135

In nursing homes and home care ............................................................................ 135

9.4.4 Official Danish recommendations ..................................................................... 135

9.4.5 Good examples ................................................................................................. 136

9.4.6 Barriers ............................................................................................................. 136

9.4.7 Areas where more research is needed ................................................................ 137

9.4.8 Moving forward ................................................................................................ 137

9.4.9 References ........................................................................................................ 137

10. CONCLUSION ..................................................................................................... 138

Current knowledge................................................................................................. 138

Current and future challenges................................................................................. 138

Barriers .................................................................................................................. 138

Solutions and further research ................................................................................ 138

Food quality ........................................................................................................... 139

Meal access ........................................................................................................... 139

The mealtime experience ....................................................................................... 139

The resident ........................................................................................................... 140

Staff skills .............................................................................................................. 140

Finances ................................................................................................................ 141

Policy .................................................................................................................... 141

FOREWORD

The Danish demographic trend points towards more older people and rising life expectancies,

which poses a number of challenges as regards food culture, food supply and the health and

welfare of older people. In Danish municipalities, demand is rising for more nutritious meals-

on-wheels to older people who live at home and can no longer cook for themselves. Given

this development, there is a focus on developing new customised solutions that can maintain

the health of the older so they can take care of themselves for as long as possible in their own

homes.

The municipalities' focus on high-quality meal services means that there is a need to assess

the benefits and costs of the various types and combinations of meals. Appetising meals with

sufficient high-quality protein and other key nutrients, as well as physical exercise , are

prerequisites for helping the older to stay mobile, self-sufficient and living in their own

homes for as long as possible.

Against this background, the Food Culture Association (Madkulturen) and the University of

Copenhagen have appointed a working group with external expertise to prepare a whitepaper

on providing nutritious, high-quality food to the older. This whitepaper examines the

challenges of providing good meals for the older while taking into account age-related

physiological, sensory and social changes that affect their life skills. The whitepaper also

describes barriers to reaching this goal and knowledge gaps and proposes solutions and

research areas.

The hope is that politicians, officials in the municipalities and regions, and other stakeholders

will use and benefit from this whitepaper in their work on providing the best possible meals

and mealtimes for the older.

The whitepaper was prepared by a working group consisting of:

Professor (with special responsibilities) Susanne Gjedsted Bügel, University of Copenhagen,

Chair

Professor Wender Bredie, University of Copenhagen

Project Manager Andreas Buchhave Jensen, Food Culture Association (Madkulturen)

Associate Professor Jørgen Dejgård Jensen, University of Copenhagen

Project Consultant Christine Bagge Petersen, Food Culture Association Food

and mealtime consultant Karen Leth, Danish Diet and Nutrition Association, on contract

with the Food Culture Association

External expertise for the working group:

Senior Researcher Anne Marie Beck, Herlev Hospital

Doctor Jerk W. Langer, independent consultant

Secretariat services for the working group:

Senior Consultant Eva Gleje, University of Copenhagen

Academic member of staff Anne-Marie Ravn, University of Copenhagen (until 15/12/2014)

Judith Kyst, Director, Food Culture Association

Arne Astrup

Professor, Head of Department, University of Copenhagen

1. INTRODUCTION

Approximately 1,000,000 Danes are over 65 years old and this number is expected to rise to

about 1,500,000 in the next 30-40 years. 13% of Danes over 65 years receive their food from

the public services.

Many older people do very well, live active lives, eat good food and have good meal

experiences. They maintain their weight, eat healthy food, age well, take steps to prevent

diseases, relieve symptoms, are very socially committed and have a high quality of life.

Unfortunately, this is not the case for many others: many are at risk of developing

malnutrition or are already malnourished. There are various reasons for this. For example, the

older person may be living alone in their home after the death of their spouse, and may no

longer experience any pleasure in eating; they may not feel physically up to shopping and

cooking for themselves; they may have a diminished sense of taste and smell; they may have

dementia, depression, poor dental health, or have had a stroke, making it difficult or

impossible to eat; or they may be hospitalised with severe illness, which means that their

nutrition is not the top priority when it comes to their treatment.

The fact is that a large proportion of older Danes do not eat optimally. Many are underweight,

which is associated with increased illness and costs of treatment and care. Many lack

important nutrients, which weakens the immune system and the body's ability to regenerate

itself. Many miss the sense of community around meals, and their sensory needs are not being

met. This can have dramatic effects on their daily lives, physical capacity, health and mood. It

can also result in high costs for society, because the older people make up a growing

proportion of the Danish population.

Conversely, preventing malnutrition and weight loss can both counteract disease and improve

older people's mobility, independent living and quality of life. Of course we believe it is

sensible to ensure that older people get the best possible food. But there are many barriers of

personal, staff-related, financial and practical nature.

The intentions are good, but they are still not being put into practice well enough, and not

always in a way that is backed-up by scientific evidence. In addition, the staff may not be

adequately qualified, and the financial resources are limited and often not used as optimal as

possible.

To shed light on this essential area in Danish society, the whitepaper's working group has

reviewed the scientific literature focusing on nutritious, high-quality meals for the older,

including randomised clinical studies. The research is still rather sporadic. In particular, there

is a need for a systematic assessment of which interventions are especially beneficial for the

older people from a holistic perspective. As this whitepaper concludes, much more research is

needed in this area.

Fortunately, we already know a lot about how to focus on providing better food for the older

who live at home or in nursing homes, as well as older hospital patients – for the benefit of

the individual and Danish society as a whole.

2. METHODOLOGY AND READING GUIDE

The focal point of this whitepaper is the "Making the Most of Mealtimes" model (M3)

developed in Canada in connection with providing meals for older people in nursing homes

(Keller et al. 2014) (see Figure 2.1).

Figure 2.1 The "Making the Most of Mealtimes" (M3) model (Keller et al. 2014).

The M3 model was inspired by another model, the "Five Aspect Meal Model" (FAMM),

which is a tool designed to give restaurant patrons the best possible meal experience. The

FAMM model describes five factors that should be taken into account in connection with the

meal: the physical environment, the encounter with the staff, the food, the management and

the atmosphere.

Although these five factors are also very important when it comes to providing meals for

older people, there are additional criteria that apply to the older. One important criterion as

regards the older is meal access, i.e. the possibility of getting something to eat at all, which

can be difficult, for example if the older person has trouble chewing and swallowing food or

needs eating assistance. Another criterion is the meal quality, including the taste and variation

of the food, which is to be eaten for a long period of time, not just in a single restaurant visit.

This whitepaper is structured as follows: first, the provision and intake of meals are described

based on the criteria of meal access, meal quality and mealtime experience. The focus here is

on reduced appetite, the meal ambience and the social interaction.

The next chapter focuses on the older person (the "Resident" in Figure 2.1) and the

importance of food and mealtimes for life skills, physical and cognitive function, and during

hospitalisation. Then follows a chapter on the importance of the care-giving staff having

appropriate education ("Home" in Figure 2.1). The following two chapters ("Government" in

Figure 2.1) describe the overarching policy, i.e. the financial and organisational framework for

providing meals for the older and the importance of a food and mealtime policy.

Each chapter takes as its starting point the three settings in which the older are offered meals

by the public services: home care, nursing homes and hospitals.

2.1. Methodology

During the preparation of this whitepaper, the authors reviewed the literature on food and

mealtimes for the older, as well as the relevant Danish studies and recommendations of which

the working group was aware. The literature reviews mostly focused on collecting

background information, on randomised controlled studies within the various frameworks, as

well as on whether these studies examined the effect of the various measures on the so-called

patient-relevant endpoints, i.e. quality of life, physical, social and mental function, morbidity

and mortality. The nutritional status is not considered a patient-relevant endpoint. In areas

where such studies were not conducted, the working group chose to describe studies with

different approaches to provide inspiration for further research in those areas.

2.2. Links to other initiatives

In January 2015, the National Board of Social Services will publish its "Recommendations

for Nutritional Interventions for Older people with Unplanned Weight Loss". This whitepaper

refers to and quotes from that document. In autumn 2014, the Ministry of Food, Agriculture

and Fisheries appointed a think-tank on meals which among other things has been tasked with

giving advice on meals to supplement the existing dietary guidelines. One of the target groups

is older people who eat alone. The think-tank's work is expected to be completed during the

winter of 2015 and will supplement the whitepaper.

In winter 2014, a Forum for Undernourishment was established through collaboration

between the Danish Agriculture and Food Council, the Danish Society for Clinical Nutrition

and the Danish Diet and Nutrition Association. The target groups include older people in

nursing homes, home care and hospitals. During 2005, the forum plans to produce 10

proposals for initiatives to prevent undernourishment.

2.3. Scope

This whitepaper focuses on today's older people in nursing homes, home care and hospitals.

Only a minority of these people were overweight in their younger days, and their main

current problem is inadequate intake of food and liquids. In future, older people in nursing

homes, home care and hospitals may have the same problem of eating too little, but many will

have been overweight for much of their lives. This double negative health impact may mean

that different measures may have to be taken in the future when it comes to the older.

As mentioned, this whitepaper focuses on older people who are already underweight or have

experienced unplanned weight loss. Thus we do not describe initiatives that are mainly aimed

at primary prevention. Such initiatives can be found in the prevention manual prepared by the

National Board of Social Services and the National Board of Health, which is currently

(January 2015) in consultation, as well as in the prevention package for food and mealtimes

prepared by the National Board of Health and the Danish Veterinary and Food

Administration.

2.4 Concepts

(Based on Beck et al. Recommendations for the development of "Attractive Meal Services for

Older People". Danish Institute for Food and Veterinary Research 2006.)

Nutrition is closely associated with the concept of diet and is understood as a person's intake

of nutrients (carbohydrates, fats, proteins, vitamins, minerals and water) and the body's use of

these nutrients.

Diet refers to how much and what type of food and liquids a person consumes in a specified

period.

Food is used in the broad sense and comprises raw ingredients, meals, drinks and menus.

Meal services are services offered under the Social Services Act to people who cannot cook

food for themselves due to temporarily or permanently impaired physical or mental capacity

or special social problems. Meal services are offered to older people in nursing homes and

hospitals and to older people in home care in the form of meals-on-wheels.

The menu plan is a composition of dishes and beverages that can form the basis for a meal.

Mealtimes is used in a broad sense to indicate a sequence of events ranging from planning

the meal to buying and preparing the raw ingredients, setting the table, gathering the diners,

eating and conversing.

The social setting of the meal refers to the sense of community among the nursing home

residents who sit together at a table and the staff who either sit at the table or work near it.

Meal quality refers to the users' assessment of the food's taste, smell, appearance,

consistency, temperature, the options and variety of the food, as well as the physical meal

ambience.

Mealtime service is a broader definition of meal services, combining food and nutrition with

a focus on the meal's social interaction. Mealtime service is thus not only a question of the

kind of food that is served, but also involves a number of external factors that create the

meal's social interaction.

Physical meal ambience refers to the physical setting of the meal, e.g. the table, the table

setting, flowers, napkins, colours, the aroma and presentation of the food, music, and so on.

2.5 References

Gustafsson, I.-B., Öström, A., Johansson, J. and Mossber g, L. The Five Aspects Meal Model:

a tool for developing meal services in restaura nts. Journal of Foodservice; 2006, 17 : 84-93

Kell er, H., Carrier, N., Duizer, L., Lengy el, C., Slaughter, S., Steele, C. Making the most of

mea ltimes (M3): Ground ing mealtime inter ven tions with a conceptual mode. JAMDA 2014;

15: 158-61

3. BACKGROUND

This chapter contains three sections that describe the special physiological factors regarding

older people's food intake, the nutritional status of older people in the three settings, the

demographic development of the numbers of older people, and the scope of meal services.

3.1 PHYSIOLOGICAL FACTORS AFFECTING FOOD INTAKE, NUTRITIONAL

STATUS, PHYSICAL FUNCTION AND QUALITY OF LIFE

With age, people experience a number of anatomical, physiological and psychological

changes that may have an effect on food intake, nutrient metabolism and physical function.

These include poorer oral and dental health, lower metabolism, decreased muscle mass, bone

decalcification, loss of nerve cells, changes in mental resilience and poorer memory. In

addition, a number of medical conditions and other factors such as financial, family and

social circumstances can affect dietary intake. In the following we describe some of the

physiological conditions that affect food intake and nutrition and thus physical function and

quality of life.

Ageing has a significant effect on weight, height and body shape. Men's body weight usually

increases up to the age of 50-60, while women's increases up to the age of 70. The weight

then stabilises for a period, after which it decreases in the very older. Due to changes in

bones, joints and muscles, body height tends to decrease from about the age of 40, more so in

women than men. With age, the body's total bone and muscle mass decreases, while body fat

increases (Paddon-Jones et al. 2008). In addition, the body's fluid content is diminished

because of physiological changes such as a decrease of body protein, reduced effectiveness

of the anti-diuretic hormone receptors with increased fluid excretion through the kidneys, as

well as reduced thirst related to a decrease in osmosis receptor sensitivity.

From the age of around 50 years muscle mass is reduced by about 1% per year (this is called

sarcopenia), and the maximum muscle strength declines accordingly. The reasons for this are

complex and include a reduction of hormones such as testosterone, oestrogen, growth

hormone and IGF-1, as well as lower insulin sensitivity. In addition, there is a slight increase

in the level of proinflammatory cytokines, changes in the function of muscle mitochondria,

loss of alpha motor neurons, inadequate energy intake (especially protein), as well as reduced

physical activity. Sarcopenia plays a primary role in the development of frailty and disability

in the older, and it is estimated that almost one in three people over 60 years and half of

people over 80 years are affected (Paddon-Jones et al. 2008). Diseases of the locomotor

system (osteoarthritis, osteoporosis) often affect the older and can reduce their physical

function, which in turn can increase the risk of undernourishment because it becomes more

difficult to shop, cook and eat.

3.1.1 Appetite regulation and intestinal function

The appetite is regulated by a delicate system which causes us to automatically adjust our

dietary intake depending on our previous meals. This means that we tend to eat less after a

period of energy-rich meals and more after a period of undernourishment. However, older

people's appetite regulation is not as delicate as that of younger people, which is why, after

periods of illness and reduced energy intake, the older do not increase their energy intake to

regain weight to the same extent as younger people. Appetite decreases as a response to the

decreased need for energy with age, partly because the metabolically active muscle mass is

reduced and partly because the older person is less physical active.

In addition, the tongue's taste receptors and senses of smell and sight are dulled ("food used

to taste better") and the stomach's ability to expand is reduced, all of which contributes to

lower appetite. The term "age-related anorexia" (Moss et al. 2012) refers to reduced appetite

and food intake in the older, which can have serious consequences, since older people's need

for nutrients such as protein, vitamins and minerals does not diminish, and the reduced

energy intake thus increases the risk of not getting enough of these nutrients.

3.1.2 Changes in large intestine and intestinal flora

The appetite is mainly regulated by intestinal hormones which are released by food intake.

With age, this hormonal response changes, so that the feeling of being full increases while

hunger is inhibited. The rate of gastric emptying also decreases, which increases the feeling

of being full. The number of nerve cells in the intestines decreases, which affects peristalsis

and propulsive activity, so the passage rate is extended (Britton and McLaughlin 2013). This

can lead to constipation, which can further reduce appetite and food intake.

Smoking, a poor diet and medication can lead to reflux disease, stomach ulcers and stomach

cancer and resulting symptoms such as anorexia, weight loss, anaemia, vomiting and

difficulty swallowing, which in turn can also reduce food intake.

3.1.3 Sight and dental health

Eye diseases such as diabetic retinopathy, glaucoma and age-related macular degeneration

(AMD), which impairs vision, are frequent among the older (Rasmussen and Johnson 2013).

Diet probably plays a role both in the development and alleviation of these diseases.

Impaired vision can limit older people's opportunities to buy and prepare food.

Loss of teeth, decreased salivary function, dryness of the mouth cavity and reduced muscle

and joint function can make it difficult to chew and swallow food. This can change the

individual's food choices and food preparation and thereby reduce their intake of nutrients;

for example, they may avoid foods that are hard to chew or boil food excessively and thus

lose nutrients.

3.1.4 Cognitive function

Dementia is an age-related brain disease that impairs memory, the ability to function in

everyday life and the ability to orient oneself. The most common type of dementia in the

older is Alzheimer's disease, which affects 25% of people over 85 (Cardozo et al. 2 013). The

reasons for this are not clear, but lifestyle-related diseases and factors such as type-2

diabetes, high blood pressure, overweight, high cholesterol, alcoholism and smoking can be

contributing factors.

Dementia can affect food intake, for example because the person forgets to eat and drink,

loses the desire to eat, or has problems swallowing.

3.1.5 Chronic diseases

Chronic diseases, infections and other conditions that require prolonged medical treatment

can lead to malnutrition in the older. Hospital admissions and medication, including possible

side-effects, increase the risk of malabsorption, loss of appetite, nausea, vomiting, delayed

gastric emptying and diarrhoea.

3.1.6 Dietary recommendations for frail older people with low appetites

For frail older people with low appetites, meals with a high energy density are recommended,

i.e. an energy mix of 15-20% protein, 50% fat and 30-35% carbohydrates. In addition, a

multivitamin and mineral supplement is recommended to meet the Nordic nutrient

recommendations. Six to eight small meals daily is recommended, individually adapted to

the older person's ability to chew and swallow (National Board of Social Services 2013).

Unlike many other countries, Denmark does not have systematic national statistics on the

nutritional status, diet and physical activity of frail older people. Information about this is

therefore derived from various research projects. Only a very small proportion of healthy

older people are underweight. However, 10-20% of frail ol der people in nursing homes and

home care who receive meals from the social services are underweight. Many frail older also

experience so-called unplanned weight loss, largely due to inadequate food intake. This is a

very serious condition, since unplanned weight loss is closely related to loss of muscle mass

and muscle strength. Weight loss thus increases the risk of disabilities and reduced physical

activity and capability. Physical function tends to decrease even after a slight unplanned

weight loss of 1% per year (National Board of Social Services 2015). Malnourished older

people are also at risk of eating even less and becoming even frailer.

3.1.7 Macronutrients

Eating enough protein is necessary to maintain enough fat-free body mass and avoid

degradation of muscle tissue, which can lead to sarcopenia and osteoporosis. A 2009

Cochrane review of 62 clinical studies found that, in 42 studies, protein and energy

supplements resulted in a slight weight gain of 2.2%, and a decrease in mortality rate among

the weakest older people (Milne et al. 2009). Similarly, sufficient fat intake is necessary as a

source of energy, for absorbing fat-soluble vitamins and for optimal health. Long-chain

omega-3 fatty acids are especially in focus when it comes to the health of older people.

Results from observational studies in particular suggest that omega-3 fatty acids can be

beneficial for cognitive function, immune function (Ubeda et al. 2012) and joint pain (Miles

et al. 2012). However, most available studies are observational; randomised controlled studies

are lacking.

3.1.8 Micronutrients

Micronutrients are also essential to optimal physical function and quality of life (see table

3.1), and a number of studies have looked at the effect of supplements of single

micronutrients on the treatment of age-related conditions. So far the results are inconclusive.

The available studies have looked at the effect of dietary supplements with increased

amounts of micronutrients, but not at an actual optimisation of diets. However, this does not

mean that optimising the diet has no effect. Studies that have examined the effect of full-day

meal plans suggest that diet optimisation improves physical function and quality of life

(Trichopoulou et al. 2005).

Table 3.1 Function of essential micronutrients and consequences of deficiency in the older

(modified from Mak and Caldeira 2014)

Night blindness, blindness

Energy conversion and metabolic

functions, DNA synthesis, cell

division, homocystein metabolism,

regulation of mental and neurological

functions, etc.

Increased homocystein concentration,

anaemia, reduced muscle strength,

memory loss, confusion, depression,

possible development of dementia,

Alzheimer's disease, etc.

Redox system, coenzyme in the

collagen synthesis, iron absorption,

antioxidant

Scurvy, impaired healing of wounds

Calcium regulation, immune system

Rickets, osteoporosis, muscle

weakness, metabolic

syndrome, increased mortality

Healthy bones and teeth, cell

signalling, coagulation, muscle

contraction, nerve transmission

Increased bone loss, osteoporosis

Energy conversion, cell division,

muscle function, cell signalling, DNA

synthesis, protein synthesis

Increased production of free radicals,

inflammation, muscle loss,

sarcopenia, impaired immune

response, cardiovascular disease,

diabetes

Included in the antioxidant and

anti-inflammatory enzymes

Impaired immune function, reduced

cognitive function, increased

mortality

Normal growth and development,

neurological function, wound

healing, immune function

Increased risk of infections,

diarrhoea, eczema, reduced sense of

taste

3.1.9 References

Britton E, McLaughlin JT. Ageing and the gut, Pr oceed ings of the Nutr iti on Societ y, 2013;

72(01): 17 3-7

Cardoso BR, Cominetti C, Co zz olino SM. Im por tance and ma nag ement of micronutrient

deficiencies in patien ts with Alzheimer's disease, Clin Interv Aging, 2013 ; 8 : 531-42

Mak T, Caldeira S. The role of Nu triti on in Active and He althy Aging. JRC – Institute f or

Health and Co nsu mer protection 2014: 1-54

Miles EA, Calder P. Influence of marine n-3 polyunsaturated fatty acids on immune function

and a systema ti c revi ew of their effects on clinical ou tco mes in rhe umato id ar thriti s, Br J Nutr,

2012;107 Suppl 2:S171 –84

Milne AC, Potter J, Vivanti A, Avenell A. Pr otein and energy su pplementa ti on in elderly

people at ri sk fr om malnutrition, Cochrane Da tabase Syst Rev, 2009(2): CD003288

Moss C, Dhillo WS, Frost G, HicksonM.Gastrointes tinal horm ones: the r eg ulation of appetite

and the ano rexia of ageing. J Hum Nutr Diet 2012; 25: 3-15

Paddon -Jones D, Short KR, Campbell WW, Volpi E, Wolfe RR.Role of dietar y protein in the

sar copenia of aging, The American Journal of Clinical Nutrition, 2008; 87:1562S-6S

Rasmussen HM, Johnson EJ. Nutr i ents for the aging eye, Clin In terv Aging, 2013; 8: 741-8

Socialstyr elsen. Natio na l handlingsplan for måltider og ernæring til ældre i hjemmep lejen og

plejeboligen. So cialstyr elsen 2013

Socialstyr elsen,. Fa glige anbef alinger og beskrivelser af god praksis for ernær ingsindsat s til

ældre med uplanlagt væg ttab . So cialstyr elsen 2015 (i høring)

Trichopou lou A, Orfanos P, Norat T, Buen o-de-Mesqui ta B, Ocke MC, Pee ters PH et al.

Modifi ed Med iterrane an diet and survival: EP IC-elderly prospective cohort study. BMJ 2005 ;

330(7498): 991

Ubeda N, Achon M, Var ela-Morei ras G. Om ega 3 fa tt y acids in the elderly, Br J Nutr 2012;

107 Suppl 2: S137-51

World He alth Organization, Tufts University School of Nutr ition Science.Keep fit for life.

Meeting the nutriti onal needs of older persons. WHO 2002

3.2 NUTRITIONAL STATUS OF OLDER PEOPLE IN HOME CARE, NURSING

HOMES AND HOSPITALS

In Denmark, the National Board of Social Services and the National Board of Health have

developed official methods to assess the nutritional status of older people in nursing homes,

home care and hospitals. Currently there is no systematic collection of data in this area in

Denmark, unlike in a number of other countries. For example, the Netherlands uses systematic

data collections of older residents' nutritional status and has demonstrated a positive effect of

this data collection on the prevalence of underweight (Meijer et al. 2014). In Denmark,

indicators for assessing the nutritional status of older citizens have been proposed by Local

Government Denmark and the Danish Institute for Quality and Accreditation in Healthcare

(www.ikas.dk).

However, none of these were developed to identify the effect of nutritional interventions on

e.g. older people's physical function and dependence on assistance with everyday living

(National Board of Social Services 2014).

In many countries, the results from what is known as the minimum data set (MDS) –

developed for older people in home care, residential care and acute hospitalisation – are used

for quality assurance of various initiatives, since MDS contains various quality indicators (for

example relating to falls, bedsores, pains and weight loss). In addition, MDS is used to

calculate resource needs and adjust care tasks based on a division of residents into subgroups

according to their functional ability (National Board of Social Services 2014). Finally, MDS

can detect changes over time and thus is also a good tool for evaluating the effect of

interventions to improve older people's nutritional status, everyday life, physical function, use

of expensive health-related interventions (such as hospitalisations and rehabilitation stays), etc.

and MDS has therefore been used in a wide range of intervention studies. This information is

not only relevant when it comes to measuring the effect of a nutritional intervention but also

more generally, for example when looking at the effect of rehabilitation interventions (National

Board of Social Services 2014).

According to the 2013 National Health Profile, which surveyed approximately 16,000

representative men and women aged 75 +, 5.4% of the women and 0.7% of the men were

underweight, defined as having a BMI under 18.5 kg/m2 (National Board of Health 2014). It is

estimated that the proportion of underweight older people in nursing homes and hospitals is up

to 10 times higher.

Unplanned weight loss is particularly common among older people in hospital, but also among

senior citizens who receive home care or live in nursing homes. Almost half of older people

who receive home care or live in nursing homes experience unplanned weight loss (National

Board of Social Services 2015).

Unplanned weight loss can have serious consequences for physical, mental and social function.

Unplanned weight loss and underweight can increase older people's need for home care, and

the risk of disease, hospitalisation, readmission, prolonged hospitalisation, complications during

illness and hospitalisation, and premature death (National Board of Social Services 2015).

Table 3.2 shows the prevalence of unplanned weight loss and underweight in older people.

The data is based on information from nutritional screenings carried out in various projects in

2008 and 2009 with funding from the Development of Better Care for the Older Fund (National

Food Institute and National Board of Social Services 2011).

A report published by the National Board of Social Services provides information on the

prevalence of underweight and unplanned weight loss based on data compiled using the

National Board of Social Services' nutritional assessment form (National Board of Social

Services 2014).

In home care

Very few projects focus on older people receiving home care, and only a single report from

Kalundborg Municipality from 2008 contains specific data on the nutritional status of older

people in home care (see Table 3.2). The prevalence of underweight was on the same scale as

in a Danish study published in 2002, in which 12% of the subjects had BMIs under 18.5 kg/m2

(Beck et al. 2002).

One research project indicated (via the National Board of Social Services' evaluation form)

that 30% of people receiving home care either had lost weight, or that it wasn't known if this

was the case. 22% had BMIs under 18.5 kg/m2, which is the threshold of underweight. The

results are based on older residents who receive meal services and therefore are not

representative.

Table 3.2 Results of screenings of older people's nutritional status

(based on National Food Institute and National Board of Social Services 2011). The MNA

(mini nutritional assessment) is a screening tool for assessing the nutritional status of older

people.

Bornholm, home care/nursing home

2008/2009

n = 1067

BMI 18.5-24 kg/m2: 37%

BMI < 18.5: 12%

Egedal, nursing home

2008

n = 117

BMI < 24 kg/m2: 52%

BMI < 18.5: 13%

Gentofte, nursing home

2009

BMI < 24 kg/m2: 60%

BMI < 18.5 kg/m2: 16%

Gladsaxe, nursing home

2009

n = 123

BMI < 24 kg/m2: 61%

BMI < 18.5 kg/m2: 12%

Kalundborg, home care/nursing home

2008

n = 396

BMI < 24 kg/m2: 39%

BMI ≤ 18.5 kg/m2: 11%

n = 212

BMI < 24 kg/m2: 48%

BMI ≤ 18.5 kg/m2: 9%

n = 120 (nursing home)

MNA 17-23.5: 59%

MNA < 17: 21%

Copenhagen I, nursing home

2008

n = 43

BMI < 24 kg/m2: 63%

BMI < 18.5 kg/m2: 22%

Copenhagen II, nursing home,

2008

n = 59

BMI < 24 kg/m2: 65%

BMI < 18.5 kg/m2: 19%

Copenhagen III, nursing home

2007

n = 144

BMI < 19 kg/m2: 22%

MNA-SF ≤ 11: 90%

Køge, home care/nursing home

2008

n = 841

MNA 17-23.5: 43%

MNA < 17: 16%

n = 358 (nursing homes)

MNA 17-23.5: 56%

MNA < 17: 23%

Middelfart, nursing home

2009

n = 20

MNA 17-23.5: 45%

MNA < 17: 15%

n = 25

MNA 17-23.5: 44%

MNA < 17: 12%

BMI < 24 kg/m2: 56%

BMI < 18.5 kg/m2: 4%

n = 55

BMI < 24 kg/m2: 42%

BMI < 18.5 kg/m2: 13%

Roskilde, nursing home

2009

n = 13

MNA 17-23.5: 85%

MNA < 17: 15%

BMI < 24 kg/m2: 46%

Aarhus, nursing home

2008

n = 19

MNA 17-23.5: 63%

MNA < 17: 26%

BMI < 24 kg/m2: 53%

In nursing homes

Table 3.2 shows that there were significant differences in the prevalence of underweight (i.e.

BMI under 18.5 kg/m2) among older people in nursing homes in 2008/2009. Thus the figures

vary from 4% in Morsø Municipality to 22% in Copenhagen Municipality.

In 2013, the National Board of Social Services indicated the prevalence of underweight and

unplanned weight loss based on information compiled by using its nutritional assessment

form (National Board of Social Services 2014). One research project that used the nutritional

assessment form indicated that 20% of older people in nursing homes either had lost weight,

or that it wasn't known if this was the case. 11% had BMIs under 18.5 kg/m2.

By way of comparison, the prevalence of underweight in the Danish study published in 2002

was 22%, and the incidence of weight loss was 38% among the residents who were weighed

on a regular basis (Beck et al. 2002). This study also found great variation in prevalence

among the five participating nursing homes.

From March 2004 to March 2007, the Department of Nutrition at the Food Institute carried

out the project "Preventing Loss of Physical, Mental and Social Function by Focusing on

Older People's Nutritional Status and Risk Factors". The participants in the project's first part

were residents of 11 Danish nursing homes, whose nutritional status was monitored for a

year. The results have been published in several scientific papers. Table 3.3 below is based on

one of these (Beck et al. 2012). It shows, for example, that 16% of the subjects had BMIs

under 18.5 kg/m2 and that almost half lost weight over the course of a 6- and 12-month period

respectively.

Table 3.3 Basic data and incidence of weight loss in older people in nursing homes in the

course of a 6- and 12-month follow-up period respectively (based on Beck et al. 2012).

Age at start, years (SD)

Time at the nursing home, years (SD)

Women (%)

Alive at first visit after 6 months (%)

Alive at second visit after 12 months (%)

BMI, kg/m2 (SD)

BMI under 18.5, kg/m2 (%)

85.2 (7.5)

2.5 (3.3)

23.4 (5.0)

Weight loss of more than 1% after 6 months (%)

Weight loss of more than 5% after 6 months (%)

Weight loss of more than 10% after 6 months (%)

Weight loss of more than 1% after 12 months (%)

Weight loss of more than 5% after 12 months (%)

Weight loss of more than 10% after 12 months (%)

In hospitals

The national database on geriatric patients compiled information about geriatric patients'

weight development during hospital stays until 2013 (national database on geriatric patients,

annual report 2013). This registration was stopped in 2013, as it was considered that the

information was already being registered during the assessment of the risks to the patients'

nutritional status. The database stills collects information about patients whose BMI is

measured when they are admitted to hospital. However, the specific results, such as the

proportion of older people with BMIs below 18.5 kg/m2 , are not available.

Thus the annual report from 2012 is the last report containing data on weight development

(national database on geriatric patients, annual report 2012). Of the 7,797 geriatric patients

(58%) who were weighed both on admission and discharge, 43% had lost weight during their

hospital stay. Two recent Danish studies among older patients in poor nutritional condition

have shown that weight loss typically continues for at least three months after discharge

(Beck 2013, Beck 2014).

Two Danish observational studies contain information on the BMIs of older patients. One of

these studies stated that 41% of older patients had BMIs under 22 kg/m2 (Poulsen et al. 2006).

In the second study, only 14% of patients over 65 years had BMIs below 18.5 kg/m2 (Beck et

al. 2000).

Summary

Data from various development and research projects suggests that many older residents in

nursing homes and hospitals experience weight loss.

In general, it appears that older people in nursing homes and home care who receive meal

services are more often underweight than healthy self-sufficient older people.

3.2.1 Proportion of older people and the extent of public meal services for the

older

According to Statistics Denmark's projections, the number of older people over 65 years of

age will increase by approximately 50% over the next 30 years. The number of people aged

85 years or above will increase most (Figure 3.1). Although in general, the older are expected

to be more self-reliant and in better health, it is still likely that more and more will use

various types of meal services in the coming years.

Statistics Denmark's projections also show that the proportion of older people in Denmark of

non-Western origin will increase dramatically, and that older non-Western people will make

up about 15% of all older people in the year 2050, which may require changes to the meals

offered to the older.

Figure 3.1 Statistics Denmark's projection of the number of older people until 2050, divided

into age ranges. Blue=65-75 years of age, red=75-84 years of age, green=85-94 years of age,

purple=95+ years of age.

In addition to the demographic developments, some aspects of the general social developments

will also play a role when it comes to meal services for older people in the future. For

example, the retail trade will undergo a structural development whereby grocery stores will

increasingly be concentrated in larger cities, meaning that older people in rural areas and

smaller towns will have fewer opportunities to shop and cook for themselves if their mobility

is limited, e.g. if they have no car, driver's license or public transport links. Such

developments will increase the need for well-function meal schemes for these older people.

In 2006, the consultancy firm Rambøll produced a survey of meal services for the Ministry of

Social Affairs (Ministry of Social Affairs 2006). In 2008, Local Government Denmark and

the Ministry of Welfare published a document detailing the costs, user fees, organisation, etc.

of meal service schemes in 2007.

According to Local Government Denmark (2008), meal services for citizens in their own

home usually consist only of the main meal of the day (typically a main course and a side

dish). According to Local Government Denmark (2008), the average user fee for a meal

service in a private home was DKK 1,541 per month in 2007, varying from an average of

DKK 1,251 per month in the 10 municipalities with the lowest fees to DKK 1,854 per month

in the 10 municipalities with the highest fees. Municipalities can provide subsidies for meal

services in private homes, and in 2007 an average of DKK 426 was provided per month. 14

municipalities offered no subsidies, while the average for the 10 municipalities with the

highest subsidies was DKK 1,442 per month. There was apparently no significant correlation

between the sizes of the user fees and the subsidies. In municipalities with high subsidies, the

total price of the meal service was almost twice as high as in municipalities without subsidies.

Meal services in nursing homes typically consist of full-day meal plans. For full-day meal

services in nursing homes, the average user fee was DKK 3,001 per month, varying from

DKK 2,440 per month in the cheapest municipalities to DKK 3,821 per month in the most

expensive municipalities. This should be seen in the light of average production costs of DKK

3,818 per resident per month (varying from DKK 2,762 to DKK 5,416 per month in the 10

cheapest and most expensive municipalities) according to Local Government Denmark

(2008).

According to Local Government Denmark's publication, almost 51,000 older Danish people

received meal services in their private homes in accordance with the rules on free supplier

choice in the municipalities in 2007. There are no statistics on the number of recipients of

meal services in nursing homes, but the publication points out that there were almost 45,000

nursing home places in 2007. In addition to this, approximately 10,000 people live in

residential homes under sections 107 and 108 of the Social Services Act (which includes

temporary residential care homes, etc.). Thus it is estimated that there are 100-110,000 older

users of meal services. As Table 3.4 shows, in 2007 there were approximately 835,000 citizens

over 65 years of age. Thus the older people made up 13% of the users of meal services. If we

assume that users of meal services in their own homes are also typically assessed for their need

for home care, these users accounted for approximately 45% of the older people who received

home care.

Table 3.4 Older users of meal services

Total no. of older people

Residents in nursing homes

primarily for older people

Women 104.1 102.7 98.8 92.5 86.3

81.2

Table 3.4 shows that the number of people who receive home care has decreased quite

sharply since 2008, although the number of older people over 65 years has increased. This

can be due to the fact that the older people have become more self-reliant during this period,

but is perhaps more likely a result of the significant restructuring and reprioritisation of care

in many municipalities during this period. It is therefore not entirely clear whether the need

for meal services has increased or decreased in recent years. Moreover, it is uncertain whether

the municipalities can continue to reprioritise their resources to accommodate the rising

number of older people in the coming years.

With an average of approximately 1,000 users per municipality, meal services play a

significant role in the municipal budgets and financial prioritisations – a role that is set to

grow in the coming years. Meals are expensive to produce and distribute for the

municipalities, but they are also a source of revenue due to the users' fees.

Since there is not necessarily a one-to-one correlation between costs and user fees, the

municipalities' net costs (i.e. the differences between the costs and user fees) for meal services

for the older may be one area where savings can be made, either in the form of increased user

fees or requirements for cost reductions.

The latter could entail a risk of rationalisations of food production, which could affect the

quality of the food and/or mealtimes, e.g. by limiting users' opportunities to eat with others in

cosy surroundings. However, rationalisations can also lead to more efficient organisation of

the production, e.g. through organisational changes that do not necessarily affect quality, as

long as the opportunities are not already exhausted.

One financial and organisational barrier may be that the suppliers do not have sufficient

financial incentive to provide high-quality meals for the older. Given that the sector that

supplies meals to the older is likely to grow significantly in the coming years, it is important

to look at these financial and organisational factors.

3.2.2 References

Beck A, An dersen UT, Leedo E, Jensen LL, Mar tins K, Quvang M, Rask KØ, Vedelspang A,

Rønholt F. Do e s adding a dietician to the liaison team after discharge of geriatric patients

improve nutrition al outco me: a randomised control led trial. Clin Rehab 2014; Dec 31. pii:

0269215514564700. [Epub ahe ad of print]

Beck A, Damk jær K, Simmons SF. The relationship between weight st atu s and the need for

health care assist ance in nursing ho m e r es idents. J Ag ing: Res Clin Pract 2012; 1: 173-8.

Beck A, Kjær S, Hansen BS, Storm RL, Thal -Jantzen K, Bi tz C. Follow -up ho m e visits with

registered dieticians have a positive effect on the function al and nutritional st atus of geriatric

med ical patients af ter discharge. A ra ndomised control l ed trial. Clin Reh ab 2013; 27 : 483-93

Beck A, Oves en L. Body ma ss index, weight loss and energy intake of old Dani sh nursing

home res ident s a nd ho me-ca re clien ts. Scand J Car ing Sci 2002; 16: 86-90.

Beck A, Rasmussen AW, Oves en L. Ernæ ringst ilstanden hos ældre og yngre pati enter indlagt

på hospital. Ug eskr Læger 2000; 162 : 3193-6

DTU Fødevareinstituttet og Service styrelsen. Pr ojekt "Udvikling af et redskab til

ernæringsvurd ering og b eh andling af ældre". DTU Fødevareinstituttet og Servicestyrelsen

2011.

Landsdækkede database for Ger iatri, årsr apport 2013

Landsdækkede database for Ger iatri, årsr apport 2012

Kommuner nes Landsforening. Fa glige kvalitetsoplysninger om plejebolig

http://www.kl.dk/Aktuelle-tema er/kvali tetspor talen/Faglig e- kvalite tsoplysninger-om-

plejeboliger/FKOplejeboliger/Systematisk-viden -om- aldres-erna ringstilst and/

Kommuner nes Landsforening og Velfærdsministeriet (2008). Kortlægning af egenbetaling,

produktionso mk ostninger, organisering mv . af madservice ordninger ef ter §83 i serviceloven.

(http://www.kl.dk/Im ageVaultFiles/id_28432/cf_202/Kor tl- gning_af_madservice omr-

det.P DF)

Meijers JM, Tan F, Scho ls JM, Halfens RJ. Nutr ition al care; do proce ss and structure

indica tors influence malnutrition preva lence over time? Clin Nutr 2014; 33: 459-65

Pou lsen I, Rahm Hallberg I, Schroll M. Nu trition al status and associated factors on ger iatri c

admission. J Nutr Health Aging 2006; 10 : 84-90

4. MEAL QUALITY

This chapter consists of three sections. The first section describes the official

recommendations for food and liquids for older people in nursing homes, home care and

hospitals. The second section concerns the importance of sensory changes and taste

preferences to older people's intake of food and enjoyment of mealtimes. The third section

deals with the diets provided to older people in nursing homes, home care and hospitals.

4.1 RECOMMENDATIONS FOR FOOD AND LIQUIDS FOR OLDER PEOPLE IN

NURSING HOMES, HOME CARE AND HOSPITALS

It is important that the menus offered to older people in the three different settings (at home,

in nursing homes and in hospitals) are adapted to their individual needs and ability to eat. A

close collaboration between caregivers and the kitchen staff is therefore necessary.

There are official recommendations for the food and liquids that older people in the three

settings should be offered. These are described in the "Recommendations for Danish

Institutional Diets" (Pedersen and Ovesen 2009) and in The Complete Danish Diet Handbook

(www.kostforum.dk). These recommendations are briefly reproduced below.

4.1.1 Normal menu

The normal menu is designed for older people with good appetite who maintain their weight.

Older people who score 0 points on the National Board of Social Services' nutritional

assessment form under "assessment of nutritional status", or older patients who score 0 points

according to the National Board of Health's method for assessing risks to their nutritional

status are usually offered the normal menu (Technical University of Denmark and National

Board of Social Services 2012, The Complete Danish Diet Handbook).

4.1.2 Menu for older people with low appetites

In the menu for older people who eat little, approximately half of the energy comes from fat.

This menu consists of three small main meals and three to five snacks throughout the day and

is designed to stimulate the appetite in older and ill people with reduced desire to eat. Older

people who score 1 or 2 points on the National Board of Social Services' nutritional

assessment form under "Assessment of nutritional status" or older patients who are at risk of

worsening nutritional status and score 3 points or more according to the National Board of

Health's method for assessing risks to their nutritional status should be offered menus for

people who eat little (or a chewing- and swallowing-friendly menu).

It is especially important to offer energy and protein drinks as snacks, since most people find

it easiest to get energy by drinking. In addition, they are less likely to lose their appetite for

the main meals. The snacks should constitute up to half of the day's energy content, so it is

very important to ensure that the older consume them (Technical University of Denmark and

National Board of Social Services 2012, The Complete Danish Diet Handbook).

4.1.3 Food that is easy to chew and swallow

A chewing- and swallowing-friendly menu is a special menu for older people with low

appetites; it has a softer consistency and is important as a nutritional addition.

A chewing- and swallowing-friendly menu is often suitable for seniors and patients who have

difficulty chewing or swallowing or need help to eat, e.g. because of paralysis, dementia,

Parkinson's disease or poor dental health.

The snacks should also constitute up to half of the day's energy in this menu, so it is essential

to ensure that the older consume them (Technical University of Denmark and National Board

of Social Services 2012).

4.1.4 Diet

Diets are used as part of the treatment of diseases and conditions such as diabetes,

cardiovascular disease, obesity and kidney disease. However, when it comes to frail older

people, there is a lack of documentation of the beneficial effect of most diets in the course of

their diseases, except in the case of kidney disease. Older people with kidney diseases should

be assigned a clinical dietician.

In addition, older people in nursing homes, home care or hospitals should not be put on diets

without the close collaboration of a physician (Technical University of Denmark and National

Board of Social Services 2012).

4.1.5 Specifically for nursing homes

Meal services for residents in nursing homes, etc. consist of a full-day meal plan that meets

the resident's need for food and liquids for 24 hours. A full-day meal plan typically consists

of six servings: three main meals (breakfast, lunch and dinner) and three snacks (late

morning, afternoon and late night). A full-day meal plan typically includes beverages such as

coffee, tea, milk, juice, juice and water, but does not usually include capsule products.

Residents usually have the opportunity to opt out of all or part of a full-day meal plan. The

full-day meal plan is typically divided into different modules, for example a morning,

afternoon and evening module, and the user has the opportunity to opt out of individual

modules. However, some municipalities stipulate that if a resident needs to receive a special

nutrient-rich diet for health reasons, he or she should receive a full-day meal plan (Deloitte

2009).

4.1.6 Specifically for delivery meal services

As a general rule, the food should be supplied seven days a week. If the kitchen only supplies

a main course, as is often the case, the energy content of the main course should make up at

least 30% of the energy content of a whole day's menu, i.e. in practice about 2.7 MJ per day.

The percentage of energy content in the main course should correspond to that of the full-day

meal plan (Pedersen and Ovesen 2009).

4.1.7 References

Deloitte. Betaling for madservi ce i plejeboliger mv . De loitte, maj 2009

Den Nation ale Kosthåndbog www.kostfor um.dk

DTU Fødevareinstituttet og So cialstyr elsen. Vejledning til er næringsvurder ing af ældre. DTU

Fødevareinstituttet og Socials tyrelsen, 2012

Pedersen A, Oves en L (red.). An bef alinger for den dans ke institutionskost. Fødevarestyrelsen

2009

4.2 SENSORY CHANGES AND TASTE PREFERENCES

4.2.1 Why it is important

Most people's food preferences and general sensory experiences in connection with food

happen at an early age and remain relatively stable through adulthood. On the other hand,

there are indications that food preferences change at an advanced age (Dovey et al. 2008), but

the reasons for this are not yet clear. There are probably several factors at play, such as

changes in diet and the functions of the sense organs (taste, smell, hearing, touch and sight),

as well as difficulty remembering to eat, retaining sensory memories and gaining new sensory

impressions. Sensory changes, as well as changes in living conditions, personal well-being

and depression can all reduce the appetite.

A critical period occurs when the older person loses the ability to control their own food

supply. Older people who are no longer able to make their own customary food are likely to

eat less if the food is not what they are used to. It is a big challenge for catering staff at

nursing homes and hospitals, as well as for meals-on-wheels services, to provide the

individual older person with meals that are tailored to their preferences and at the same time

are nutritious, tasty and well made. A meal can easily be of a high culinary quality from the

chef's point of view, and still not appeal to the "customer's" taste.

4.2.2 Sensory changes

Food intake is affected by the individual's sensory sensitivity to particular tastes and textures.

Some sensory impressions stimulate food intake (sweet flavour, soft consistency, etc.),

whereas other flavours (e.g. bitter and strong) and hard textures reduce the desire to eat. In

addition, the person's own experience of the sensory aspects of the product and how full it

makes them affects how much of it they eat.

The senses are central to the perception of the food's quality. In healthy adults the senses are

usually very stable and are therefore important for determining whether a food or a meal

meets one's expectations. The senses can weaken as we get older, which can affect how

satisfied we are with a certain food or meal. A high consistency between expectations and the

experience of the meal's quality is an essential factor in food intake.

It is well documented that the senses weaken with time. In particular, sensitivity of taste and

smell and the ability to discriminate between different tastes and smells start to fade from

around the age of 55, often a little more slowly for women than men (Figure 4.1). However,

this differs widely from person to person: some people preserve their sense of taste and smell

into old age, while others start to lose their ability to taste relatively early (Doty 2014).

Impairment of the sense of smell is also closely linked to changes in memory function, which

in turn can be related to the development of forms of dementia such as Alzheimer's disease.

Dementia affects the sense of smell earlier than the other senses and can be tested with specific

scent tests (e.g. Doty 2003).

Figure 4.1 Reduction in the sensitivity of the sense of smell as a function of age (Doty 2014).

Disorders of the sense of smell are very common: 20% of the population suffers from one or

more smell-related dysfunctions. Losing the sense of smell mainly interferes with the ability

to enjoy meals. Most people can manage this limitation of the sense of smell, but a minority

have considerable problems and experience a noticeable decrease in their general quality of

life and become more vulnerable to depression (Croy et al. 2014).

Smell is essential to sensing nuances of taste. The sense of taste, too, is affected by the ageing

process. The taste buds change in older people, as does the processing of taste signals to and

in the brain. Several studies have shown the consequences of this in the form of reduced

sensitivity to and discrimination between basic tastes. Less saliva production while eating and

changed saliva composition affects the release of flavour in the mouth. Medication can affect

the experience of aromas and flavours (Doty 2003). There is still insufficient systematic

information about how the combination of medicines and changes in diet affect the sense of

taste.

The literature shows that the decline in the function of the senses differs fairly widely from

person to person. At the same time, only relatively big changes affect older people's daily

routines and living conditions. In many cases, moderate changes in taste and smell do not

affect the experience of the quality of food or food preferences (Mojet et al. 2001; Mojet et al.

2003; Kremer et al. 2005; Kremer et al. 2007; Croy et al. 2014; Giacalone et al. 2015).

4.2.3 Food preferences and desire to eat

There is a substantial amount of information about the mechanisms involved in the

development of food preferences and eating habits, especially in children and younger adults.

The degree of acceptance of new foods varies throughout life (Figure 4.2). Adults have a very

stable preference for the foods they have learned to eat, while still remaining open to new

foods. This changes in old age, when people tend to become more averse to new foods

(Dovey et al. 2008). The reasons for this are not yet entirely clear, but are likely to be related

to health issues, changes in the supply of food, as well as a number of psychological and

social factors.

Many food preferences are learned through frequent exposure to certain foods in various

eating situations, which are linked to the local food culture one grows up in. Through

exposure one learns to associate certain foods and products with certain sensory experiences

and to eat foods in certain portions. This presents a challenge to the older person who, having

been self-sufficient suddenly becomes dependent on a meal service and has to adapt to a new

diet. There is insufficient systematic information about how new food is accepted by older

people and how the level of acceptance relates to their health and well-being.

There have only been a few studies on older people's food preferences and habits. It is likely

that the food preferences of the older have specific patterns that can be identified and grouped

through segmentation analyses. Models based on these segmentation analyses can be used to

plan meals for individual people based on their preferences and eating habits. Predictive

consumer models are known from consumer analyses of adults, but also have potential to be

further developed with the care sector of older people in mind. New methods have been

developed to identify dietary preferences and fussy eating in older people (e.g. Maitre et al.

2014; Den Uijl et al. 2014), but it may also be possible to adapt and use other methods of

measuring food preferences and phobias in adults.

Figure 4.2 Development of food acceptance throughout life (Dovey et al. 2008).

4.2.4 Official Danish recommendations

The older people's food preferences are taken into account to some extent when the

municipal meal service offers are planned. The National Food Institute and the National

Board of Social Services (2012) have prepared a guide to provide nutritious diets to older

people in nursing homes and home care. The guide suggests ways to involve older people in

planning the meals and refers to material on the National Board of Social Services' website.

Inspiration for the dialogue with the older can be found in the pamphlets "Open Me –

Refrigerator", "Open Me – Kitchen Cupboard" and "When You Need to Put on Weight"

(National Food Institute and the National Board of Social Services 2012). The government

has decided that older people receiving home care should be offered a choice between at least

two meal providers.

4.2.5 Barriers

Older people's changing perceptions of food can have important consequences for their food

intake and nutritional status. We still lack sufficient understanding of the causes of these

changes and about measures that can stimulate food intake. A number of options for

stimulating appetite should be examined, such as providing tastier meals of a high culinary

quality or food-nudging to remind the older of their mealtimes.

To help older people eat more, we need a better understanding of the degree of pleasure the

older take in eating a delivered meal and of the options for letting them compose their own

meals.

There is a fair amount of information about the decline in the function of the senses, but not

about when this begins to affect the older person's quality of life.

More knowledge is needed about the importance of sensory memory for food choices and

quality of life in old age and what can be done to promote quality of life.

4.2.6 Areas where more research is needed

In Denmark there is no systematic registration of sensory changes in the older and their food

preferences. Gaining more research of this through cohort and intervention studies would

help develop test methods and give the municipalities specific information they could use to

develop and adapt meal services in nursing homes, home care and hospitals. It is very

important that the food for the older is matched as closely as possible to the individual's

needs, eating patterns and preferences. Areas where knowledge is lacking include:

 Encouraging food acceptance and new eating habits in the older.

 The importance of altered sensory memory for food acceptance.

 Sensory factors that promote appetite and food intake.

 Basic preference types, i.e. segmentation of older people into food preferences.

 Systematic information about how combinations of medicines and changes in nutrition

affect the older persons taste sensations.

 Knowledge of preferences and food habits among older people.

4.2.7 Next steps

There is a need for research into the following areas, among others:

 Identifying and segmenting food preferences in older people in nursing homes and home

care in order to form a better basis for developing meal services and deliveries.

 Identifying food preferences from an earlier age (55+) to provide a guideline for meal

services for the future generations of older people.

 Gaining a better understanding of the mechanisms (sensory factors, exposure and

memory) that form the older persons preferences for new foods and product categories,

and using these to promote quicker acceptance and stable food intake.

4.2.8 References

Croy, I., Nordin, S., Hummel, T. Olfactory Disorders and Quality of Life – An Updated

Review. Chemical Senses, 2014; 39: 185-194

Den Uijl, L.C., Ja ger, G., de Graaf, C., Waddel, J., Kremer, S. It is not just a mea l, it is an

emot ional experience – A segmen tation of older persons based on the emotions that they

associate with mealtimes. Appetite, 2014; 83 : 287-296

Doty, R. and Ka ma th, V. The influences of age on olfaction: a review. Frontiers in

Psycholog y, 2014; 5: 1-20

Doty, R. L., Shaman, P., Ap pleb aum, S. L., Giberson, R., Siksorski, L., & Rosenber g, L.

Smell iden tifi cation ability: changes with age. Sc ience 1984; 226, 14 41-1443

Dovey, T.M., Stap les, P.A. , Gibson, E.L., Halford, J.C.G. Food neophobia and 'p icky/f uss y'

eating in children: A review. Appet ite, 2008; 50 : 181-93

DTU og So cialst yrelsen. Ve jled ning t il er næringsvurdering af ældre. DTU og Socialstyr elsen

2012

Giacalone, D., Wendin, K., Kremer, S., Frøst, M.B., Bredie, W.L.P., Olsson, V., Otto, M.H.,

Skjoldbor g, S., Lindber g, U., Risvik, E. Health and quality of life in an aging population -

Food and beyon d. Fo od Quality and Pr eference, 2015 (i trykning).

Handbook of Olfaction and Taste. Doty, R (ed.), CRC Pres s, 2003; 1176 p

Kremer, S., Mojet, J. O. S., Kroeze, J. H. Perception of te xture and flavor in soups by elderly

and young subjects. Journal of te xture studies, 2005; 36, 255-272.

Kremer, S., Mojet, J., Kroeze, J. H. Di fferences in perception of sweet and savou ry waffles

bet ween elder ly a nd young subjects. Fo od Quality and Preference, 2007; 18, 106-116

Maitre, I., Van Wym elbeke, V., Ama nd, M., Vigneau, E, Issa nch ou, S., Su lmon t-Rossé, C.

Food pickiness in the elder ly: Relationship with dependency and malnutrition. Food Quality

and Pr eference, 2014; 32: 145-151

Mojet, J., Christ -Hazelhof , E., Heidema, J. Taste per cep tion with age: generic or specific

losses in threshold sensitivity to the fiv e ba sic tastes?. Chemical Senses, 2001; 26, 845-860

Mojet, J., He idema , J., Christ-Haz elho f, E. Taste perception with age: generic or specific

losses in supra-threshold intensities of five ta ste qualities? Chemical Senses, 2003; 28, 397-

413

4.3 DIETS FOR OLDER PEOPLE IN NURSING HOMES, HOME CARE AND

HOSPITALS

4.3.1 Why it is important

Diets involving food and mealtime restrictions can have a negative impact on the nutritional

status and quality of life of older people. It is therefore important that restrictive diets are only

offered on the basis of evidence.

4.3.2 Use of disease-specific diets

In nursing homes and home care

A survey of residents in 11 different Danish nursing homes showed that 10% had diabetes,

5% had cardiovascular diseases, and 13% had BMIs over 29 kg/m2 (Beck and Damkjær

2007). Among the older with BMIs over 29 kg/m2 there was a higher prevalence of lifestyle

diseases than among those with BMI less than 29 kg/m2 , but also better survival and quality of

life (Beck and Damkjær 2008). The available data does not show whether the residents with

lifestyle diseases were on disease-specific diets.

The report "Meal Services in Nursing Homes" (Beck and Kofod 2003) shows the frequency

of different diets offered to older recipients of meal services in nursing homes and home care.

The total number was 5,572, which corresponds to 15% of the total food that was produced.

By far the most frequent diets were disease-specific diets designed to counteract obesity,

diabetes and cardiovascular diseases. 55% of these diets were diabetic diets (almost 10% of

all produced food), 13% were energy-reduced diets (2% of all produced food), and 12% were

fat- and/or cholesterol-reduced diets (almost 2% of all produced food). By comparison, diets

for people with low appetites made up 6% of all the food produced. As far as we know there

is no newer data, but the websites of various meal service providers status that the disease-

specific diets are still offered.

In hospitals

There is no information on the use of disease-specific diets for older people in hospitals.

4.3.3 Dietary interventions

In nursing homes

No systematic reviews of the evidence basis for disease-specific diets have been found. One

review paper considers, among other things, disease-specific diets designed to counteract

obesity, diabetes and cardiovascular diseases (Darmon et al. 2010). As regards energy-

reduced diets, the authors conclude that these should be avoided for older people over 80

years due to the risk of loss of muscle mass that often accompanies weight loss. A single

randomised controlled study was found that dealt with type-2 diabetes (Coulston et al. 1990).

18 residents of nearly 80 years of age in nursing homes with well-treated type-2 diabetes and

BMIs of around 25 kg/m2 were put on a diabetes diet for four weeks, followed by eight weeks

with regular food, and then again four weeks with a diabetes diet. The participants increased

their energy intake during the period when they ate normal food, mainly because they ate more

cakes and sweets. However, they were not people with low appetites beforehand. During both

periods, 50% of their calorie intake was made up of carbohydrates. During the period with a

regular diet, the proportion of their calorie intake made up by fat rose from 31% to 35%. There

was no difference in weight, blood sugar and cholesterol. It is not clear what the participants

thought of the changes, for instance whether they had difficulty accepting that the foods that

had been forbidden were now allowed again. This was a small study involving well-treated

participants with normal weight and a relatively small change of diet, so it is difficult to make

any general conclusions based on its results.

Similarly, there does not seem to be any evidence as regards fat- and cholesterol-modified

diets, so the preliminary conclusion must be that diets should be based on individual

assessments. As in the case of overweight and high blood pressure, the paradox is that there is

better survival among older people with high levels of total cholesterol (Petersen et al. 2010).

In home care

No intervention studies among older people receiving home care have been found.

In hospitals

In a Swedish study, older patients were given guidance from a clinical dietician once just

before their discharge and then once after (Persson et al. 2007). The focus of the intervention

group was to increase the intake of fatty foods. At the same time the participants were offered

an industrially manufactured nutritional supplement. Cholesterol and other values were

measured in the course of the study. A positive effect was found on weight and everyday

living functions, but no change in cholesterol levels after four months. Unfortunately the

resulting diet composition is not available.

4.3.4 Official Danish recommendations

Pedersen and Ovesen (2009) make the following recommendations for institutional diets:

Like other patients, patients on disease-specific diets can be at risk of undernourishment […].

In such cases it may be necessary to deviate from the diet to restore a good nutritional status.

If the patient is at risk of malnutrition, the diet should be changed to the hospital diet or the

diet for people with low appetites. The same applies to older people in nursing homes and

home care. In any case it is advisable to work with a clinical dietician. Normal menus should

only be used for nutritionally "healthy" people who are hospitalised, moved into nursing

homes or receive meals-on-wheels.

4.3.5 Barriers

There is rarely a chance to make an individual assessment, which is necessary to determine

whether an older person benefits from a certain diet.

If an older person has been on a certain diet for many years, it can be hard for them to

understand that it is suddenly possible to eat as much as they want.

4.3.6 Areas where more research is needed

There is very limited understanding of the effect of disease-specific diets for older people

with diet-related lifestyle diseases in all three settings.

There is a lack of new data on the prevalence of lifestyle diseases among frail older people, as

well as on the effect of different disease-specific diets.

There is also a lack of information about the effect of diets for older people with low

appetites on their blood sugar, cholesterol values, etc.

4.3.7 Next steps

More research is needed in the areas pointed out above.

4.3.8 References

Abbott RA et al. Effectiveness of mealtime in terventions on nutrition al outcomes for the

elder ly living in residential care: A systema ti c review and met a-analysis. Ag eing Research

Reviews 2013; 12 : 967– 981

Beck A, Kofod J. Måltidss ervi ce på plejec entr e. Fødevarerapport 2003; 04

Beck A, Damk jær K. Forebyggelse af tab af fysisk, men tal og so cia l funk tionsevne ved fokus

på ældres ernæringst ilst and og risikof akto rer. DTU Rapport 2007

Beck A, Damk jær K. Op timal body mass index in a nursing ho m e pop ulation. J Nutr Heal th

Aging 2008; 12 : 675-77

Coulston AM, Mandelbaum D, Reaven GM. Di etar y management of nursing home r esiden ts

with non-insulin-dependent diab etes mellitus. Am J Clin Nut r 1990; 51: 67 -71

5. MEAL ACCESS

This chapter consists of three sections focusing on different aspects of older people's ability

to eat and access food. It can be difficult for older people to eat if they are dependent on

eating assistance or have trouble chewing and swallowing food.

5.1 EATING ASSISTANCE IN NURSING HOMES, HOME CARE AND HOSPITALS

5.1.1 Why it is important

Weakening of the hands and arms can cause problems eating and drinking. Older people may

have trouble opening packaging, peeling vegetables or holding a knife, fork, frying pan,

coffee mug, or a heavy glass. It can be hard to bring food and liquids to their mouth or it can

take so long to eat that the food gets cold. Some older people are unable to cook for

themselves, which can make it hard to retain their life skills. Others need to be fed and in

these cases it is especially important to ensure they have a good mealtime experience.

5.1.2 The importance of eating assistance to ensure intake of food and liquid

In nursing homes and home care

Need of eating assistance is one of the risk factors in the National Board of Social Services'

nutritional assessment form. The reason for this is that a close correlation has been found

between need of eat ing assistance and an increased risk of weight loss and death during a 6-

and 12-month follow-up period, respectively, for older people in three nursing homes (Beck

2015). In this study almost one in three residents needed eating assistance.

The National Board of Social Services' cost-effectiveness study, which used the nutritional

assessment form, found that 16%, 12% and 44% of residents at the three participating nursing

homes needed eating assistance – defined as assistance with setting the table, cooking,

serving and eating (National Board of Social Services 2014).

It is unclear how many older Danes receiving home care need eating assistance. If the

nutritional assessment form were applied to older people receiving home care, all those who

receive meal services would score points in the risk factor category "needs eat ing assistance".

However, the experiences from the cost-effectiveness study show that this category was

rarely selected for senior citizens (National Board of Social Services 2014).

The report "Mealtime Services in Nursing Homes" indicates that there are very limited

possibilities of receiving assistance during mealtimes, since there are often only two people

present to assist all the residents, including those who need to be fed (Beck and Kofod 2003).

Feeding is a time-consuming process, especially when more than one person needs it.

In hospitals

In a German study of geriatric patients, 46% said they have trouble cutting up their food,

while 22% needed eating assistance. The challenge was that the nursing staff only indicated

figures of 34% and 10% (Volkert et al. 2010).

(See also the sections on dementia and the importance of the social and meal ambience,

where other intervention studies are described).

5.1.3 Interventions regarding eating assistance

In nursing homes

A systematic literature review including meta-analyses on mealtime interventions among

older people in nursing homes identified six studies (two of which were randomised

controlled studies) focused on eating dependency. Most the studies focused on feeding, but

one also involved offering snacks between meals (Abbott et al. 2013). In one randomised

study, information was compiled about the participants' weight changes, and a positive effect

of feeding was observed. In another randomised study, information was gathered about the

participants' dietary intake, and here a positive effect was also observed. No studies focused

on making it easier for the older to eat by themselves, for example by adapting the mealtimes

to their physical function or using eating aids. No studies used patient-relevant endpoints.

A scoping1 review of multidisciplinary interventions that might improve energy intake, etc. in

older people in nursing homes identified studies focused on the need for assistance with

eating, including the mobilisation of paid staff and volunteers to help and urge residents to eat,

training in this area, social interaction and conversation at mealtimes, as well as measures to

promote older people's ability to eat by themselves (Vucea et al. 2014). There were few

randomised controlled trials, and the endpoints were very different. No conclusions about the

effectiveness of the various methods can be made based on this review.

In home care

No intervention studies among older people receiving home care have been found.

In hospitals

A scoping review of "food first interventions" for hospitalised patients identified 35 studies,

five of which (including one randomised controlled study among older patients) focused on the

patients' need for eating assistance (Cheung et al. 2013). Four of the five studies used trained

volunteers to assist the participants, while the nursing staff in the fifth study was professional

staff. There seems to have been a positive effect on energy intake, which was the main

endpoint. However, all these studies lasted only a few days, and the volunteers mainly helped

during main meals on weekdays. Furthermore, time was spent on training the volunteers

before the start of the studies. The intervention was assessed positively by the volunteers.

1 A scoping review provides an o verall picture o f a specific area in order to i dentify areas where there ma y be a need fo r furth er research. A

systematic review is more in- depth. A scoping review, as o pposed to a s ystematic review, does not assess the quality of the literatu re and

therefore also i ncludes studi es of a lower quality, such as non-randomised studies (Cheung et al. 2013).

No studies focused on making it easier for the older to eat by themselves, for example by

adapting the mealtimes to their physical function or using different aids for eating.

5.1.4 Official Danish recommendations

Needing eating assistance is included as a risk factor in the National Board of Social

Services' nutritional assessment form. This means it is recommended that staff pay attention

to and deal with this risk factor.

The National Board of Social Services' ideas catalogue offers suggestions for this (National

Board of Social Services 2009), as does part two of the Danish Veterinary and Food

Administration's publication "Without Food and Drink" (Danish Veterinary and Food

Administration 2002).

5.1.5 Barriers

Staff should be aware of the residents' potential need for eating assistance. This risk factor is

included in the nutritional assessment form, but there can be challenges when it comes to

older recipients of meal services.

The "needing eating assistance" risk factor is not included in the system used to assess

hospital patients' nutritional risk (National Board of Health 2008), so there may be a risk that

the problem is overlooked by the nursing staff.

Although the use of volunteers is becoming more widespread, it is unlikely to be a useful

basis for a systematic initiative, partly because it takes time to train the volunteers.

5.1.6 Areas where more research is needed

Studies on older people in nursing homes who need assistance to eat have not provided clear

conclusions.

There is a lack of general information about whether meals adapted to the physical abilities of

hospital patients, nursing home residents and older people living at home have a positive

effect on patient-relevant endpoints.

5.1.7 Next steps

The above section describes a number of issues that researchers may want to cover in future.

5.1.8 References

Abbott RA et al. Effectiveness of mealtime in terventions on nutrition al outcomes for the

elder ly living in residential care: A systema ti c review and met a-analysis. Ag eing Research

Reviews 2013; 12 : 967– 981

Beck A. We ight loss, mor tality and associated potentially modifiabl e nutrition al risk fa ctor s

among nursing ho m e residen ts – a Danish follow -up st udy. J Nutr Health Aging 2015; 19 : 96-

101

Beck A & Kofod J. Måltidsservice på plejec entre. Fødevarerapport 2003;04

Cheu ng G et al. Diet ary , Fo od Service, and Mea ltim e Inter ven tions to Promote Food Intake in

Acute Care Adult Pa tien ts. J Nutr ition Gerontol Geriatr 2013 ;32: 175-212

Fødevarestyr elsen. Uden mad og drikke ….del 2. Fødevarerapport 2002; 15

Service styrelsen. Idekatalog – ideer t il gode måltider i plejeboliger og ældres eget hjem.

Service styrelsen 2009

Socialstyr elsen. Cost- effektiveness studi e af tværfa glig ernær ingsindsa ts hos skrøbelige

underernærede ældre. So cial st yrelsen 2014

Sundhedsst yr elsen. Ve jled ning til læger, sygeplejersker, social- og su ndhe dsassistenter,

syg ehjælpere og klin is k e diætister. Su nd hed sst yr elsen 2008

Volkert D et al. Undiagnosed ma lnutrition and nutrition-related problems in ger iat ric patien ts.

J Nutr Health Aging 2010; 14 : 388-92

Vucea V et al. Interven tions for improving mealtime experiences in l ong-te rm care. J

Nutrition Ger ontol Geriatr 2014; 33 : 29 4-324

5.2 DYSPHAGIA IN OLDER PEOPLE IN HOME CARE, NURSING HOMES AND

HOSPITALS

5.2.1 Why it is important

Dysphagia refers to problems with food intake, swallowing and/or other difficulties with

eating and drinking, and often occurs as a result of strokes, dementia or Parkinson's disease.

Dysphagia makes it difficult for the older to chew and swallow normal food. The food's

consistency is rarely ideally suited to the older's ability to chew and swallow, which is why it

is often hard for them to eat neatly and normally. To remedy this problem, many older people

are offered blended food with a low nutrient content and a sad, uniform appearance, which

neither promotes appetite or quality of life.

5.2.2 The significance of dysphagia to the intake of food and liquids

All three settings

The "Thematic Report on Dysphagia: On the Dangers of Problems with Swallowing"

(National Agency for Patients' Rights and Complaints 2012) highlights the fact that

dysphagia is widespread among older people in nursing homes. Up to 90% can experience

problems, especially older people with Parkinson's disease, dementia or complications after

strokes.

Dysphagia is associated with high morbidity and mortality and has great social and personal

costs. In addition, dysphagia may result in poor oral nutrition, malnutrition, dehydration,

problems with swallowing, aspiration pneumonia and even asphyxiation.

The National Agency for Patients' Rights and Complaints has compiled the reported adverse

events in which dysphagia has been a contributing factor. These have been included in the

Danish Patient Safety Database. 121 such adverse incidents were reported between January

2011 and May 2013, of which four were fatal, 14 were classified as serious, and 103 incidents

had moderate to no consequences for the patients. The incidents were primarily reported from

municipalities and hospitals (Bommersholdt 2013).

For some older people, dysphagia becomes a chronic condition, so that the person has to live

with it and consume a chetexture modified diet for many years, which affects both their

nutritional status and quality of life (Andersen et al. 2012).

In nursing homes and home care

Chewing and swallowing problems are two of the risk factors included in the National Board

of Social Services' nutritional assessment form. A close link has been found between

problems with chewing and swallowing and an increased risk of weight loss. Swallowing

problems were also related to an increased risk of death among older people in nursing homes

in a 6- and 12-month follow-up period, respectively (Beck 2015).

A European study among older people receiving home care, which included Denmark, found

a close relationship between swallowing problems and weight loss (Sørbye et al. 2008).

As mentioned above, up to 90% of older people in nursing homes may have problems with

dysphagia (National Agency for Patients' Rights and Complaints 2012). By comparison, a

Danish study among older residents has found that, according to the nursing staff's own

documentation, only 10% of the residents have problems swallowing (Beck 2015). The

National Board of Social Services' cost-effectiveness study, which used the nutritional

assessment form, found that only 18%, 12% and 24% of residents in the three participating

nursing homes had problems with chewing and swallowing (National Board of Social

Services 2014). Another Danish study showed that only 11% of older residents were offered a

texture modified diet (Beck and Kofod 2003). As shown, it is a big challenge simply to

recognise that there is a problem.

Among the 11% who were offered texture modified diets, the most frequently offered diets

were minced diets (8%) and blended diets (2%), while 1% were given other types of food

(Beck and Kofod 2003). The 2005 report "Readymade Food for Pensioners" analysed the

macro-nutrient composition of various diets in 10 kitchens that deliver and serve food to older

people in nursing homes and home care (Hansen and Beck 2005). Minced and blended diets

rarely meet the official recommendations for calories and fat, and both contain too little

protein in the main meals and too few calories in the snacks compared to the recommended

quantities. The report concluded that these diets did not improve the nutritional status and

well-being of older people.

In hospitals

There is not enough documentation of patients' difficulties with eating after being discharged

from hospital wards for stroke victims and released to the primary care sector and this can

have implications for their further rehabilitation. There is currently no documentation of eating

difficulties among people who have had strokes (Zielke Schaarup et al. 2013).

5.2.3 Interventions regarding dysphagia and the intake of food and liquids

In nursing homes

In August 2012, the Centre for Clinical Guidelines approved new guidelines for

recommendations of modified diets and liquids for adults (Andersen et al.2012). The

background was the lack of guidelines for various types of modified diets and liquids, both in

Denmark and internationally.

The guidelines were designed to ensure that people with dysphagia are given sufficient

nutrition and hydration with the lowest possible risk of not being able to swallow. A

systematic literature review was conducted to answer the following questions:

 What evidence is there that a modified diet can significantly reduce aspiration in adults

with upper dysphagia?

 What evidence is there that adults with upper dysphagia can achieve better nutrition and

fluid intake with a modified menu than with a normal menu?

 What evidence is there that adults with upper dysphagia who receive modified menues

and/or liquids achieve better nutrition (weight and BMI) than with normal food and

liquids?

 What evidence is there that adults with upper dysphagia who receive modified diets

and/or liquids experience significantly less aspiration pneumonia than with regular food

and liquids?

The clinical guidelines were based on 16 papers (10 papers based on randomised controlled

studies, four systematic review papers and two papers based on cohort studies). In many of

these papers it was unclear what food and liquids the participants had actually been given, so it

was only possible to give specific recommendations regarding the type of food and liquids that

should be given to older people in nursing homes to improve their nutritional status and intake:

customised and nutrient-enriched modified diets (soft and pureed food in the form of timbales)

and liquids (nectar, honey and pudding consistency) plus options can be recommended for

older people with chronic dysphagia. This recommendation was based on a single randomised

study which was downgraded because it did not meet part of the criteria when it was reviewed

(Andersen et al. 2012). It was not possible to draw any conclusions with regard to patient-

relevant endpoints, in this case aspiration pneumonia.

In home care and hospitals

No randomised controlled studies were found.

5.2.4 Good examples

In its food and mealtime policy "Appetite for Life", Copenhagen Municipality has set out its

aim "to provide food with a consistency that is easy for older people to eat, and to assess the

older persons ability to chew and swallow". To achieve this aim, the municipality has started

an interdisciplinary project involving nurses, occupational therapists and kitchen staff. It is

also important to work on the food's sensory qualities, i.e. to make the texture modified food

look inviting and taste and smell good (Diætisten 2013).

Aalborg Municipality has established an interdisciplinary collaboration on food for older

people with dysphagia that involves assessment, home care, dieticians, occupational

therapists and Ålborg meal service. In addition, on-the-job training courses have been

established for different professional groups, along with a close cooperation with the hospital

(Diætisten 2013).

5.2.5 Official Danish recommendations

The clinical guidelines (Andersen et al. 2012) include the following recommendations (Figure

5.1):

Individual advice and continuous guidance, as well

as adjustment of modified fluid and diet in

cooperation with a clinical dietitian and an

occupational therapist

As an example, the "stairs of texture" from the

"Recommendations for Danish Institutional Diets"

can be used in examination and training situations

Chin down procedure and thin fluids.

Self-selected diet texture

For older nursing home residents, there should be a

choice of different options of chew- and swallowing

friendly diets, such as a soft diet, a purée diet and a

gratin diet.

Figure 5.1

Chewing and swallowing problems is one of the risk factors in the National Board of Social

Services' nutritional assessment form, so care staff should be aware of and deal with it.

There are official Danish recommendations for texture modified diets. These are described in

the "Recommendations for Danish Institutional Diets" (Pedersen and Ovesen 2009) and in

The Complete National Diet Handbook (http:/www.kostforum.dk/).

5.2.6 Barriers

It is important that the staff is aware of the risk of dysphagia so they can take appropriate

measures. This risk factor is included in the nutritional assessment form, but it seems to be a

challenge to recognise the problem.

Dysphagia is not included in the method used to assess the nutritional risk to hospitalised

patients (National Board of Health 2008), so there is a risk that the staff may overlook the

problem.

The National Agency for Patients' Rights and Complaints points out that one of the problems

is that the staff is unable to recognise and distinguish between the different types of texture

modified diets (National Agency for Patients' Rights and Complaints 2012). When the clinical

guidelines for modified diets and liquids for people with dysphagia were being prepared, it

was also very difficult to identify what kind of texture modified diets the participants were

actually given in the individual studies. The problem with recognising the various types of

texture modified diets is not confined to Denmark, and an international initiative has been

launched to achieve consensus in this area (see more here http://iddsi.org).

5.2.7 Areas where more research is needed

There is very limited understanding of the effect of modified diets and liquids for people with

dysphagia. In particular, there is a lack of knowledge about the possibilities of optimising

these diets when it comes to nutrient composition, taste, variety and appearance.

Keller has suggested a number of relevant research and development opportunities (Keller et

al. 2012):

 How widespread is the use of texture modified diets in the different settings?

 What are the indications for the use of texture modified diets?

 What are the barriers to offering texture modified diets?

 Can prescribing a specific texture modified diet have a positive effect on the patients'

nutritional status and relevant endpoints?

 Do the recipes meet the recommendations for macro-nutrient composition?

 Which taste sensations are most important for people with dysphagia?

5.2.8 Next steps

The above section describes a number of issues that researchers may want to cover in future.

5.2.9 References

Andersen UT et al. Klinisk r etningslinje for modificeret kost og væske til voksne (≥18 år )

personer med øvr e dy sfagi, Ce nter for Kliniske Retningslinjer 2012. Publiceret i: Andersen

UT, Beck A, Hansen T, Kjærsgaard A, Poulsen I. Systema ti c revi ew and evidence ba sed

reco mm en dations on texture mod ifi ed foods and thickened fluids for adul ts (≥ 18 years) wi th

oropharyngeal dyspha gia. e-SPEN online June 2013

Beck A. We ight loss, mor tality and associated potentially modifiabl e nutrition al risk fa ctor s

among nursing ho m e residen ts – a Danish follow -up st udy. J Nutr Heal th Aging 2015; 19 : 96-

101

Beck A & Kofod J. Måltidss ervi ce på plejec entre. Fødevarerapport 2003; 04

Bommersholdt ME. Utilsigte d e hæn delser giver brugbar viden om forebyggelse af

fejlsynkning. Diætisten 2013; 125 : 10-12

Diætisten. Temanummer om dysfa gi. Diætisten oktober 2013

Hansen K & Beck A. Færdigmad til pen sionis ter. Danmarks Fødevareforskning, marts 2005

Kell er H, Chambers L, Niezgoda H, Duizer L. Issues associated with the use of m odified

texture foods. J Nu tr Heal th Aging 2012; 16 : 195-200

Patien to mb uddet. "Tem arapport om dysfa g i – om faren ved fejlsynkning". Pati entomb uddet,

2012

Pedersen A, Oves en L (red.). An bef alinger for den dans ke institutionskost. Fødevarestyrelsen

2009

Socialstyr elsen. Cost- effektiveness studi e af tværfa glig ernær ingsindsa ts hos skrøbelige

underernærede ældre. So cialst yrelsen 2014

Sundhedsst yr elsen. Ve jled ning til læger, sygeplejersker, social- og su ndhe dsassistenter,

syg ehjælpere og klin is k e diætister . Su nd hedsst yr elsen 2008

Sørbye LW, Schroll M, Finn eS overi H, Jonsson PV, Topinkova E, Ljunggren G, Bernabei R.

Unintended we ight loss in the elderly living at ho me: the aged in Home Car e Project

(AdHOC). J Nutr Health Aging. 2008 ; 12 : 10-6

Zielke Schaarup S et al. Identifikation af vanskel ighe der med at spise hos patien ter/borg ere

(>65 år) efter ap opleksi med henb lik på at iværksætte en må lret tet indsats. Center for Kl iniske

ret ni ng sl injer 2013

5.3 CHEWING PROBLEMS IN OLDER PEOPLE IN HOME CARE, NURSING

HOMES AND HOSPITALS

5.3.1 Why it is important

Losing teeth is not a natural part of old age. With the right dental hygiene, people can keep

their own teeth for their whole lives. However, many people either lose some or all their teeth

and need dentures. Dental problems make it harder to bite and chew properly. Losing teeth

can also make the older person lose the desire to eat. Dentures can create problems, as can

poor oral hygiene.

5.3.2 The importance of chewing problems to the intake of food and liquids

In nursing homes and home care

There is a high prevalence of dental disease in older people in nursing homes and home care,

and an unmet need for help with daily dental care.

Among residents of Swedish nursing homes in 2009, 78% needed help with oral hygiene, but

only 7% received the necessary help (Hede et al. 2014). In a Danish study among older

residents, according to the nursing staff's documentation, only 20% of the residents had

chewing problems and only 5% had problems with oral hygiene (Beck 2015). According to the

National Board of Social Services' cost-effectiveness study, which was based on the

nutritional assessment form, only 18%, 12% and 24% of residents in the three participating

nursing homes had problems with chewing and swallowing (National Board of Social

Services 2014). Only 5% of older people in nursing homes and home care were offered dental

care.

Dental diseases and deficient oral hygiene contribute to serious health problems in the older.

Several studies conclude that poor oral health significantly lowers older people's quality of

life (Hede et al. 2014).

Chewing and swallowing problems are one of the risk factors in the National Board of

Social Services' nutritional assessment form, because a close link between chewing and

swallowing problems and increased risk of weight loss among older people in nursing homes

was shown in a 6- and 12-month follow-up period respectively (Beck 2015).

A European study among older people receiving home care, which included Denmark,

demonstrated a clear link between mouth problems and weight loss (Sørbye et al. 2008).

A 2003 report, "Mealtime Service in Nursing Homes", states that the most frequently offered

chewing- and swallowing-friendly diets were minced diets (8%) and blended diets (2%)

(Beck and Kofod 2003). The 2005 report "Readymade Food for Pensioners" analysed the

macro-nutrient composition of various diets in 10 kitchens that deliver and serve food to older

people in nursing homes and home care (Hansen and Beck 2005). Minced and blended diets

rarely meet the official recommendations for calories and fat, and both contain too little

protein in the main meals and too few calories in the snacks compared to the recommended

quantities. The report concluded that these diets, as they were composed at the time, did not

improve the nutritional status and hence the well-being of older people.

In hospitals

A Danish survey among geriatric patients found a clear link between mouth problems and

poor nutrition (Poulsen et al. 2006).

5.3.3 Interventions regarding poor dental health and intake of food and liquids

All three settings

Danish studies have provided evidence that effective mouth care programmes can

significantly prevent pneumonia in nursing homes (Hede et al. 2014). These studies have

focused on tooth brushing, etc., rather than on interventions regarding food and mealtimes.

Data on the participants' dietary intake, etc. is not available, but some studies have found

positive effects on various aspects of everyday living, which indicates that there may also

have been a positive effect on the nutritional status.

In nursing homes

An 11-week study covering a total of 121 Danish residents in nursing homes included several

types of interventions: providing chocolate and energy-rich drinks, exercise, and dental care

once or twice a week by the dental hygienist. The study found a positive effect on the older's

nutritional status, muscle strength, balance and social function (Beck et al. 2008; Beck et al.

2010). However, there were problems with compliance with the dental care, since many

residents were not ready when the hygienist came, and plaque was not reduced (Beck et al.

2009). The prevalence of pneumonia was not included as an endpoint.

In home care and hospitals

No intervention studies among older people in home care or hospitals were found.

5.3.4 Official Danish recommendations

Dental health problems are one of the risk factors in the National Board of Social Services'

nutritional assessment form. This means it is recommended that staff pay attention to and deal

with this risk factor.

5.3.5 Barriers

According to the official recommendations, diets for people with low appetites should include

plenty of sweet foods, and between-meal snacks are important, especially in the evening

(Pedersen and Ovesen 2009). In practice, snacks in the form of energy-rich drinks are

particularly effective at increasing older people's calorie intake. But trying to improve the

nutrition of older people by serving them goodnight drinks containing sugar may aggravate

another big problem, namely poor dental health (Kragelund and Beck 2004).

Not nearly enough people are offered dental care, and the staff may not have time to offer

oral hygiene care (Klebak 2014).

5.3.6 Areas where more research is needed

There is clear evidence that poor oral and dental health has a negative impact on older

people's nutritional status. It has also been shown that it is possible to improve oral and

dental health through systematic care by a dental hygienist and dentist. However, there is a

need for studies on whether the improved oral and dental health in fact results in better

nutrition.

In addition, we do not know enough about the possibilities of optimising texture modified

diets (i.e. their nutrient composition, taste, variety and appearance), or about the effects of an

intervention focused on both oral hygiene and meals and mealtimes.

5.3.7 Next steps

The above section describes a number of issues that researchers may want to cover in future.

5.3.8 References

Beck A. We ight loss, mor tality and associated potentially modifiabl e nutrition al risk fa ctor s

among nursing ho m e residen ts – a Danish follow -up st udy. J Nutr Health Aging 2015; 19:96-

101

Beck A, Damk jær K, Be yer N. Multifaceted nutrition al inter ven tion am ong nursing ho m e

residen ts has a positive influence on nutrition and function. Nutr ition 2008; 24 : 1073-80

Beck A, Damk jær, Sørbye LW. Physical and social function al abilities seem to be maintained

by a multifaceted ra ndomized control led nutrition al interv ention among old (65+ y) Danish

nursing home r es iden ts. Arch Gerontol Geriatr 2010; 50: 351-355

Beck A, Damk jær K, Tetens I. Lack of co mp liance of staf f in an interv ention study with focus

on nutrition, exercise and oral car e am ong old (65+ y) Danish nursing ho me res iden ts. Aging

Clin Exp Res 2009; 21: 143-9

Beck A & Kofod J. Måltidss ervi ce på plejec entre. Fødevarerapport 2003; 04

Hansen K & Beck A. Færdigmad til pen sionis ter. Danmarks Fødevareforskning, marts 2005

Hede B et al. Shared Oral Care – evaluering af et mund hygiejneprogra m på fem plejec entre.

Tandlægeblad et 2014; 118: 980-986

Kleb ak A. Bedre mundhygiejne på plejec entr e kan redde liv . Tandlægebladet 2014; 12: 1012

Kragelund I & Beck A. Et sødt smil. Sygeplejersken 2004; 22 : 38-41

Pedersen A, Oves en L (red.). An bef alinger for den offen tlige institutionskost.

Fødevarestyr elsen 2009

Pou lsen I et al. Nu triti onal st atu s and associated factors on ger iatri c admission. J Nutr Health

Ageing 2006; 10: 84-90

Socialstyr elsen. Cost- effektiveness studi e af tværfa glig ernær ingsindsa ts hos skrøbelige

underernærede ældre. So cialst yrelsen 2014

Sørbye LW, Schroll M, Finn eS overi H, Jonsson PV, Topinkova E, Ljunggren G, Bernabei R.

Unintended weight loss in the elderly living at home: the aged in Home Car e Project

(AdHOC). J Nutr Health Aging 2008; 12: 10-6

6. MEALTIME EXPERIENCE

This chapter consists of two sections, both of which deal with issues that are important to the

meal experience. The first section concerns reduced appetite and resulting reduced intake of

food and liquids. The second concerns the meal ambience and the social interaction.

6.1 REDUCED APPETITE AND INTAKE OF FOOD AND LIQUIDS IN OLDER

PEOPLE IN NURSING HOMES AND HOME CARE

6.1.1 Why it is important

With age, the delicate appetite regulation system becomes less sensitive, so that energy intake

is not automatically adapted to energy needs. This often results in a negative energy balance,

leading to weight loss, which has serious consequences for the older person's well-being,

quality of life and physical and social function. Poor nutrition can also have major societal

consequences.

6.1.2 Knowledge about intake of food and liquids

There is no systematic collection of data on the food intake of older Danish people aged 75

years old or more, since this group is not covered by the Technical University of Denmark' s

nationwide diet studies. The following is therefore based on information compiled in

connection with various research projects.

In a Danish study from 2002, the energy intake of older people in nursing homes and home

care was above the estimated need; with a PAL value of 1.4-1.5 (PAL is a measure of

physical activity level). Despite this, a number of older participants were underweight (Beck

and Ovesen 2002).

In a more recent Danish study among older people in nursing homes, the energy intake was

slightly lower, with a PAL value of 1.2 (Beck et al. 2008, Beck et al. 2010). In this

intervention study, the participants in the control group did not increase their energy intake,

but still maintained their weight, which indicates that their energy intake was sufficient.

However, here too, some participants were underweight.

The above findings would seem to illustrate the problem many older people have with

recurring periods of reduced energy intake due to various nutritional risk factors. These risk

factors can be due to disease, lack of appetite regulation, etc. After a period of reduced energy

intake, they do not necessarily start to eat more, unlike younger people (Ingerslev et al. 2002).

Thus they only slowly reach the level of their original energy intake, if at all, before a new

period of reduced appetite occurs.

6.1.3 Interventions to increase intake of food and liquids

This section focuses on interventions to increase energy intake by means of food and liquids,

without using appetite stimulants or other similar methods.

Systematic reviews of the literature on the effect of nutritional interventions among older

people with poor nutrition show that these interventions mostly use industrially produced

energy- and protein-rich drinks. The biggest of these reviews, covering 62 studies including

meta-analyses, is a Cochrane review on the effect of nutritional interventions among older

people who are malnourished or are at risk of malnutrition, including older people in nursing

homes and home care (Milne et al. 2009). The review concluded that the interventions had a

positive effect on the participants' weight and a tendency towards a positive effect on

survival, but that there was no demonstrated effect on physical and mental function or quality

of life, mainly due to lack of data.

The same conclusion is drawn in a more recent systematic literature review focused on

industrially produced energy and protein drinks (Cawood et al. 2012). The most recent

systematic review by the Swedish Council on Health Technology Assessment, which only

comprises 10 studies because it uses different inclusion criteria, also concludes that there is a

lack of documentation of a positive effect on patient-relevant endpoints (Swedish Council on

Health Technology Assessment 2014).

A systematic literature review looked at three randomised controlled studies in which the

food was adapted by offering snacks and exemptions from the diet (Abbott et al. 2013). The

meta-analysis found no changes in the participants' nutritional status.

When the National Board of Social Services prepared its "Recommendations for Nutritional

Interventions for Older People with Unplanned Weight Loss", it conducted a systematic

literature review to identify randomised controlled studies of the effect on physical function,

etc. in older people who are discharged from hospitals with or without a plan for rehabilitation,

older people who are assessed for municipal rehabilitation, and older people in nursing homes

and home care (National Board of Social Services 2015). The board found 15 studies of older

people in nursing homes and eight studies of older people in home care.

Two studies of older people in nursing homes focused on optimising the food. In one of these

studies, 41 residents with BMIs under 18.5 kg/m2 were given calorie-rich meals with added

cream, etc., and homemade energy and protein drinks for 12 weeks (Leslie et al. 2012). A

non-significant but nevertheless positive weight gain was found in the intervention group.

Patient-relevant endpoints were not evaluated, but there appears to have been a positive effect

on survival (5% vs. 26% dead), which the authors, however, do not comment on.

In the second study residents at risk of undernourishment (mini-nutritional assessment

(MNA) ≤ 23.5) were given energy- and protein-rich meals and snacks with added cream,

protein powder, etc. for 12 weeks (Smoliner et al. 2008). Among the 52 participants (22 in the

intervention group), there was no difference in intake, weight, quality of life and everyday

physical function after 12 weeks.

No studies among older people receiving home care focused on optimising the food.

(See also the section on dementia and physical function, which describes other intervention

studies).

6.1.4 Good examples

Figure 6.1 is from the National Board of Social Services. National Action Plan for Meals and

Nutrition for Older People in Nursing Homes and Home Care.

Figure 6.1

6.1.5 Official Danish recommendations

There are official Danish recommendations for food and liquids for older people in nursing

homes and home care. These are described in the "Recommendations for Danish Institutional

Diets" (Pedersen and Ovesen 2009) and in The Complete National Diet Handbook

(http:/www.kostforum.dk).

Reduced dietary intake is listed as a risk factor in the National Board of Social Services'

nutritional assessment form. This means it is recommended that staff pay attention to and deal

with this risk factor.

The National Board of Social Services is preparing its "Recommendations for Nutritional

Interventions for Older People with Unplanned Weight Loss", which partly focuses on

 Senior Center "Kastaniehaven"

At the senior center, "Kastaniehaven" in Give, they have experience

working with food, meals and nutrition as part of the overall effort. The

food is produced in each individual unit with the greatest possible

involvement of the residents. Social and health care staff in charge of

shopping and cooking, is supported both kitchen technically and

nutritionally by the professional kitchen manager of the day center café.

The kitchen manager of the day center café has the overall responsibility

for the quality of the menus and the self-inspection. The nurse at the

senior center ensures that there will be developed action plans in

relation to residents who are particularly at nutritional risk. Thereby, the

meals are planned and prepared with the involvement of the older as

well as various professional groups.

nutritional interventions for older people in nursing homes and home care (National Board of

Social Services 2015, in consultation).

The National Board of Health's "Tools for Early Detection of Signs of Disease, Impaired

Physical Function and Undernourishment" describe how to become aware of changes in the

older persons physical function and nutritional status at an early stage (National Board of

Health 2013).

Danish Regions, Local Government Denmark and the Danish College for General

Practitioners oversee various initiatives to ensure increased information, availability and use

of the "Tools for Early Detection of Unplanned Weight Loss" as well as better collaboration

and communication between GPs and municipalities. The work on these tools will support

nutritional interventions in nursing homes and home care (National Board of Health 2013).

6.1.6 Barriers

One barrier is that it takes extra time to screen the older people, train the staff and enlist the

assistance of a clinical dietician (NICE 2006). However, the time spent on the actual

intervention, e.g. serving snacks and nutritional drinks, is minimal.

The National Board of Social Services' cost-effectiveness study also calculated the time spent

on interdisciplinary nutritional interventions, including time spent on screening, training and

the assistance of the clinical dietician, though not on serving the food and fluid (National

Board of Social Services 2014). The conclusion was that the extra time was well spent, since

the older persons increased quality of life made the intervention cost-efficient.

In a survey carried out in the Danish municipalities in October 2013 in connection with the

preparation of the report "Malnutrition: the Hidden Social Problem", 65 out of 98 surveyed

municipalities responded (Arla Foods and the Danish Diet and Nutrition Association 2014).

Only 16% of the municipalities prioritise the food's energy density; almost a third do not

have a written strategy for providing food to the older; almost half follow the official

recommendations for the Danish institutional diet; 60% carry out systematic nutritional

screening; and 40% offer dietary and nutritional guidance.

6.1.7 Areas where more research is needed

There is a lack of recent data on the dietary intake of older Danish people in nursing homes

and home care.

Although many intervention studies have been conducted among older people in poor

nutritional condition, they have primarily involved adding industrially produced energy- and

protein-rich drinks, and there is seldom data on patient-relevant endpoints.

There is a lack of information on whether optimising food for older people in nursing homes

and home care can have a positive effect on their well-being, quality of life and physical and

social function, as well as on the national economy as a whole.

6.1.8 Ne xt steps

Studies in the areas where more information is needed, as pointed out above.

6.1.9 References

Abbott RA et al. Effectiveness of mealtime in terventions on nutrition al outcomes for the

elder ly living in residential care: A systema ti c review and met a-analysis. Ag eing Research

Reviews 2013; 12 : 967– 981

Arla og Kost- og Ernæ ringsf orbund et. Underernær ing – det skjulte samfundsprob lem . Arla og

Kost - og Ernæ ringsforbund et 2014

https://www.kost.dk/sites/default/files /uplo ads/ public/underernaer ing- publikation.p df

Beck A, Oves en L. Body ma ss index, weight loss and energy intake of old Dani sh nursing

home res ident s a nd ho me-ca re clien ts. Scand J Car ing Sci 2002; 16: 86-90

Beck A, Damk jær K, Be yer N. Multifaceted nutrition al inter ven tion am ong nursing ho m e

residen ts has a positive influence on nutrition and function. Nutr ition 2008; 24 : 1073-80

Beck A, Damk jær K, Sørbye LW. Physical and social functional abilities seem to be

maintained by a multifaceted ra ndomized control led nutriti onal inte rvention am ong old (65+

y) Danish nursing home r es idents. Arch Gerontol Geriatr 2010; 50 : 351-355

Cawood AL et al. Systema ti c review and meta-analysis of the effects of high protein oral

nutrition al su pplements. Ag eing Research Reviews 2012; 11: 278–296

Ingerslev J et al. Ernæring og aldring. Ernæringsråd et 2002

Leslie WS et al. Im proving the dietar y intake of under nourished older peop l e in r esiden tial

car e homes using an energy-enriching food approach: a cluster ra ndomized controlled study. J

Hum Nu tr Diet 2012; 26: 387– 394

Milne et al. Protein and energy su pplemen tation in elder ly people at risk fr om ma lnutrition.

Cochra ne Database of Systematic Reviews 2009, Issue 2. Ar t. No.: CD003288.

DOI:10.1002/14651858.CD003288.p ub3

NICE. Nutr ition support in adults: oral su pplemen ts, en teral tube feeding and paren teral

nutrition. Ap pen dices 2006

Pedersen A, Oves en L (red.). An bef alinger for den dans ke institutionskost. Fødevarestyrelsen

2009

SBU. Kost tilläg g för undernärda äldre. SBU no vemb er 2014

Smol iner C et al. Effects of food for tifi cation on nutrition al and funct ion al status in frail

elderly nursing ho m e resident s at risk of malnutritio n . Nutr ition 2008; 24: 1139–1144

Socialstyr elsen. National Handlingsplan for må ltider og er nær ing til ældre i hjemmep lejen og

plejeboligen. So cialstyr elsen 2013

Socialstyr elsen. Cost- effektiveness studi e af tværfa glig ernær ingsindsa ts hos skrøbelige

underernærede ældre. So cialst yrelsen 2014

Socialstyr elsen. Fa glige anbef alinger og beskrivelse af god praksis for ernær ingsindsat s til

ældre med uplanlagt vægttab So cialst yrelsen 2015. I høring

Sundhedsst yr elsen. Værktøjer til tidlig opspor i ng af sygdomstegn, nedsat fysisk

funk tionsniveau og und erernæring - sa mmenfa tning af anbef alinger. Sundhe dsstyr elsen 2013

6.2 THE SOCIAL INTERACTION AND THE IMPORTANCE OF THE MEAL

AMBIENCE FOR THE DESIRE TO EAT

This section first deal with the social aspects of the mealtime experience and then discusses

the importance of the meal ambience.

Among other things, this section considers the extent to which older people's senses and

appetites are stimulated when they smell food; the importance of the dining room's layout;

the importance of feeling that one is eating in a community with others; the importance of a

comfortable eating situation; and the consequences of getting the necessary assistance during

the meal.

6.2.1 Why it is important

Older people thrive better when they have a good meal ambience and a good social

interaction during mealtimes, whether they are eating in their own homes, in nursing homes

or in hospitals.

The social framework for meals differs depending on whether the older person lives at home,

in a nursing home, or has been admitted to hospital. It also depends on the older people

themselves. How self-reliant are they? Is the meal being served in the home of a person who

is alone and lonely? Is the meal being served in a nursing home, where meals are usually

eaten together with others, but where some residents may prefer to eat alone? Is the meal

served in a dining club for the older? If the older is in the hospital, do they eat their meals in

the common room or in their bed in the ward?

Regardless of the settings they eat their meals in, most people associate meals with a social

context, such as being with their spouse, family, friends or colleagues. For older people it is no

different, regardless of whether they eat their meals at home, in a nursing home or in a

hospital. However, experience shows that many older who still live at home eat alone, that

meal times in hospitals are not used as part of the treatments, and that meal times in nursing

homes are focused on all kinds of other things than creating a social interaction. This can have

consequences for the older persons health and quality of life, which is why it is important to

know what opportunities there are for organising mealtimes differently.

6.2.2 The significance of the meal's social interaction

All three settings

One study (Kofod 2000) among users of public meal services in all three settings found that

the most important parameter for a good mealtime experience was a social setting that the

users felt comfortable with. This increases older people's satisfaction with the meals, as well

as the amount of food they eat. In other words, the social interaction is more important than

what is on the plate.

The older attach great importance to eating with people they know and whom they

themselves have chosen to eat with. They don't want to eat with older people who eat and

drink messily because they are given food and liquids with a texture modified consistency or

do not get enough eating assistance (Danish Veterinary and Food Administration 2002a). This

shows that the perception of a meal can be complex, as can preparing and serving meals as

part of a social service.

As for the older people who eat less neatly, the awareness of this can worsen their nutritional

condition, and there is a risk that the surrounding diners may lose their appetite. Similarly,

physical disabilities can make it challenging for older people to eat and thereby weaken their

nutritional status.

In nursing homes

In nursing homes, older people with dementia, Parkinson's disease, etc. may have trouble

communicating. This makes it hard for them to take active part in the socialising during

mealtimes. Other residents will often avoid talking to them because they seem unresponsive.

Thus older people with these types of illnesses often feel socially isolated. Some people with

dementia have periods of disruptive behaviour such as yelling, excessive suspicion, jealousy,

delusions or aggression, which can also lead to social exclusion (Danish Veterinary and Food

Administration 2002b).

The older person may find it undignified not to be able to cut up their own food. Instead of

asking for help, some may choose to eat alone.

Serving food and liquids with the wrong consistency to older people with chewing and

swallowing problems can lead to them filling their mouths with food, drooling, coughing,

feeling pain, spitting out the food and vomiting. The result is a poor mealtime experience for

both the older people themselves and their fellow diners (Kofod 2000).

A 2003 Danish study found that there was a larger proportion of underweight older people

among residents of nursing homes with a low level of social interaction (Beck, Ovesen 2003).

Also, older people who chose to eat alone were more likely to be underweight than those who

ate with others. However, an interesting finding was that the older who chose to eat alone

functioned better mentally than the other residents, and perhaps precisely for this reason did

not want to eat with lower-function residents.

Social statuses and life histories also affect who the older want to eat with, and their

experience of the quality of mealtimes increases when they can be in the company of the

residents they want to eat with (Kofod 2000). Where the residents are placed during

mealtimes is important, as their nutritional condition can be negatively affected if they do not

enjoy the social interaction (Kofod, Birkemose 2004).

In a Swedish study, some residents clearly stated that they did not want to eat with others at

all. They were reluctant to share a table with residents with various eating problems, though

the nursing staff considered this better (Sidenvall et al. 1994).

Many mealtime-related conflicts can be resolved early if the staff are sufficiently attentive to

the importance of the social interaction (Kofod 2000, Beck et al. 2006). The report "The

Future Diet for Older People" (Beck and Kofod 2003) therefore recommended that basic

degree programmes and on-the-job training courses for care workers focus more on how to

create social contact between residents and preventing and resolving conflicts so that they do

not negatively affect the common meals (see also the chapter on staff skills).

In home care

For single older people in particular, losing their physical abilities can make it difficult to

maintain a social network, including during meals. This can have a very negative impact on

their appetite and nutrition, since one of the areas where the social interaction is key to the

experience of mealtime quality is with single older recipients of meal services. The food does

not become a "proper" meal, because the social interaction around food is completely missing

(Kofod 2000).

In connection with "The Future Diet for Older People" report, the researchers wanted to look

more closely at whether single older people receiving meal services would change their

calorie intake if they were offered communal meals. The idea was that the carer, as well as

preparing the meal, would also eat a snack or their packed lunch and speak to the older person

during the meal (Beck and Kofod 2003). However, the study was not carried out, since not

enough participants could be found. A potential participant said that they refused because "I

eat messily because I have a paralysed arm".

For the same reason, in a Swedish study, two older women who were hospitalised for long

periods of time refused to participate in the common meals in the dining room due to frailty

or paralysis, since they did not feel able to live up to their own standards for table manners

(Sidenvall et al. 1994).

There are various possible reasons for the lack of interest in participating in the trial. Like the

Swedish women, some do not wish to participate in communal meals because they do not feel

they can live up to their own standards for table manners due to paralysis or other types of

impairment. Others may not feel that the home carers are attractive social company (Beck and

Kofod 2003).

In hospitals

Some older patients do not have the opportunity to socialise because they cannot get out of

bed or their rooms. Others would like to, but have a hard time making friends because the

patient turnover is too rapid. Other older people choose not to eat with the others because

they do not want to be identified as "a sick person". A final group prefer to eat alone because

they do not feel up to being around other people and cannot live up to the norm of socialising

or eating neatly (Kofod 2000).

6.2.3 Interventions regarding the meal's social interaction

In nursing homes

A systematic review focusing on food assistance for residents with dementia in nursing

homes found a single controlled intervention study that focused on the social framework for a

group of residents who planned, prepared, ate and cleaned up after breakfast together, assisted

by an occupational therapist, which improved a number of cognitive functions compared to

the control group (Whear et al. 2014).

Another systematic review identified a single controlled study in which residents with

dementia in a nursing home had lunch together with the nursing staff. At the same time, an

effort was made to improve the meal ambience. This had a positive effect on the residents'

weight after three months when compared to residents in another nursing home (Abbott et al.

2013).

In home care and hospitals

No intervention studies with a focus on the social interaction were found.

6.2.4 Good examples

The evaluation of a project in Herlev Hospital shows that meal hosts can give older patients

with low appetites a greater desire to eat (Lund 2012). Meal hosts are people with expertise in

food and mealtimes who act as supporting staff to help give the patients back their desire to

eat. The meal hosts helped ensure a greater focus on the individual's dietary intake and on the

meal experience. In addition, they increased cooperation between the kitchen staff and the

other staff and reduced food waste.

The National Action Plan for Meals and Nutrition for Older People in Nursing Homes and

Home Care describes how the organisation DaneAge and Odense Municipality have

collaborated on the project "Eating Friends", designed to help recipients of home care meal

services (National Board of Social Services 2013). An "eating friend" is a volunteer visitor

from DaneAge who eats with and keeps the older person company. The initial experiences

show that a volunteer eating friend can improve an older person's weight, physical function

and mood. Among 25 older people, 15 gained weight and 10 of those improved their physical

functions. Every third participant stated that they felt in better health as a result of the project.

6.2.5 The significance of the meal ambience

In nursing homes

According to a report based on a survey of Danish nursing homes, as early as 2003, many

nursing homes sought to improve their meal ambiences (Beck and Kofod 2003). However,

there is still room for improvement. For example, only one in four nursing homes set tables

before meals, and two out of three dispense medication during meals. This can create unease

and disturbance, especially among older residents. In general, there is often a lot of traffic

(including wheelchair users) in the dining room during meals, as well as a fair amount of

noise from the diners themselves.

In home care

No studies focusing on the meal ambience were found.

In hospitals

In a study among older medical patients in Glostrup Hospital, 11 issues that affected the

patients' mealtime experiences were identified: communication, food ordering, preparation of

the meal ambience, space, hosting, urging patients to eat, interruptions, social interaction,

organisation, snacks and the food.

These factors all play a part. For example, the hospital could serve gourmet dishes or set up a

new ordering system without necessarily improving the patients' overall meal experience.

Therefore, to improve the overall mealtime experience it is necessary to address more than a

single issue (Glostrup Hospital 2012).

6.2.6 Interventions regarding the meal ambience

The following describes the intervention studies that were found. a systematic review

identified three randomized controlled studies focused on the meal ambience in nursing

homes. A meta-analysis showed that the studies found no positive effect on older people's

energy intake and weight (Abbott et al. 2013). However, a Dutch study found very positive

results regarding nutrition, physical function and quality of life when seeking to imitate

typical family meals based on the following five factors: table setting, food serving, the role

of the staff, the role of the resident, and a mealtime setting without other disruptive activities

(Nijs et al. 2006).

In home care

No intervention studies that focused on the meal ambience among older people in home care

were found.

In hospitals

A scoping review focusing on mealtime interventions in nursing homes and among older

people who were hospitalised for long periods of time found an older Swedish study with a

before-and-after design in which changing the interior decoration of the dining room to a

1940s style improved the residents' energy intake (Vucea et al. 2014).

Another scoping review focusing on nutritional interventions for hospitalised patients,

including the effect of so-called protected meals, found eight studies, but none were

controlled (Cheung et al. 2013). Many of the studies have focused on preventing disturbances

during the meal, which has often been difficult to do in practice. When it has succeeded, the

results suggest that it has had a positive effect on energy intake.

(See also the chapter on dementia, which describes various interventions in relation to the

meal ambience for this target group).

6.2.7 Good examples

Ålborg Hospital has focused on the eating environment in connection with the project

"MORE" and has made various improvements to the patients' dining rooms in collaboration

with architects. This was one of many initiatives, which included establishing nutrition teams

and improving the patients' food. On average the patients were 65 years old, and the before -

and-after measurements showed positive effects on energy and protein intake, among other

things (Holst et al. 2014).

6.2.8 Summary of the significance of the meal ambience

The above studies and research projects on mealtimes have mainly focused on staff in nursing

homes rather than in private homes and hospitals. Stays in hospital tend to be more temporary

than stays in nursing homes, but there are parallels between the needs of hospital patients and

nursing home residents. For example, the older may want to be shielded and assisted during

mealtimes; they may want to eat with others; or they may expect to be greeted by an

"ambassador" like the meal hosts in Herlev Hospital. Older people living at home may need

assistance with shopping, cooking and eating in their own homes, and with maintaining their

day-to -day skills. These issues are elaborated in the chapter on older people's life skills.

In addition to the benefits of communal meals, studies of nursing homes point to other

relevant social issues that should be addressed to create better social frameworks (Kofod

2000). To some extent it may be possible to apply this knowledge to the hospital setting.

In general, there are indications that the social framework can affect older people's desire to

eat in all three settings (i.e. own home, nursing home or hospital).

6.2.9 Official Danish recommendations regarding the meal ambience and the

social framework of the meals

Most of the above findings were included in the National Board of Social Services'

recommendations to the Danish municipalities and regions, e.g. the National Action Plan for

Meals and Nutrition for Older People in Nursing Homes and Home Care (National Board of

Social Services 2013). In connection with its "Good Food, Good Life" project, the National

Board of Social Services has published practical tools for improving meals and mealtimes for

older people living at home or in nursing homes.

"Idea Catalogue: Ideas for Good Meals for Older People Living at Home or in Nursing

Homes" (National Board of Social Services 2009) focuses on the social significance of meals,

for example the fact that menus are identity markers, and that the older person's wishes about

sitting in certain places with certain people must be respected. The ideas were developed to

provide inspiration for staff in nursing homes and concern issues such as communal dining,

table settings and serving, the physical environment, food and appetite, mealtime atmosphere,

mealtime conversation and meal presentation.

According to the idea catalogue, there are different challenges when it comes to older people

receiving home care. It can be hard to create a good meal setting for older people who live

alone and who often lack a social network. This is why it is important to find out whether the

older person wants to be included in meals with others or whether they prefer to eat alone,

and on that basis create the desired setting for the individual.

Concerning the physical environment, the National Board of Social Services writes: "The

physical environment in which the meal takes place is important in determining how long the

person wants to sit at the table, and the longer you sit, the more your eat. Therefore it is a

good idea to set aside some time to make sure the physical setting is cosy and comfortable to

eat in. It is also a good idea to make some changes now and then for the sake of variety, so

the residents have something new to look at and talk about" ("Idea Catalogue: Ideas for Good

Meals for Older People Living at Home or in Nursing Homes" National Board of Social

Services 2009).

On the topic of conversations during the meal, the Board writes: "A good meal is often

associated with good company and lots of chatting, but as we age, it becomes harder for most

of us to follow a fast-moving conversation between several people. Moreover, if the residents

do not know each other very well due to a high turnover, it may be difficult for them to ask

questions about each other and thus start and maintain a conversation. Therefore it is

important that the nursing staff initiate a conversation that involves all the residents. This can

be done by preparing some good conversation topics before the meal or by talking to the

individual people around the table as a starting point" ("Idea Catalogue: Ideas for Good

Meals for Older People Living at Home or in Nursing Homes" National Board of Social

Services 2009).

The mealtime barometer (National Board of Social Services 2010) is a quality assessment

tool for gaining an overview of the local conditions for providing good meals for the older,

and for identifying areas for improvement. The mealtime barometer can give the municipal

administration, kitchen staff, nursing homes and home care districts a clearer picture of the

quality with which they jointly provide meals for the older, and suggest further measures to

enhance the quality by focusing on the whole process from making the food to the actual

meal.

6.2.10 Barriers

In a Dutch study, nursing homes imitated the "family meal" to create the best possible

mealtime setting (Nijs et al. 2006). But for older people who live at home and receive meal

services, "family meals" are no longer an option. They no longer have a natural social setting

for meals. Kofod (2000) points out that older people living at home do not feel that eating a meal

they receive from a meal service is a "real meal". At the same time, they are nutr itionally more

vulnerable due to reduced appetite. "Eating depends on delicate habits that can easily change"

(Kofod 2000). On the other hand, older people living at home who eat at a nursing home once or

several times a week experience a significant sense of community during mealtimes.

The challenge is that many older recipients of meal services are or become malnourished.

Potential barriers:

 In practice, the staff is not trained to help create a good meal ambience and social

interaction. In a field study of mealtimes in nursing homes, 60 meals were observed

(Kofod 2012). The observations and interviews showed that the meals did not meet the

residents' needs and that the staff was frustrated about not being able to include the

residents in conversations. One challenge is that nursing home residents have changed.

For example, there are more people with dementia, which demands more from the staff

than in the past. "Mealtimes are a pedagogical exercise that they are not particularly well

equipped to handle" (Holm-Petersen 2012).

 There is a lack of understanding of the importance of mealtimes in relation to the rest of

the care, as well as of the preventive and rehabilitative prospects. Consequently,

mealtimes are not given priority in nursing homes, home care and hospitals. An example

of this is that older people living at home in Faaborg-Midtfyn Municipality are given

vacuum-packed sandwiches for a week at a time. According to the chair of the Social

Affairs Committee Herdis Hanghøj, "it was a question of making cuts where it hurt least

and keeping the funding for the direct care work intact so that the older still get regular

cleaning and help with bathing and so on" (Johansen, Jyllandsposten, 5 October 2014).

6.2.11 Areas where more research is needed

The research performed so far on meal ambience is inconclusive, and there is a need for

further research. There are some tentative indications that the meal ambience can influence

eating behaviour. We need more knowledge about the possibilities to influence the creation of

good mealtime environments in peoples own home and if this have effect on well-being and

life quality. It can be hard for older people living at home to create a good physical mealtime

environment by themselves. Another question is whether an extra focus on the physical

environment can really change the eating behaviour of older people living in their own

homes, where they have their own routines and traditions. In the other two settings - nursing

homes and hospitals - much can be done to ensure the best possible physical meal ambience.

There is very little evidence from randomised controlled studies concerning the importance of

the social interaction and physical environments, and the existing documentation stems from

studies carried out in nursing homes. However, the systematic literature reviews have

identified a number of non-controlled studies suggesting that, for example, the dining room's

layout, scents, colours, music, serving customs etc. influence how much older people eat.

This can provide inspiration for future scientific studies in this area. To ensure increased

public focus on the social and physical frameworks of meals for the older, the following

needs and questions should be addressed:

 More systematic research into the effect of meals and their physical and social

interactions on the well-being of the older who live at home or in nursing homes, and

those in hospitals.

 How many nursing homes, home carers and hospitals base their work on the National

Board of Social Services' material? What effect does it have?

 More information about whether the measures suggested by the National Board of Social

Services work in practice and contribute to the older peoples well-being, and whether

direct effects can be measured.

 What the meal's social and physical environments mean for weight loss and gain,

medicine intake etc. in all three settings.

6.2.12 Next steps

 Carrying out research projects with the municipalities investigating the effect of meals-

hosts on quality of life and nutrition of older people. These research projects should be

highly interdisciplinary, so that the meal is looked at in all its complexity.

 Supporting the municipal implementation of the National Board of Social Services'

"Good Food, Good Life" scheme, as well as relevant additional research.

 Calculating the financial savings that can be made by prioritising mealtimes as part of the

care of older people in home care, nursing homes and hospitals.

 Defining ideal forms of cooperation and division of tasks and responsibilities between the

carers and kitchen staff as regards the meal ambience.

6.2.13 References

Abbott RA et al. Effectiveness of mealtime in terventions on nutrition al outcomes for the

elder ly living in residential care: A systema ti c review and met a-analysis. Ag eing Research

Reviews 2013; 12 : 967– 981

Beck A, Oves en L,. Influence of social engagement and dining location on nutriti onal intake

and body ma ss index of old nursing ho m e r es idents. J Nutr Elder 2003; 22 : 1-11

Beck A, et al. Anbefalinger for udvikling af Den attraktive måltidsserv ice til ældre. Da nmarks

Fødevareforskning, 2006

Beck & Kofod. Fremtidens kost til ældre. Fødevarerapport 2003; 03

Beck & Kofod. Måltidsservice på plejec entr e. Fødevarerapport 2003

Cheu ng G et al. Diet ary , Fo od Service, and Mea ltim e Inter ven tions to Promote Food Intake in

Acute Care Adult Pa tien ts. Journal of Nutriti on in Gerontology and Geriatrics 2013; 32: 175-

212

Fødevarestyr elsen Uden ma d og drikke…del 1. Fødevarerapport 2002; 14 (2002a)

Fødevarestyr elsen. Uden ma d og drikke… del 2. Fødevarerapport 2002; 15 (2002b)

Glostrup Hospital . Pr ojekt Måltidsoplevelser: Forbed ring af ældre småts pisend e patien ters

måltidsoplevelse på Glostrup Hospital. Glostrup Hospital 2012

Holm-Petersen K,. Har du brug for at komm e på to il et tet, kære? Socialforskning 2012; 4

Holst M et al. Multi-modal inter vention improved or al intake in hosp italiz ed patien ts. A one

year fol l ow-up study. Clin Nutr 2014; May 10. pii: S0261-5614(14)00132-0

Johansen M, Gaardmand NG. "Velbekomme morfar" In dblik. Mor genav isen Jyllandsposten,

5. oktober 2014

Kofod J, Bi rkemose A. Mea l s in nursing homes. Scand J Caring Sci 2004; 18: 128-34

Kofod J. Du er dem du spiser sammen med – et br ugerperspekt iv på den offen tlige

måltidss ervice. Fødevarerapport 2000; 09

Lund LS. Projekt: Måltidsværter. Herlev Hosp ital, Re gion Hovedstaden 2012

Måltidsbar ometeret (w ww.maltidsbar ometeret.dk)

Nijs K, et al. " Effect of fa mily style mealtimes on quality of life, physical performa nce, and

body we ight of nursing home r es iden ts: clus ter randomised control l ed trial." BMJ 2006 ; 332 :

1180-1184

Service styrelsen. Idekatalog: Ideer til gode måltider. i plejboliger og ældres eget hjem.

Service styrelsen 2009

Sidenvall B, Fjel lst rom C. The meal situation in geriatric care-intentions and exp er iences. J

Adv Nur s 1994 ; 20 : 613-621

Socialstyr elsen. Introduktion til måltidsb arometeret, Et redskab til vurd ering af kv ali teten af

måltidssituationer for ældre borg ere og med anbefalinger til forbed ringer. Socialst yr elsen

2010

Socialstyr elsen. National handlingsplan for må ltider og er næring til ældre i hjemmep lejen og

plejeboligen. So cialstyr elsen 2013

Vucea V et al. Interven tions for improving mealtime experiences in l ong-te rm care. J

Nutrition Ger ontol Geriatr 2014;33:294-324

Whear R et al. Effectiveness of Mealtime Interventions on Behavior Symptoms of People

With Dementia Living in Care Homes: A Systematic Review. JA MDA 2014; 15: 185-193

7. THE RESIDENT

The four sections of this chapter deal with the effect of nutrition on older peoples physical

function, as well as the importance of dementia, hospitalisation and life skills for food intake.

7.1 THE EFFECT OF NUTRITION ON THE PHYSICAL FUNCTION OF OLDER

PEOPLE IN NURSING HOMES AND HOME CARE

7.1.1 Why it is important

Older people want to continue to do the activities that are important for them. Many normal

daily activities such as climbing stairs, getting up from or sitting down on chairs or walking

around indoors require a certain amount of muscle strength. Ordinary and necessary daily

functions that are easy for younger people may require all the older persons muscle strength.

Many older people fear becoming dependent on the help of others, and this can diminish their

sense of independence. A good nutritional status helps maintain physical function and reduce

the need for help.

7.1.2 The significance of food and liquids on physical function

In nursing homes and home care

Unplanned weight loss and loss of muscle mass and strength are closely related, and weight

loss therefore increases the risk of reduced physical function and activity. A decline in

physical function can be observed already after a slight unplanned yearly weight loss of 1%

(Figure 7.1).

Weight loss increases the need for assistance with everyday skills. In a Danish study that

followed 450 older nursing homes residents for a year, residents who lost weight needed more

help with everyday tasks from the nursing staff than those who maintained their weight (Beck

et al. 2012). A 2005 Swedish study measured the amount of care needed for residents in

sheltered housing from a scale of 1 to 7 (with 7 requiring the most care). Residents in good

nutritional condition scored 2, while residents in poor nutritional condition scored 5 (Olin et al.

2005). A similar Norwegian study found that people in home care who lost weight received

1.5 times more visits by home carers and home nurses than people who did not lose weight

(Sørbye et al. 2008).

One major challenge is that the older people do not often manage to regain their weight and

physical function before a new period of reduced appetite occurs as a result of various risk

factors; cf. Figure 7.1 (Ingerslev et al. 2002).

Figure 7.1. Example of the interaction between illness, social event and loss of weight and

function (from Ingerslev et al. Danish Nutrition Council 2002).

7.1.3 Interventions to improve the intake of food and liquids as well as physical

function

All three settings

A systematic review of the literature on the prevalence of sarcopenia and the impact of

interventions found that there is a high prevalence of sarcopenia among older people –

especially in nursing homes – and that physical training seems to have a positive effect, but it

is difficult to assess whether a simultaneous nutritional intervention can have an additional

effect (Cruz-Jentoft et al. 2014). One of the intervention studies included in the review

involved a clinical dietician, but none of the studies focused specifically on optimising the food

itself.

A systematic literature review that included several meta-analyses focused on whether protein

supplements (mainly whey or casein powder) can contribute to the positive effect of physical

training (Cermak et al. 2012). This seems to be the case for healthy "younger older " (> 50-72

years of age), but there is a lack of studies among the frail "oldest older". None of the

intervention studies included in the review focused on optimising the food itself.

In nursing homes and home care

In connection with its work on drawing up recommendations for helping older people with

unplanned weight loss, the National Board of Social Services carried out a systematic

literature review to identify randomised controlled studies among different groups of older

people whose physical function has been assessed (National Board of Social Services 2015).

The target audience included older people discharged from hospital with or without a

rehabilitation plan, older people being assessed for municipal rehabilitation, and older people

in nursing homes and home care. Only a few of the identified studies among older people in

nursing homes and home care used a multidisciplinary approach that included improving the

food.

The first study involved 121 residents in Danish nursing homes and lasted 11 weeks (Beck et

al. 2008; Beck et al. 2010). The intervention consisted of the following:

 25 g of chocolate per day

 450 ml of hot chocolate per week

 600 ml of homemade energy and protein drinks per week

 Chewing- and swallowing-friendly diet

 Group exercises (moderate intensity) 45-60 min. twice a week led by physiotherapist

 150 ml calorie-rich drinks (chocolate milk and whipped cream) twice a week after

exercising

 Dental care once or twice a week by dental hygienist

The intervention had a positive effect on the residents' strength, balance and social function.

The second study included 95 Danish older people in nursing homes or home care with two

points on the nutritional assessment form (National Board of Social Services) and lasted 11

weeks. Before the start of the study, key personnel were given skills training. The aim was to

determine whether the intervention group gained better physical function, nutrition and quality

of life and whether the intervention was therefore financially viable. The investigated method

was a new model for interdisciplinary nutritional intervention, independent of an initial

assessment. It involved a clinical dietician and a formalised interdisciplinary collaboration

between a clinical dietician, occupational therapist and physiotherapist; see Figure 7.2

(National Board of Social Services 2014).

Figure 7.2. New model for interdisciplinary nutritional intervention. The different

professional groups associated with the study are responsible for the intervention. The dashed

line symbolises an ongoing interdisciplinary collaboration between the different offers for

each person (National Board of Social Services 2014).

The new model for nutritional intervention had a very high level of compliance, and the

results showed that:

 The intervention group experienced a positive effect on physical function.

 The intervention group in home care experienced a positive effect on quality of life.

 Weight gain was closely linked with an increase in quality of life.

The financial analyses show that the nutritional intervention was cost-effective and thus

clearly acceptable as a new intervention (National Board of Social Services 2014).

A targeted rehabilitation effort for frail older people can improve physical function, and

rehabilitation has therefore become widely used in the care system in recent years. The rate

adjustment pool agreement (2012-2013) allocates funds to prepare and disseminate a

rehabilitation model in the municipalities that is focused on social, physical and mental

function and is based on the latest research. In this connection, the National Board of Social

Services has carried out a systematic literature review to determine whether there is evidence

of the efficacy of rehabilitation for older people with reduced physical function .

Unfortunately, nutrition was not among the applied search criteria, and it is therefore not

possible to make any conclusions about its importance for rehabilitation (National Board of

Social Services 2013a).

7.1.4 Good examples

Figure 7.3 is from the National Board of Social Services. National Action Plan for Meals and

Nutrition for Older People in Nursing Homes and Home Care 2013 and from Copenhagen

Municipality. More about food vouchers can be found here

http://www.preprod.kk.dk/da/borger/omsorgogsaerligstoette/hjemmehjaelp/mad-og-

maaltider-til-aeldre (in Danish).

Figure 7.3

7.1.5 Official Danish recommendations

The National Action Plan for Meals and Nutrition for Older People in Nursing Homes and

Home Care states that nutritional interventions should be integrated into the preventive and

rehabilitative work (National Board of Social Services 2013c):

 The Good Kitchen – Holstebro municipality

In the central kitchen of the municipality of Holstebro, called "The Good

Kitchen", they work with accommodating the older people's wish for food, meals

and nutrition. All older people associated with home care that receive meal

service, gets a visit from The Good Kitchen in order to support the older people in

preparing their own meals, as far as possible. It is the municipal dietitians who

visit the citizen. In cooperation with the citizen, his nutritional status, needs and

wishes are described. Thereafter, the offers in the menu catalog are organized in

the knowledge that the older in home care often do not have the opportunity to go

grocery shopping. This means that the offers cover all of the day's needs. Social

and health care staff will also visit the kitchens and get the chance to taste the food

and learn how it should be handled in everyday life. In this way, the caregivers are

made more aware of what they are serving the citizen. Supporting the preparation

of own meals is part of everyday rehabilitation.

Since a large proportion of older people in nursing homes and home care etc. are

malnourished, they can benefit from a nutrition screening and a subsequent nutritional

intervention that can help them retain or regain their physical function and quality of life. It

is important to incorporate nutritional interventions in preventive and rehabilitative work, as

this can improve the person's quality of life and self-reliance. With the strong focus on

physical training in connection with rehabilitation interventions and with awareness of the

importance of the composition of nutrients in rebuilding and preserving muscle mass, it is

important to focus on food, nutrition and mealtimes when it comes to preventive and

rehabilitative work. When muscle mass is rebuilt, physical function improves. It is therefore

highly likely that beneficial effects can be achieved by integrating nutritional interventions

into rehabilitation interventions. In addition, there is much to suggest that the greatest effect

is achieved through interdisciplinary nutritional efforts, e.g. interventions that also focus on

exercise and improving the meal ambience, the social framework and dental health. This has

a beneficial effect even on very frail residents. The National Food Institute recommends that

residents are encouraged to take part in the cooking in order to maintain their skills.

The National Board of Social Services is preparing its "Recommendations for Nutritional

Interventions for Older People with Unplanned Weight Loss", which partly focus on

nutritional interventions for older people with reduced physical function (National Board of

Social Services 2015, in consultation).

7.1.6 Barriers

The study involving 121 nursing home residents showed good compliance with the

intervention when the foods were actually offered to the older. The main cause of lack of

compliance was that the nursing staff sometimes did not serve chocolate and homemade

energy and protein drinks despite having agreed to (Beck et al. 2009). However, there was a

lot of variation between the seven participating nursing homes, which may be due to different

levels of interest in nutrition.

In its initial phase, the National Board of Social Services' study involving older people who

received meal services found a problem with the existing meal service: it was provided by a

private supplier who was obliged to follow certain requirements and standards for meal

services, which meant that it was not possible to optimise the meal service (National Board of

Social Services 2014). This was an unexpected barrier, but exemplifies the real-world

challenges that may be encountered. Other municipalities that want to improve their meal

services should be aware that changes can result in new requirements.

According to various regulations, the municipalities are obliged to:

 Initiate a short-term rehabilitation effort before assessing the person's need for home care.

The effort is initiated if it is likely to improve the person's physical function and thus

reduce the need for home care.

 Offer people with reduced function rehabilitation therapy to achieve the same level of

physical function as before, or the best possible level.

 The municipalities are responsible for all rehabilitation that does not take place during

hospital stays.

 Offer citizens maintenance training, i.e. training activities designed to prevent loss of

physical function and maintain existing skills.

However, the regulations do not specify whether the rehabilitation and training activities must

be combined with a nutritional intervention.

In connection with the above-mentioned rate adjustment pool agreement (2012-2013), the

National Board of Social Services has reviewed the municipalities' experiences with

rehabilitation in the older care sector. This review shows that only a few municipalities have

integrated meal optimisation in their rehabilitation activities (National Board of Social

Services 2013b).

7.1.7 Areas where more research is needed

A systematic review is needed of what improving food and mealtimes means for the

rehabilitation process. As described above, a number of intervention studies have been carried

out to improve both physical function and nutrition. Though only a few have focused on

optimising food and mealtimes, they can provide inspiration for future studies in this area.

It may be beneficial to integrate the meals-on -wheels into the rehabilitation processes, for

example by finding out whether the meals-on-wheels can support the municipalities' work on

rehabilitation in the care of the older by delivering the daily meals in different components, so

the resident can prepare them together with the carer, and the preparation of the meal thereby

becomes part of the rehabilitation service (National Board of Social Services 2014b).

The National Board of Social Services' report states that "to follow up, it would be relevant

to carry out a health-technology assessment, which is a good tool to provide a basis for

decision-making by managers and politicians in the municipalities. Carrying out a health-

technology assessment requires knowledge of the technology, the users' experiences, and the

organisation and finances behind the intervention. The current CES study has provided

information about the technology (i.e. a new model for nutritional intervention), the user

aspect (i.e. compliance with the new model) and finances.

A model that involves appointing and training key nutritional staff in nursing homes is also

suitable for nutritional interventions. As regards a similar model for home care, knowledge is

still needed about what an optimal organisation of nutritional interventions would look like.

Furthermore, although the results suggest that the new model for nutritional intervention is

effective, the number of participants was relatively low, and there still appears to be very few

studies on the effect of nutritional interventions among older people receiving home care"

(National Board of Social Services 2014).

7.1.8 Next steps

The above section describes a number of issues that researchers may want to cover in future.

7.1.9 References

Beck A, Damk jær K, Be yer N. Multifaceted nutrition al inter ven tion am ong nursing ho m e

residen ts has a positive influence on nutrition and function. Nutrition 2008; 24 : 1073-80

Beck A, Damk jær K, Simmons SF. The relationship between weight st atu s and the need for

health care assist ance in nursing ho m e r es idents. J Ag ing: Res Clin Pract 2012; 2: 173-8

Beck A, Damk jær, Sørbye LW. Physical and social functi onal abilities seem to be maintained

by a multifaceted ra ndomized control led nutrition al interv ention among old (65+ y) Danish

nursing home r es iden ts. Arch Gerontol Geriatr 2010; 50: 351-355

Beck A, Damk jær K, Tetens I. Lack of co mp liance of staf f in an interven tion study wi th focus

on nutrition, exercise and oral car e am ong old (65+ y) Danish nursing ho me res iden ts. Aging

Clin Exp Res 2009; 21:143-9

Cermak NM et al. Pr otein su pplementa ti on augmen ts the adaptiv e response of skeletal mus cle

to res istanc e-type exerci se t raining: a meta-analysis. Am J Clin Nutr 2012; 96 : 1454–64

Cruz-Jentoft AJ et al. Pr eva lence of and inter ven tions for sa rcopenia in ageing adults: a

systema tic review. Report of the Interna tion al Sarcopenia Initiative (EWGSOP and IWGS).

Age Aging 2014; 43 : 748– 759

Ingerslev J et al. Ernæring og aldring. Ernæringsråd et 2002

Olin AÖ, Koochek A, Ljungqvist O, Ce der holm T. Nutr ition al st atus, well -being and

function al ability in frail elderly service flat residen ts. Eur J Clin Nutr 2005; 59: 263-70

Socialstyr elsen. Evidensen for ef fekten af rehab ilite ring for ældre med ne dsat funktionsevne.

Socials tyrelsen, juni 2013 (So cialstyr elsen 2013a)

Socialstyr elsen. Kort lægning af komm uner nes erfaringer med rehabilitering på ældreområdet.

Socials tyrelsen maj 2013 ( So cialstyr elsen 2013b)

Socialstyr elsen. National Handlingsplan for må ltider og er nær ing til ældre i hjemmep lejen og

plejeboligen. So cialstyr elsen 2013 (Soc ialst yrelsen 2013c)

Socialst yr elsen. Cost-effektiveness studie af tværfa glig er næringsindsa ts hos skrøbelige

underernærede ældre. So cialst yrelsen 2014

Socialstyr elsen. Fa glige anbef alinger og beskrivelse af god er næringspraksi s for

ernæringsindsat s til ældre m ed uplanlagt vægttab; Socialstyrelsen 2015; januar , i hø ring

(Socialst yrelsen 2015)

Socialstyr elsen. EVS. http://w ww.socialst yrelsen.dk/aeldre/forebyggelse-og- sund hed/mad-

og-ma ltider-1/ernaer ingssc reening

Sørbye LW, Schroll M, Finn eS overi H, Jonsson PV, Topinkova E, Ljunggren G, Bernabei R.

Unintended we ight loss in the elderly living at ho me: the aged in Home Car e Project

(AdHOC). J Nutr Health Aging 2008; 12:10-6

7.2 DEMENTIA IN OLDER PEOPLE IN NURSING HOMES, HOME CARE AND

HOSPITALS

7.2.1 Why it is important

Older people with dementia can develop a reluctance to eat, which can have serious

implications for their nutritional status and may have a negative effect on their own and their

fellow eaters' meal experience.

In addition to dementia, older people with poor nutrition are at risk of a number of other

chronic diseases, including depression, Parkinson's disease, strokes, cancer, chronic

obstructive pulmonary disease, chronic heart disease, rheumatoid arthritis, gastrointestinal

problems and osteoporosis. The nutritional issues related to these conditions will not be

described here, but more information can be found in part two of the Danish Veterinary and

Food Administration's publication "Without Food and Drink" fr om 2002 (Danish Veterinary

and Food Administration 2002).

7.2.2 The significance of dementia for food intake and mealtimes

All three settings

Weight loss is very common among older people with dementia. Often the weight loss begins

even before the diagnosis, and worsens as the disease develops. The consequences are just as

serious as with other conditions (ADI 2014). The problem is aggravated by the fact that, as

the disease advances, unwillingness to eat occurs both as a direct and indirect effect of the

disease.

The indirect effect can take the form of a reflexive physical resistance to eating and drinking:

the person with dementia may hold their hands in front of their mouth, push food and liquids

away, refuse assistance, etc. Another indirect effect is apraxia, which causes a loss of ability

to use cutlery, cut food out, etc. Apraxia can also cause older people with dementia to mess

with the food and liquids without eating anything, talk during the meal, leave the dining room

table repeatedly, and eat things that are not meant to be eaten.

The direct impact of dementia, due to chewing and swallowing problems, can take the form

of selective choices: the older person may prefer drinks rather than food, or special food that

they nevertheless end up not eating. Another direct impact is that even the physical ability to

eat and drink becomes compromised due to lack of coordination between the muscular and

nervous systems. Persons with dementia may not open their mouth when they are assisted

with eating and drinking, or their tongue and mouth may move constantly, so that food and

liquids are dropped out of the mouth. The older person with dementia may want to eat and

drink, but have difficulty swallowing, bite the cutlery so the food cannot get into their

mouths, or take in the food and liquids only to spit them out. These symptoms occur primarily

in the late stages of dementia, so the necessary interventions will vary greatly (ADI 2014;

Danish Veterinary and Food Administration 2002).

The Nutrition Council's report "Nutrition and Ageing" states that "tube feeding in the final

stages of the disease serves no purpose. The (major) remaining problem is thus to find the

ri ght time to stop nutritional supervision and intervention in each individual situation"

(Ingerslev et al. 2002).

7.2.3 Interventions with food and liquid in older people with dementia

All three settings

A systematic review of studies on the efficacy of various interventions among dementia

patients' unwillingness to eat has been performed (Liu et al. 2013). The review comprised 22

intervention studies, nine of which were randomised controlled studies, involving six different

types of interventions: industrially produced energy and protein drinks; training of the older

people and the staff; improving the meal ambience (use of music, colours, serving food on

serving dishes); eating assistance; and miscellaneous ( eating assistance and meal ambience;

training and meal ambience, etc.). In general, there were problems with the quality of the

studies. The only intervention that seems to have had a positive effect on nutrition was the

one involving industrially produced energy and protein drinks, while training/education

seems to have had a positive effect on need for eating assistance. In general, there was limited

evidence of an effect on the patient-relevant endpoints of mental and physical function.

When dementia progresses and the person's energy intake become insufficient despite

various efforts, tube feeding is usually the next step. A Cochrane review found no randomised

studies, but seven observational studies, and concluded that there was no positive effect on

survival (Sampson et al. 2009). None of the studies examined quality of life, there was no

evidence of a positive effect on nutrition or the prevalence of pressure ulcers, and there was no

data about the possible negative effects of the intervention.

In nursing homes

A systematic literature review concerning the effect of mealtime interventions on dementia

patients' unwillingness to eat found 11 studies with four different kinds of interventions:

music; changing the food and drinks; meal ambience; and group conversations (Whear et al.

2014). None of the studies were randomised, and generally there were problems with their

quality, which made it difficult to draw an overall conclusion despite the fact that all the

interventions appeared to have a positive effect on the older people's willingness to eat.

7.2.4 Official Danish recommendations

The national clinical guidelines for assessing and treating dementia recommend that the

nutritional condition of people with dementia is preserved as long as possible (National Board

of Health, 2013). The following factors are assumed to have a positive effect on weight and

nutrition despite sparse evidence: education of relatives; weight and nutritional screening in

nursing homes and home care; individualised diet planning; and individually tailored support

and eating assistance.

The National Board of Social Services' idea catalogue offers suggestions for interventions in

relation to dementia (National Board of Social Services 2009), as does part two of the Danish

Veterinary and Food Administration's publication "Without Food and Drink" (Danish

Veterinary and Food Administration 2002).

7.2.5 Barriers

The reasons for dementia patients' reluctance to eat are complex. Therefore what is needed is

individualised interventions and close cooperation between different personnel groups, such

as kitchen staff, clinical dieticians, occupational therapists and physiotherapists. However,

formalised cooperation is not always possible in practice.

7.2.6 Areas where more research is needed

A number of studies on optimising food and mealtimes have been carried out in all three

settings. Although the various interventions seem to have had a positive effect, the studies are

often of poor quality, making it difficult to draw any real conclusions. There is therefore a

need to test whether the positive trends can be confirmed in actual randomised controlled

studies.

7.2.7 Moving forward

A systematic review of the literature, including meta-analyses, have shown that despite the

fact that dementia is a serious disease in which the nutritional condition deteriorates as the

disease progresses, industrially produced energy and protein drinks can have a beneficial

effect on weight, mental physical function, and survival (Allen et al. 2013). It is therefore

very worthwhile to seek to improve poor nutritional status. However, there is a lack of

information about whether the same positive effect can be achieved by optimising food and

mealtimes, and research in this area is therefore needed.

7.2.8 References

ADI (Alzheimer Disease Interna tion al). Nu trition and demen tia . A lzheimer's Disease

Internation al, London. February 2014

Allen VJ et al. Use of nutriti onal complete supplements in older adul ts with demen tia:

Systematic review and meta-analysis of clinical outco mes. Clin Nutr 2013; 32: 950-957

Fødevarestyr elsen. Uden mad og drikke – del 2. Fødevarerapport 2002; 15

Ingerslev J et al. Ernæring og aldring. Ernær ingsråd et 2002

Liu W et al. Interven tio ns on mea ltime diffi cu lties in older adults with demen tia: A systema ti c

review. Int J Nur s Stud 20 14 ; 51 : 14– 27

Sampson EL et al . Enter al tube feed ing for older peop l e with ad vanced demen tia (Review).

Cochra ne Database of Systema tic Reviews 2009, Issue 2. Art. No.: CD007209 . DOI:

10.1002/14651858.CD 007209.pub2.

Service styrelsen. Idekatalog – ideer t il gode måltider til ældre i plejebolig og eget hjem.

Service styrelsen 2009

Sundhedsst yr elsen. Na tion al kliniske r et ningsl inje for udredning og behandling af demens.

Sundhedsst yr elsen 2013

Whear R et al. Effectiveness of Mealtime Interv entions on Behavior Symptoms of Peopl e

With Dementia Living in Care Homes: A Systematic Review. JAMDA 2014; 15: 185-193

7.3 REDUCED INTAKE OF FOOD AND LIQUIDS DURING HOSPITALISATION

7.3.1 Why it is important

Many older people have reduced appetite due to age-related anorexia, which is further

exacerbated by diseases. Many older patients are already in poor nutritional conditions when

they are admitted to hospital, often as a result of recent weight loss, which typically worsens

during the hospital stay with accompanying loss of physical function (Ayoub et al. 2002). Put

simplistically, 30 days in a hospital bed can equal a loss of 30 years in physical function if no

action is taken (McGuire et al. 2010).

7.3.2 Intake of food and liquids during hospitalisation

Data on older patients' food intake is not being compiled systematically. The following is

therefore based on information compiled in connection with various research projects.

One Danish study have shown that older people's dietary intake during hospital stays is often

insufficient (Hansen et al. 2008). In a Danish intervention study whose target group was not

specifically older patients, but where the average age was around 75, protein intake in

particular was too low in the control group, as only 30% had their protein requirements met,

while 70% had their energy requirements met (Monk et al. 2014).

In time, low dietary intake inevitably leads to critical weight loss. Figures from the database

on geriatric patients show that 42% of older people hospitalised in Denmark lose weight

during their hospital stays (national database on geriatrics 2012). Many older people suffer

from sarcopenia and are therefore particularly vulnerable to loss of muscle mass resulting

from bed rest, and at the same time do not get enough to eat and drink. The many hours of

bed rest combined with metabolic stress during disease accelerates the loss of muscle mass

and thereby the loss of strength and physical function; see Figure 7.4 (English and Paddon-

Jones 2010).

Figure 7.4 Hypothetical model of how age-related muscle loss is affected by accelerated

muscle loss related to repeated episodes of acute illness or injury when the patient does not

fully recover (from English and Paddon-Jones 2010).

Even short hospital stays thus increase older people's risk of losing physical function and no

longer being able to perform everyday activities after they are discharged (Alley et al. 2010).

The challenge is that older patients typically do not take the initiative to talk with the staff

about their lack of appetite and reduced food intake. Only after significant weight loss will

patients tend to become aware of the problem (Haddad et al. 2011). Low calorie intake and

resulting weight loss often continue after discharge, as shown by two recent Danish studies

among older patients in poor nutritional status who were monitored for three months after

discharge (Beck et al. 2013; Beck et al. 2014). Many never recover their former functional

level (Alley et al. 2010; Miller et al. 2006). A high proportion is in poor nutritional condition

when they start rehabilitation processes (Kaur et al. 2008). It is therefore important that the

nutritional interventions continue after discharge (Ingerslev et al. 2002).

A recently published Danish study documented a number of barriers in this area through

interviews with staff in hospitals and the primary sector (Holst et al. 2013). In general, it was

agreed that many more patients and citizens should be offered nutritional interventions. This

did not happen due to lack of time, training, knowledge and division of responsibilities,

which are barriers that have been identified for a number of years (Beck et al. 2006).

An audit of two Copenhagen hospitals in the summer of 2013 found that no care plans

contained nutrition plans (Thal-Jantzen 2014). In a 2012 Danish survey of 925 participants,

only 20% indicated that they were automatically given nutritional information when they

were discharged (Haddad et al. 2014).

7.3.3 Interventions to increase intake of food and liquids during hospitalisation

Two major systematic literature reviews, including meta-analyses, found that offering

industrially produced energy and protein drinks to older patients in hospital had a beneficial

effect. A positive effect was observed on the older patients' energy and protein intake ,

weight, complication frequency, risk of re-admissions and survival (Milne et al. 2009;

Cawood et al. 2012). The studies in the review included older patients who were malnourished

and had acute illnesses or suffered from worsening of chronic diseases, i.e. patients at

nutritional risk.

We are not aware of any systematic literature reviews of nutritional intervention studies

focused on energy and protein enrichment of food for older hospitalised patients. However,

one literature review on different methods for optimising older people's energy and protein

intake also includes energy and protein enrichment of food (Nieuwenhuisen et al. 2010). In a

randomised controlled trial among older patients admitted to medical or orthopaedic surgical

wards, the intervention group was offered foods in addition to the normal menues, such as

whipped cream with their desserts, cakes or cheese sandwiches as snacks, milk powder in

soups, etc. (Gall et al. 1998). This had a positive impact on energy intake, but not on protein

intake. Patient-relevant endpoints were not assessed.

In a Danish randomised controlled study of the effect of an energy- and protein-rich menu on

patients at risk of undernourishment, the target group was not specifically older patients, but

the average age of the participants was 75 (Monk et al. 2014). In this study, the intervention

group was offered an à la carte menu consisting of small energy- and protein-enriched dishes

in addition to the normal food. This had a positive effect on energy and protein intake, but no

difference was seen in weight, hand-grip strength and the length of hospital stays.

When the National Board of Social Services prepared its "Recommendations for Nutritional

Interventions for Older People with Unplanned Weight Loss", it conducted a systematic

literature review to identify randomised controlled studies of the effect on physical function.

The target group included older people during and after hospital stays (National Board of

Social Services 2015). No studies on optimising the food were found.

One systematic review of the literature included meta-analyses of the effect of interventions

on the prevention and treatment of malnutrition in older people who move onto a

rehabilitation stay after hospitalisation (Collins and Porter 2014). One of these studies was a

randomised controlled study in which the intervention group was offered small energy-

enriched meals, mainly in the form of extra butter, cream, cheese and maltodextrin (Barton et

al. 2000). This had a positive impact on energy intake, but not on protein intake. Patient-

relevant endpoints were not assessed.

As regards multidisciplinary interventions, a systematic review by Thorne and Baldwin did

not find any studies carried out during and after hospitalisation that focused on optimisation

of the food combined with other interventions (Thorne and Baldwin 2014).

7.3.4 Good examples

At He rlev Hospital patients at risk of malnutrition are offered a specifically designed energy-

and protein-rich menu for people with low appetite. So far the menu is being offered on four

of the hospital's wards.

7.3.5 Official recommendations

As mentioned, there are official Danish recommendations for food and liquids for

hospitalised older people. These are described in the "Recommendations for Danish

Institutional Diets" (Pedersen and Ovesen 2009) and in The Complete National Diet

Handbook (http:/www.kostforum.dk).

The national action plan for meals and nutrition for older people in nursing homes and home

care (National Board of Social Services 2013) recommends that the cross-sectoral

cooperation on nutritional interventions for older people be strengthened through a clear

division of responsibilities and guidelines for action.

The National Board of Social Services is preparing its "Recommendations for Nut ritional

Interventions for Older People with Unplanned Weight Loss", which partly focuses on

nutritional interventions for older people who have been discharged from hospital (National

Board of Social Services 2015, in consultation).

7.3.6 Barriers

The Danish quality model includes a standard for nutritional screening, planning and

following up. In practice this has meant that far more patients have received nutrition

screenings on admission, namely 75%. Half of them are also given nutrition plans, which are

followed up on. Still, many are not helped in this way, and the main reason is lack of

knowledge in this area (Hackney et al. 2014).

Short hospital stays are often given as a reason for the lack of interventions. However,

malnourished patients are often hospitalised longer than other patients (Arla Foods and the

Danish Diet and Nutrition Association 2014), which should provide enough time to start a

nutritional intervention, which can then continue after discharge.

The existing DRG system does not provide funding for nutritional interventions, so there is

no financial incentive for the ward or hospital. This option is available in other countries,

where it has been financially beneficial (Boltong et al. 2013).

The patients indicate that they are satisfied with the food in the hospitals, but they still lose

weight (Centre for Patient Experience and Evaluation 2014). Therefore it is important that the

patients' intake of food and liquids is closely monitored, even if they say they are satisfied.

Plans for extra nutritional interventions for the older are not included in the Danish Healthcare

Act or the current official healthcare agreements (2011-2014). In addition, there are no

standardised fields for nutritional conditions and nutritional interventions in MedCom's

municipal standards for hospitalisation, care pathways, discharge and rehabilitation. This

makes it difficult to continue nutritional interventions across sectors.

7.3.7 Areas where more research is needed

There are only a few studies of the effects of optimising the food offered to older patients

during and after hospitalisation. The results have been positive with regard to increasing

energy intake and, in a single case, protein intake. However, information is needed about the

significance of this for patient-relevant endpoints.

7.3.8 Next steps

Studies, as pointed out above.

7.3.9 References

Alley DE, Koster A, Mackey D, et al. Hospitalization and ch ange in body comp os ition and

strength in a population-based cohort of older persons. J Am Geriatr Soc 2010; 58: 2085-91

Arla og Kost- og Ernæ ringsf orbund et. Underernær ing – det skjulte samfundsprob lem. Arla og

Kost - og Ernæ ringsforbund et 2014

https://www.kost.dk/sites/default/files /uplo ads/ public/underernaer ing- publikation.p df

Bar ton AD et al. A recipe for improving food intakes in elderly hospitalized patien ts. Clin

Nutr 2000; 19 : 451-454

Beck A, An dersen UT, Leedo E, Jensen LL, Mar tins K, Quvang M, Rask KØ, Vedelspang A,

Rønholt F. Do e s adding a dietician to the liaison team after discharge of geriatric patients

improve nutrition al outco me: a randomised control led trial; Clin Rehab 2014 Dec 31. pii:

02692155145 64700. [Epub ahe ad of print]

Beck A, Kjær S, Hansen BS, Storm RL, Thal -Jantzen K, Bi tz C. Follow -up ho m e visits with

registered dietitians hav e a positive effect on the function al and nutritional status of geriatric

med ical patients af ter discharge: a randomised control led trial. Clin Rehab 2013; 27 : 483-93

Beck A et al. Ældre patien ter skal følges orden tligt hjem fra syg ehuset! Diætisten 2006; 80: 5-

Bolto ng AG, Loeliger JM, Steer BL. Using a public hospital funding model to strengthen a

case for improved nutriti onal care in a cancer setting. Aust Health Rev 2013 37): 286-90

Cawood AL, Elia M, Stra tton R. Systema ti c review and meta-analysis of the effects of high

protein oral nutrition al su pple men ts Aging Res Rev 2012; 11: 278-96

Collins J & Porter J. The effect of inter ventio ns to prevent and treat ma lnutrition in patient s

admitted for rehabilitation: A systematic review with met a-analysis. J Hum Nutr Diet 2014;

doi. 10.1111/jhn.12230

Eng li sh KL & Padd on -Jones D. Pr otecting muscle ma ss and function in older ad ults during

bed rest. Curr Opin Clin Nutr Metab Care 2010; 13: 34-9

Enhed for Evaluering og Brugerinddragelse. Patienters oplevelse af maden. Region

Hovedstaden 2014

Gall MJ et al. Eff ect of providing for tified mea ls and bet ween-mealsn acks on energy and

protein intake of hospital patients. Clin Nutr 1998: 17 : 259-264

Hansen MF, Nielsen MA, Bitz C, et al. 2008 Catering in a large hospital-does serving from a

buffet system meet the patien ts' needs? Clin Nutr 2008; 27:666-9

Holst M, Rasmussen HH, Laursen BS. Can the patient perspective contr ibute to quality of

nutrition al care? Scand J Caring Sc. 2011; 25: 176-84

Holst M, Rasmussen HH. Nutriti on Therapy in the Transition between Hospital and Ho me:

An In vestigation of Barriers. J Nutr Metab. 2013;463751. doi:10.1155/2013 /463751. Epub

2013 Dec 29

Holst M, Staun M, Kondrup J, Bach- Dahl C, Rasmussen HH. Good nutrition al practice in

hospitals during an 8-year period: The impact of accred itation. E- SPEN 2014, 9: e155-160

Ingerslev J et al. Ernæring og aldring. Ernær ingsråd et 2002

Kaur S et al. Nu tritional status of ad ults participating in amb ulator y rehabilita tion. Asia Pac J

Clin Nutr 2008; 17 : 199-207

Landsdækken de database f or Ger iatri, år srapport 2012

McG uire DK, Levine BD, Wi lliamson JW, Snell PG, Blomq vist. A 30-year fol low - up of the

Dallas Bedrest and Training Study: I. Effect of age on the card iovasc ular response to exercise.

Circulation 2001, Sep 18; 104(12): 1350-7

Miller MD, Crotty M, Whi tehead C, et al. Nutrition al su pplementa tion and res ist ance training

in nutrition ally at risk older ad ults following lower limb fract ure: a ra ndomized trial . Clin

Rehab 2006; 20: 311-23

Milne AC., Potter J, Vivanti A, et al. Pr otein and energy su pplemen tation in elderly peop l e at

risk from malnutrition (Review).Cochrane Database of Systema tic Reviews, 2009; Issue 2.

Art. No.: CD003288. DOI: 10.1002/14651858.CD003288.pub3.

Munk T et al. Pos itive effect of protein-su pplemented hospital food on pr otei n intake in

patients at nutr ition al risk: a ra ndomized controlled trial. J Hum Nu tr Diet 2014; 27 : 122-32

Nieuwen huizen WF et al. Older adults and patien ts in need of nutrition al support: Review of

current tr eatm ent op tions and fa ctors influencing nutriti onal intake. Clin Nutr 2010; 29: 160–

169

Pedersen A, Oves en L (red.). An bef alinger for den dans ke institutionskost. Fødevarestyrelsen

2009

Socialstyr elsen. Den nati onale ha ndlepla n f or må ltider og er næring til ældre i hjemmep lejen

og plejeboligen. So cialstyr elsen 2013

Socialstyr elsen. Fa glige anbef alinger og beskrivelse af god praksis for ernær ingsindsat s til

ældre med uplanlagt væg ttab ; Socialstyrelsen 2015, i høring

Thal-Ja ntzen K. Diætister styrker den tvær faglige kommunikation om und er vægtig e ældre.

Kost, Ernæ ring & Sundhed 2014. www.kost.d k

Tho rne F & Ba ldwin C. Multim odal inter ven tions including nutrition in the preven tion and

management of disease-related malnutriti on in adults: A systema ti c review of randomised

control trials. Clin Nutr 2014; 33 : 375-84

7.4 THE IMPORTANCE OF LIFE SKILLS FOR OLDER PEOPLE'S DESIRE TO EAT

Retaining or regaining life skills affects older people's desire to eat. It gives them more scope and

control over their own lives, and is often mentioned in connection with rehabilitation, since

rehabilitation is a targeted and time-limited cooperation between the care receiver, caregivers and

other professionals designed to help the person overcome limitations in their physical, mental and/or

social function and lead an independent and meaningful life. Rehabilitation that is based on a holistic

view of the person's living situation and decisions requires a coordinated, coherent and knowledge-

based effort (Marselisborg Centre 2004).

Rehabilitation in this sense can involve both prevention and retraining. Life-skill training depends on a

number of factors, including the older person's understanding of ageing and old age, food and

mealtimes, the everyday skills that are important for them to master in relation to food and mealtimes,

whether they can get the necessary assistance to live and eat independently, whether there is adequate

communication between the older person and the professionals, and the role of the relatives.

7.4.1 Why it is important

Life skills appear to be very important in relation to older people's desire to eat and how they

approach mealtimes, be it meals in their own home, in nursing homes, or in hospitals. Ideally the older

people should be in a position where they are able to independently choose what, with whom and

when to eat.

Meals in all three settings are prepared, consumed and cleared away as important set routines

throughout the day. Being involved in the meal and its related chores can help older people eat more

and improve or retain their quality of life and their physical, social and mental well-being. We believe

that having independence and being given a say in their everyday lives can be beneficial to older

people.

Being able to handle everyday tasks independently within the scope of one's ability enhances quality

of life. Since meals are a big part of daily routines, it is natural that the chores associated with them

contribute to maintaining older people's skills in all settings. These chores include shopping, peeling

potatoes, folding napkins and setting the table.

7.4.2 General comments on life skills and rehabilitation

Rehabilitation is a big part of the municipalities' strategies for older people in nursing homes and

home care, because helping the older to become more self-reliant can both save resources and

potentially enhance their quality of life. One important question is whether the care system can

increase preventive efforts and how such efforts might help the older people become more

independent in the long term.

Rehabilitation is partly focused on food and mealtimes, and the chores around the meal can be

included in the rehabilitation process. "Rehabilitation focuses on the resident's everyday activities

and participation in social life, and is about finding holistic individual solutions based on the

resources of the older person and their dependants. The process should be carried out in a coordinated

and coherent way based on the resident's circumstances" (Marselisborg Centre 2004).

The resident should decide the framework for the life-skill training based on the areas where he or she

needs most help (Marselisborg Centre 2004). To promote health and rehabilitation, the interventions

must be useful in daily life.

One common factor for older people in all three settings – home, nursing home, and hospital – is that

they face a transition process in which they have to accept that they need or will need assistance in the

short or long term. They may experience dependence on professional care and home care as a form of

institutionalisation that prevents them from expressing their own identity (Grøn and Andersen 2014).

It can be hard to accept becoming weaker or being at risk of getting weaker due to the physiological

consequences of ageing. The transition from independence to short-term or permanent dependence on

help can mean a loss of identity and a consequent late-life crisis. "A rehabilitation process often means

that residents need to reorient themselves, reorganise their everyday lives and find their feet in a new

way of life that may involve a change in their understanding of themselves and others" (Marselisborg

Centre 2004).

To manage what and how much they eat , the older need to understand their own needs for food and

liquids and be able to handle their own day-to-day meals. Physiological and mental changes can

reduce appetite, and as a result the older may not eat enough energy and protein to meet their needs.

This is significant in terms of the foods and meals that are ideal to eat. It is usually necessary to eat

more protein-rich and fatty foods, which can be a challenge to prepare and make appetising if the

person has so far preferred low-fat food.

In home care

Older people living at home make up a diverse group. Some are clear-minded and resourceful and

can continue to actively maintain good physical and mental health. Others need some assistance,

while a third group have extensive and complex care needs (Home Care Commission 2013).

In relation to the daily food and mealtime situation, it is relevant to look at life-skill training in

everything from planning the meal and shopping for groceries to preparing the food, setting the table,

clearing the table and doing the dishes. Life skills regarding food and mealtimes can also involve

social needs, such as eating some meals with others, for instance in dining clubs. After a meal-service

assessment, the meal can be delivered in parts, from which the older person can then create a warm

tasty meal with assistance. The older person, the residential carers and the families all have a role to

play in ensuring that the older person retains or regains their life skills.

In nursing homes

Older people in nursing homes are often in a weakened status and dependent on the help of others,

but can still make decisions about their everyday life, e.g. about their clothing, food, bed times, etc.

(Commission on Quality of Life and Self-Determination in Care Homes and Nursing Homes 2012).

An example of a good experience is a meal with an atmosphere of homeliness and comfort, where the

resident can participate in the cooking, if there is a kitchen. Other ways to involve residents in the food

and mealtimes are menu planning, table settings and conversations around the table.

In hospitals

Hospitalised older people are often malnourished (Beck et al. 2013) and in addition have been taken

outside of their normal environment. In one interview survey, older people stated that the hospital stay

was something they needed "to get over with" and that they spent a lot of energy thinking "thoughts

about illness". A typical hospital day was described as follows: "First I eat breakfast, then I wait for the

ward round. Then there are examinations, and of course you have to wait for the examination when

you've been moved down there. When you're back in the ward you wait for lunch, then for coffee and

finally for a visit and dinner" (Kofod 2000). The opportunity for self-determination and retention of

skills is limited to choosing the food at the buffet, and whether one wants to eat with someone.

7.4.3 Assessing older people for municipal care services

According to Section 83 of the Danish Act on Social Services, the purpose of care and assistance is to

help the citizen to help themselves, facilitate their everyday lives, and improve their health and quality

of life (see Table 7.1).

Table 7.1 Based on an overall assessment of the person's life circumstances, level of function and

everyday life, he or she is offered an intervention in the form of personal and practical assistance with

everyday life, food and mealtimes.

Nursing and care services regarding food, liquids and meals. Residents aged 65+

The individual resident's life

skills/care needs regarding

food, liquids and meals

E.g. in home care and

care interventions relating to

everyday life, food and mealtimes –

according to Section 83 of the Act on

Social Services

Interventions/services are allocated

based on assessments of the resident's

training potential, home, network and

family circumstances2

No need for professional care.

The resident and any relatives

take care of all necessary

tasks when it comes to

personal care.

Own

home.

Assessed

for home

care

Partial need for professional

help with practical and

personal tasks relating to

food, liquids and mealtimes.

Practical tasks

Shopping:

writing shopping list,

picking up shopping list,

shopping using shopping scheme,

shopping via staff.

Food

Meal service with delivery

Eating, drinking, bathing, washing,

caring for the body,

dressing and undressing, using the

toilet, moving around in one's own

home, getting everyday goods, cooking,

cleaning, washing clothes and linen,

going out, using public transport,

moving around, preventing deterioration

of illness/loss of physical function

Clearing up and washing dishes after

meal Personal activities

Personal hygiene:

Oral hygiene

Cleaning feeding tubes

Preparing and serving food and drink

Help with eating and drinking

Increased need for

professional assistance with

practical and personal tasks

and with the resident's

everyday life at the nursing

home, often including

socialising and meaningful

activity.

Practical and personal tasks and

assistance with everyday life in nursing

homes, e.g.:

Socialising

Daily chores and activities

Walks inside and

outdoors

Decorating for holidays and

anniversaries

Cooking and baking

Music, movies and reading aloud

Games

Daytrips

Frail

resident

rehabilit

ation

Periodic need for professional

care and nursing

Periodic home care if needed

Need for professional care 24

hours a day

2 Eating, drinking, bathing, washing, caring for the body, dressing and undressing, using the toilet, moving

around in one's own home, getting everyday goods, cooking, cleaning, washing clothes and linen, going out,

using public transport, moving around, preventing deterioration of illness/loss of physical function.

7.4.4 The significance of life skills for older people's desire to eat and prioritise

meals

In home care

For older people in their own home, preparing and eating meals often make up a big part of

the day (Kofod 2000). A Swedish study from 2013 focused on older women living at home,

some of whom were healthy while others were weakened by arthritis, Parkinson's disease or

strokes (Gustafsson et al. 2003). The study showed that the subjects had a strong need for

independence when it came to cooking and mealtimes. For some women, cooking has

traditionally been a central part of everyday life, while for others it has just been one of their

obligations. For many, cooking is a source of joy, especially cooking for others. Eating

regularly and with the family is also regarded as valuable.

Preparing one's own food is a way of expressing one's identity, and the wish for

independence is a way of maintaining or rethinking that identity. Healthy older married

women considered cooking essential and often made traditional dishes (Gustafsson et al.

2003). Healthy older single women saw meals more as an obligation and simplified the work

with cooking, though they still made their own meals. Among other things, they said it was

boring only to cook for themselves. Older women with Parkinson's disease still found it

important to make homemade food, but had simplified the cooking, with some combining it

with meal services. The women who were no longer able to cook for themselves, for

example because they had suffered a stroke, still felt independent because they could go to

the supermarket, buy readymade meals and decide when to eat them.

The Swedish study (Gustafsson et al. 2003) identified three life-skill or coping strategies that

older women living at home used to stay independent: municipal support, self-help and

adaptation.

Municipal support included medication, assistive devices and transport services. Self-help

involved, for example, reorganising kitchen cupboards to make things easier to reach,

purchasing a microwave, boiling carrots instead of grating them, shopping several times a

week in small quantities that the women could carry, eating with a spoon, or cutting food up

and eating it with their hand. The women's adaptation was sometimes part of the acceptance

of their disease, so that they lowered their ambitions for their cooking and did things in

accordance with their mood and illness. Simplifying the meal was another way to adapt and

might for instance involve buying sliced bread or readymade meatballs. Social withdrawal was

a third adaptation option, which meant that the older person no longer had the desire to eat

with others, or did not want to go out from fear of meeting other people and having to explain

their illness.

Another Swedish study similarly found that cooking and maintaining the skills associated

with cooking are experienced as important to expressing one's own identity (Sidenvall 2001).

Another Swedish study showed that many of the oldest women (80+) and single older women

were affected by their bodies' dwindling strength and changes in the family such as the loss

of a spouse. Such factors may mean that they do not get enough to eat (Sidenvall 2001).

In yet another Swedish study (Medin et al. 2010) of older people's experience and ability to

cope with the meal situation, two out of three still had disabilities six months after suffering a

stroke. The most frequent challenges to eating were that many only ate three quarters or less

of the food on the plate and had problems handling the food on the plate and leading the food

up to their mouths. This despite the fact that eating can be improved through the right

training, even after several years of difficulties with eating.

In one study involving 104 participants living in their own home, all the participants

expressed the desire to be able to eat normally again (Medin et al. 2010). Those who needed

eating assistance either saw the people around them as facilitators or as people who made it

more difficult to eat. Strangers in particular were seen as obstacles to eating. In general it can

be hard to ask for help and eat with others when you are not in full control of your ability to

eat.

In nursing homes

For older people in nursing homes with reduced physical function, it is important that they are

able to add their own touches to their food, for example by sprinkling herbs or spices onto a

meal or putting extra cream in the sauce (Kofod 2000).

As regards involving older people in cooking in nursing homes, questionnaire surveys among

the kitchens in Danish nursing homes in 2006 found that the residents' involvement in meals

was limited (Beck et al. 2006). In one in four nursing homes, residents were not involved;

often the comment was that "they do not function well enough". Experiences from various

projects during the same period suggested that the staff found it hard to involve the older. "It

was mainly minor things that the older residents participated in, such as coming up with ideas

for menus, setting the table or helping with some of the cooking, such as frying fish fillets or

pork chops" (Beck et al. 2006). The projects also found significant differences between how

the staff approached this task. In some homes, a resident stirring a pot was not seen as an

activity, while in other homes a resident being in the kitchen and being able to smell the food

was seen as an activity. In other places the residents peeled potatoes and chopped vegetables.

Frail older people sat and observed, and according to the staff thereby took part in the

experience. It is not clear whether all this was discussed with the residents, but the staff did

consider how the residents could benefit from being involved.

In hospitals

A project called "Project Mealtime Hosts" (with mealtime hosts affiliated with the

Department of Infectious Diseases and the Respiratory Ward in Herlev Hospital) was

designed to help older patients feel more independent when it came to meals and eating. One

older patient who had been fed by tubes for a long time and was at risk of malnutrition now

began to eat soup, and a few weeks later had visibly improved. "They [the meal hosts] ask me

what I feel like eating all the time, and that makes me feel like eating" (Søgaard Lund 2012).

7.4.5 Interventions to give older people better life skills and more desire to eat

and prioritise meals

In hospitals

Another study in Herlev Hospital shows that three home visits by a dietician during three

months after discharge had a positive effect on the physical function (mobility) and

nutritional condition (weight, energy and protein intake) of older patients at risk of

malnutrition. However, they had no effect on the risk of re-admissions and mortality (Beck et

al. 2013). In relation to coping with food and mealtimes, the patients who received catering

services were part of the intervention group, and with the help of the dietician, the male

participants in particular found that they could cook themselves.

An earlier Danish study showed that involving the older patients in the nutritional

interventions increased their intake of food and liquids (Pedersen 2005).

In nursing homes and home care

No intervention studies among older people in nursing homes and home care were found.

7.4.6 Good examples

In 2013, Roskilde Municipality tested "food workshops" among older residents in four

daycare and community centres. Food workshops offer an integrated course of activities with

the aim of maintaining and strengthening residents' cooking skills to give them more desire to

make food in their own homes. Food workshops also give the older the chance to have good

and meaningful experiences with others.

The course consisted of six food workshops in which up to five residents made food and ate

together, with guidance from a culinary adviser and the centre's staff. Residents with different

needs and backgrounds, such as people with diabetes or dementia, took part in the pilot project

(Madkulturen 2014).

Among other things, the experiences from the food workshops show that:

 Food and mealtimes can create a basis for strong communities.

 Even minor kitchen skills can be seen as a major contribution to a communal meal.

 Food brings back memories.

 Everyone has the desire to learn.

 Meals help people talk about other topics, such as over- and underweight, loneliness and

old age.

 Practising improves skills in the kitchen, regardless of age.

In 2015, food workshops will be carried out in all day centres and community centres in

Roskilde Municipality with a focus on enabling the staff to conduct workshops on their own.

7.4.7 Official Danish recommendations

The report "Recommendations for Developing Attractive Meal Services for the Older",

published by the Danish Institute for Food and Veterinary Research, recommends that

residents be encouraged to participate in cooking meals to maintain their skills (Beck et al.

2006). The National Action Plan for Meals and Nutrition for Older People in Nursing Homes

and Home Care recommends that food, nutrition and meals be organised based on the

individual older person's own wishes and needs (National Board of Social Services 2013).

7.4.8 Barriers

 There is a lack of understanding of how food and meals can be used to rehabilitate older

people who live at home or in nursing homes or are hospitalised, and to help them

maintain their life skills.

 There is a lack of focus on making food and mealtimes focus areas for rehabilitation.

Older people should be actively involved in the care activities. For example, they can help

set the table, peel potatoes and butter bread.

 In general, meal services for older people living at home do not use differentiated

solutions, which mean that all recipients of meal services are offered the same meals, even

though there is a big difference between what they can physically manage.

7.4.9 Areas where more research is needed

 How do the municipalities use food and mealtimes to help rehabilitate older people in the

three settings?

 What effect does involving older people in activities related to food and mealtimes have

on their quality of life, life skills and rehabilitation?

 There is a lack of case studies and recommendations regarding how working with food

and mealtimes can be applied in individualised rehabilitative efforts for older people. For

example, older people who have been assessed as being eligible for meal services can be

encouraged to do some of the cooking themselves, such as boiling potatoes.

 There is a lack of understanding of whether social interventions and non-food-related

activities indirectly boost appetite and weight retention among the older who do not want

to participate in the nursing home's communal meals.

7.4.10 Next step

Identifying which activities and offers already exist and what effect they have on life skills

and quality of life.

Conducting research into the impact of various activities, tools, routines, etc. on life skills,

physical function, morbidity and quality of life.

Developing appropriate guidelines for refurbishment of homes for the older and nursing

homes that stimulate residents to do as much as possible for themselves.

7.4.11 References

Beck A et al. An bef alinger for udvikling af den attraktive måltidsservi ce til ældre. Da nmark s

Fødevareforskning, 2006

Beck A et al. Follow-up ho m e visits with registered dietitians have a positive effect on the

funct ional and nutrition al status of geriatric medical pati ents after discharge: a ra ndomized

controll ed trial. Clin Rehab 2013; 87 : 483-93

Grøn L, Andersen, CR. Så rbarhed og handlekraft i alder domm en. Et etnografisk feltarb ejd e

blandt fagpersoner og ældre i Horsens og om egn. KORA 2014

Gustafsson K, et al. Older Women's Perceptions of Independence Versus Dependence in

Food-Re lated Work. Public Health Nursing 2003; 20: 237-247

Hjemm ehjælpskommissionen, Sekretar iate t. Fremtid ens hjemmehjælp – ældres res sou rcer i

centrum f or en sammenhængen d e indsat s 2013

Kofod, J. Du er dem du spiser sammen med – et br ugerperspektiv på den offen tlige

måltidss ervice. Fødevarerapport 2000; 09

Kommiss ionen om livskvalitet og se lvbestemmelse i plejebolig og plejehjem, Livskvalitet og

selvbestemm else på plejehjem, 2012

Madkulturen. Madværksteder for ældr e. Planlæg ning og praktik. Madkulturen 2014

http://madkulturen.dk/fileadmin/user_upload/madkultur en.dk/dokumen ter/projekte r/madvaerk

steder/mk_drejebog_aeldre_final.pdf

Marse lisborgCe ntret. Hvidbog om rehabiliteringsbegrebet. Marse lisborgCe ntret, Århus. 2004

Med in J, et al. Elderly persons' exp er ience and ma nag ement of ea ting situations 6 mon ths

after st roke. Disability & Rehabilitation 2010; 32 : 32: 1346-1353

Pedersen PU . Nutr itional care: the effec tiveness of act ivel y involving older pati ents. J Clin

Nurs 2005 ; 14: 247-55

Sidenvall B et al. Managing food shopping and co oking : the exper iences of older Swedish

women. Ageing Society 2001; 21 : 151-168

Socialstyr elsen. Den nati onale ha ndleplan om må ltider og er nær ing til ældre i hjemmep lejen

og plejeboligen. So cialstyr elsen 2013

Søgaar d Lund L. Pr ojekt måltidsværter. Herlev Hospital, Region Hovedstaden 2012

8. THE STAFF'S SKILLS

This chapter concerns the importance of the professional skills of the nursing and kitchen

staff in prioritising and providing meals.

8.1 THE SIGNIFICANCE OF THE STAFF'S SKILLS FOR PRIORITISING AND

PROVIDING MEALS

Some of the key questions in this area are: What do the nursing and kitchen staff knows about

the nutritional and mealtime needs of older people? Is there a dialogue and interdisciplinary

collaboration between the staff when it comes to meals and mealtime settings? How does the

management prioritise meals in relation to the rest of the care? Is there a policy that can

ensure coherence and direction in this area?

8.1.1 Why it is important

To prioritise and provide meals to the older, it is crucial that the staff have the necessary skills

to support and enhance the residents' existing capabilities. And the skills of the staff should in

turn be supported by the management by making a clear division between the responsibilities

of the kitchen staff and the carers in all three settings. The professional staff must ensure that

the older's nutritional and quality of life needs are met.

A specific example of the need for interdisciplinary dialogue between kitchen staff and car e

staff concerns the food's texture and consistency. "Serving food and liquids with the wrong

consistency will often result in residents with chewing and swallowing problems, storing up

food in the mouth, slobbering, coughing, having pain, spitting out the food and throwing up.

The result is a bad food experience for both the older themselves and the people they share

the table with" (Kofod 2000).

Another example concerns the nursing staff's skills in helping older people with various

disabilities socialise around the meal. "In nursing homes, older people with, for example,

dementia, Parkinson's disease and strokes can have trouble communicating. They can

therefore find it difficult to take active part in the social community around mealtimes in

nursing homes" (Kofod 2000).

8.1.2 The significance of the staff's skills for prioritising and providing meals

All three settings

The staff have a role in adjusting any negative or positive expectations the older residents

may have regarding the meal (Beck et al. 2006). This applies to all three settings: in their own

homes, the older may have a negative expectation of the food, because it is delivered and

because they have to eat it alone, which is why many do not consider it a real meal (Kofod

2000). In hospitals, the older patient may have negative expectations of the food because it is

"hospital food".

In home care

No studies were found on the importance of the nursing staff's professional competences in

relation to food and mealtimes for older people living at home.

In nursing homes

A Danish study concluded that although many carers in nursing homes have received training

concerning food, mealtimes and nutrition for the older, more training is needed regarding food

and mealtimes, the carer's role before and during the meal (Beck et al. 2006; Kofod. 2012), as

well as screening off and caring for vulnerable individuals with special needs (Sidenvall et al.

1994; Sidenvall et al. 1996).

An interview study of 136 staff employed at 15 randomly selected nursing homes in Aarhus

County found that the staff had limited understanding of older people's nutrition, and that the

nurses did not know more than staff with shorter basic training. At the same time, the

researchers' impression was that the older's nutrition was a low priority (Beck et al. 2006).

There is also a mismatch between the role of the nursing homes' staff and their tools and

approach to the actual meal. Kofod's observations and interviews showed that the intentions

of politicians and nursing home managers to create the conditions for good, cosy meals for

the residents were far from being realised. "A number of residents said they felt embarrassed

at the communal table and sometimes left it as fast as they could after finishing the meal.

Why? Many employees spoke of the frustration they felt when they failed to get residents to

take part in conversations during the meal" (Kofod 2012). Kofod suggests that care assistants

lack the necessary pedagogical skills for this.

The staff handling the meal also plays a role as fellow diners, which is particularly important

in relation to residents with dementia, who mirror other people's behaviour in the meal

situation (Beck et al. 2006).

Staff must furthermore be able to screen off individuals who eat messily, both for the sake of

the individual and the other diners. The residents' awareness that they eat messily can make

them eat less and weaken their nutritional status, and there is also a risk that the other diners

lose their appetite (Beck et al. 2006).

In hospitals

Disease-related undernourishment is a major problem among older hospital patients. In 2002,

the Council of Europe identified five key barriers to ensuring good nutritional care in

European hospitals (Council of Europe 2002):

 Lack of clearly defined responsibilities in planning and managing nutritional care

 Lack of sufficient education with regard to nutrition among all staff groups

 Lack of influence and knowledge among the patients

 Lack of cooperation between different staff groups

 Lack of involvement by the hospital management.

In addition to the managerial barriers, the training of all the staff groups does not focus

enough on meals and nutrition, and there is not enough cooperation between the staff groups.

The staff must become better at involving the patients and informing them about the

importance of meals and nutrition. All the staff need more on-the-job nutritional training, and

much closer cooperation and dialogue is needed between the various staff groups, including

doctors, nurses, dieticians and meal services staff, in order to optimise the nutritional care.

Studies indicate that staff is not good enough at identifying and acknowledging disease-

related undernourishment among older patients (Suominen et al. 2009; Ross et al. 2011). In a

Finnish study, only 15% of older patients were assessed as undernourished using the mini

nutritional assessment (MNA) tool, although more than 60% were in fact undernourished

(Suominen et al. (2007a). An Australian study concluded that there was a lack of a

coordinated approach to and knowledge of nutritional interventions, as well as a lack of

interdisciplinary communication and perception of a shared responsibility. Employees felt that

the desired focus on nutrition competed with many other activities (Ross et al. 2011).

The Danish quality model, in which nutrition is one of the indicators, has put more focus on

nutrition during hospitalisation, mainly through greater nutrition screening of patients, but

follow-up action is still lacking (Haddad et al. 2014). In addition, a recent Danish study

showed that there are a number of barriers to continuing nutritional interventions after the

patients are discharged from hospital (Haddad et al. 2013), such as lack of time, training,

knowledge, and allocation of responsibilities.

8.1.3 Interventions regarding the staff's skills

In home care

No intervention studies focusing specifically on the training of home care staff were found.

In nursing homes

A systematic review focusing on the impact of food interventions on the nutrition of nursing

home residents included studies on the training of nursing staff (Abbott et al. 2013), no

randomised controlled studies were included in the review. However, the results indicate that

educating the staff on nutrition has a positive impact on the nutrition of the residents.

A scoping review of studies on meal interventions in nursing homes in general found no

randomised controlled studies (Vucea et al. 2014). The conclusion was that training the

nursing staff seemed to have some effect on detecting older people at risk of

undernourishment and making efforts to improve their nutrition.

In connection with a Danish initiative called "Good Food, Good Life", funded by rate

adjustment pools and carried out by the National Board of Social Services, a literature review

of three studies (including one randomised controlled study) concluded that on-the-job

training that combines nutritional theory and practice has a positive spill-over effect on older

residents' nutritional st atus (National Board of Social Services, 2010).

In hospitals

A scoping review assessed nutritional interventions for hospitalised patients (Cheung et al.

2013), none of the identified studies focused exclusively on staff training.

8.1.4 Good examples

In nursing homes

In 2006, superintendent Bo Pedersen of Bryggergårdens nursing home in Copenhagen started

a collaboration with kitchen manager Jytte Jensen on changing the food and mealtimes in the

nursing home. This resulted in a significant improvement in the culinary quality, more focus

on improving the social interaction, and more targeted interdisciplinary activities around the

work with food and mealtimes. The process was very hands-on and has helped to change the

working culture regarding food and mealtimes in Bryggergården (Madkulturen 2013).

In hospitals

In 2010-2012, nutrition assistants were brought into Herlev Hospital's central kitchen as part

of the Meal Hosts project, which assigned meal hosts to hospital departments to support the

daily work on the wards (Lund 2012). The meal hosts took over some of the kitchen and

nursing staff's tasks, including helping with menu selection and presenting and serving meals.

The project concluded that, as a result of the project:

 The staff was relieved in a working area they did not have time to prioritise.

 There was more focus on the individual patient's dietary intake.

 There was more focus on the patients' food and mealtime experience.

 The patients had more desire to eat.

 The meal hosts experienced their function in the wards as meaningful.

 There was greater cooperation between the kitchen and food staff and the rest of the staff.

 Food waste was reduced.

 It was a challenge for the meal hosts (the nutrition assistants) to find a platform in the

departments for a professional hosting role.

 The staff's focus on work relief was seen as more important than the patients' satisfaction

and improved intake of food and drink.

8.1.5 Official Danish recommendations

The National Board of Social Services' National Action Plan for Meals and Nutrition for

Older People in Nursing Homes and Home Care (2013) recommends that:

 All staff groups around the older should be aware of the importance of food, mealtimes

and nutrition to the quality of life and physical function of older people.

 Interdisciplinary cooperation between staff groups should be promoted.

The National Board of Social Services' project "Good Food, Good Life" (2011) recommends

skills development of managers, kitchen staff and carers. The National Board of Social

Services has developed the implementation model "Roads to Good Food and a Good Life for

Older Residents – An implementation guide to interventions regarding food and mealtimes"

for three professional groups: local government employees, carers and kitchen staff. The

guide offers advice for each group on focus areas such as proper nutrition, good ingredients,

and a good meal setting (see Figure 8.1 below).

Figure 8.1. In connection with the National Board of Social Services' project "Good Food,

Good Life" (2011), on-the-job training courses have been developed to train social and health

assistants and nutrition staff.

8.1.6 Barriers

The Council of Europe's report from 2002 suggested that none of the staff groups received

adequate nutrition training and that there was poor cooperation between individual staff

groups (Council of Europe, 2002)

8.1.7 Areas where more research is needed

How are students taught about food and mealtimes in the various programmes that train them

to care for the older?

How does the staff's level of training affect the older's nutrition, physical function and

quality of life in the three settings?

Studies should be conducted in these areas before and after offering the necessary courses in

the vocational training programmes.

8.1.8 References

Abbott RA et al. Effectiveness of mealtime in terventions on nutrition al outcomes for the

elder ly living in residential care: A systema ti c review and met a-analysis. Ag eing Research

Reviews 2013; 12 : 967– 981

Beck A, , et al. An befalinger for udvikling af den attraktive madser vice til ældre. Da nmarks

Fødevareforskning, 2006

Cheu ng G et al. Diet ary , Fo od Service, and Mea ltim e Inter ven tions to Promote Food Intake in

Acute Care Adult Pa tien ts. Journal of Nutrition in Gerontology and Geriatrics 2013; 32: 175-

212

Counc il of Europe. Report and recommen dations of the Committee of Experts on Nutrition,

Food Safety and Co nsu mer Protection. Health protection of the consumer. Co unc il of Europe

Publishing 2002

Holst M, Rasmussen HH. Nutriti on Therapy in the Transition between Hospital and Ho me:

An In vestigation of Barriers. J Nutr Metab. 2013;463751. doi: 10.1155 /2013/46 3751. Epub

2013 Dec 29

Holst M, Staun M, Kondrup J, Bach- Dahl C, Rasmussen HH. Good nutritiona l practice in

hospitals during an 8-year period: The impact of accred itation. E- SPEN 2014, 9: e155-160

Kofod, J. Du er dem du spiser sammen med – et br ugerperspektiv på den offen tlige

måltidss ervice. Fødevarerapport 2000;09

Kofod,J. Fo od, Culture and So ciet y: An International Journal of Multidisciplinary Research,

2012; 15: 665-78

Lund, LS. Projekt måltidsværter, Herlev Hosp ital, Re gion Hovedstaden 2012

Madkulturen 2013. B rygger gården. Den lange rejse - Bryggergården oml ægger til økologi.

Film. http://w ww.kbhm adhus.dk/servicenavigatio n/om-os/mate rialer /filmarkiv/den- lange-

rejse-bryggergaarden -omlaegger-ti l-oekologi

Ross LJ et al. Ever yone' s probl em but no bod y's job: staff percepti ons and explanations for

poor nutrition al intake in ol der medical patients. Nutr ition & Dietetics 2011; 68 : 41-46

Service styrelsen. Baggrundsmate riale til kv alificering af en måltidspolitik. Servi cestyrelsen

2010

Servicestyrelsen. "God mad - godt liv," Social Fokus Ældre, juni 2011

Socialstyr elsen. National handlingsplan for må ltider og er næring til ældre i hjemmep lejen og

plejeboligen, So cialstyr elsen 2013

Suominen, MH et al. "How well do nurses rec ogniz e malnutrition in elderly pati ents." Eur J

Clin Nutr 2009; 63 : 292-96

Vucea V et al. Interven tions for improving mealtime experiences in l ong-te rm care. J

Nutrition Ger ontol Geriatr 2014; 33 : 29 4-324

9. POLICY (GOVERNMENT)

This chapter consists of two sections. The first describes the importance of the financial and

organisational framework. The second deals with the importance of a food and mealtime

policy.

9.1 THE SIGNIFICANCE OF THE FINANCIAL AND ORGANISATIONAL

FRAMEWORK FOR FOOD AND MEALTIMES

The issue of finances in relation to meal services for the older has to do partly with the overall

financial framework for this area of older care and partly with how the available financial

resources are used. The following deals mainly with the latter.

Two financial aspects related to meal services for the older seem to be particularly

significant:

1. The importance of older people's nutritional status to the cost of older care.

2. The importance of the municipalities' use of the available financial resources to provide

food to the older.

These two points are dealt with separately below.

9.2 THE IMPORTANCE OF OLDER PEOPLE'S NUTRITIONAL STATUS TO THE

COSTS OF OLDER CARE

The financial consequences of the nutritional status of the older are mainly indirect. Apart

from the fact that good nutrition is important to the health and physical and mental well-being

of older people, an increase in the number of older people in good health also reduces the

costs of medical care and often they can handle many daily tasks themselves, such as personal

care, cleaning services, etc. This results in public savings on home care, nursing, etc.

9.2.1 Why it is important

The financial gains that can potentially be derived from good nutrition among the older do

not directly benefit the providers of the meal services. This unclear relationship between the

costs and benefits of good meal services for the older presents a potential barrier to delivering

meals with adequate nutritional and gastronomic quality. A clearer link between the costs of

meals and the financial benefits of improved nutrition could potentially strengthen the

financial incentives to enhance the quality of the meals and ultimately improve the physical

function, nutrition and quality of life of older people.

9.2.2 The significance of inadequate intake of food and liquids for the costs of

older services

All three settings

A Dutch systematic review looked at costs associated with illness-related undernourishment

(Freijer et al. 2013). The target group was people over 18 in poor nutritional condition,

including older people in nursing homes, home care and hospitals. The conclusion was that in

2011 these costs represented an extra expenditure of EUR 1.9 billion, or 5% of the total

expenses of the Dutch healthcare system. The largest costs were associated with people over

60.

In nursing homes

Another Dutch study estimated the cost of improving the poor nutrition of older residents in

nursing homes (Meijers et al. 2012). There was an extra expenditure of EUR 10,000 a year per

older resident with poor nutrition due to the efforts required to improve their condition,

including employing clinical dieticians, offering industrially produced energy and protein

drinks, and the time spent weighing the residents and following up on their health.

In home care

Livingston et al. (1997) examined the costs of caring for older people in Greater London with

various disorders (dementia, depression, limitations on physical activity and anxiety

diagnoses), as well as different types of care costs. Their analysis found that the average

monthly cost of personal care and practical help was 150-500% higher for older people with

these disorders than for healthy older people. A substantial part of the costs of personal care

was directly associated with these specific disorders, but on average the costs of practical

assistance were also higher (200-300%, and up to 700% for people with dementia) than for

healthy older people. The difference was mainly due to the fact that healthy older people use

these services far less than older people with these disorders. The study thus suggests that

there is a considerable difference between the costs of bringing out meals to older living at

home and the costs of helping them to eat the food – a difference that may be useful to

examine in the Danish context as well.

These significant differences between the costs of meal services for healthy older people and,

for example, for depressed or frail older people may also indicate a potential for long-term

savings, in so far as a higher quality of food and mealtimes can help prevent or postpone

depression and physical impairment.

9.2.3 Interventions to increase the intake of food and drink, and their significance

in terms of the costs for older care and services

All three settings

A systematic Dutch review looked at the financial significance of a nutritional intervention

among hospital patients over 18 and older people in nursing homes and home care (Freijer et

al. 2014). The nutritional interventions typically involved providing industrially produced

drinks, sometimes in collaboration with a clinical dietician. The results, which were based on

academically sound studies, were that the nutritional efforts either led to financial savings

(three studies), were cost-neutral (one study), or were more expensive than the standard

nutritional services, but still within an acceptable level compared to other expenditures in the

healthcare system (four studies).

An earlier Dutch study looked specifically at the financial significance of a nutritional

intervention involving providing industrially manufactured nutritional drinks to older people

(Freijer et al. 2012). The focus was on older patients, but these were also defined as including

older people in care homes and home care. The conclusion was that the intervention was

financially viable, especially because it resulted in fewer hospital admissions. This reduction

in hospital admissions was also seen in three studies involving providing nutritional drinks to

older patients being discharged from hospital.

In nursing homes and home care

Sahyoun and Vaudin (2014) provided an overview of the scientific literature relating to the

nutritional and health-related effects of meal services delivered to older people in the United

States and found that they improved the users' nutrition and r educed the need to move into

care homes.

A recent Danish study (National Board of Social Services 2014) also showed that it is

possible to organise a cost-effective nutritional intervention for frail and undernourished older

people. This study examined an intervention based on a formalised cooperation between

clinical dieticians, occupational therapists and physiotherapists. The intervention had positive

effects on the participants' physical function and quality of life. The results also showed that

weight gain was closely linked to improved quality of life. The study suggests that the

formalised cooperation between the different areas of expertise was a significant reason for the

intervention's effectiveness. The study calculated that the cost of the intervention was DKK

64,000 per QALY (quality-adjusted life year), which is low compared to the cost of achieving

similar results in other parts of the healthcare system, where the report indicates DKK

200,000 per QALY as a relevant benchmark.

Kretser et al. (2003) investigated the difference between the effects of two alternative

concepts of delivered food on the users' degree of self-reliance: either one meal a day five

days a week (USD 5.50 per day including transport, delivered warm and recommended for

eating immediately), or a full week's menu (three meals and two snacks per day for USD 11

per day, delivered frozen once a week). The recipients of the full week's menu gained more

weight and were in better nutritional condition than those who received a single daily meal.

But the residents' degree of self-reliance was linked more to their BMIs than to whether they

received one or the other type of delivered food. Of those who received the full-week diet,

52% said they did not finish the food every day because there was too much. However, the

users were satisfied with the scheme, for example with their ability to select meals, the taste of

the food and the weekly delivery, which gave them more flexibility to choose their meal times.

The users consumed more ready-to-drink beverages than drinks that needed preparing. Frozen

dishes specifically prepared for the target group received the highest rating.

In hospitals

Calculations by Lassen et al. (2005) and Pedersen (2009) suggest that undernourishment

among medical patients costs the Danish hospital sector around DKK 144 million annually

(calculated in 2003 prices).

Based on a Dutch study (Freijer et al. 2013), a report prepared by Arla Foods and the Danish

Diet and Nutrition Association (2014) tried to calculate the socioeconomic consequences of

undernourishment among the older.

In addition to more hospitalisation days for undernourished older medical patients, the

report's calculations also included increased care costs in nursing homes, home care and in

GP's surgeri es. The calculations suggest that undernourishment costs the Danish public sector

around DKK 6 billion a year, that DKK 1.5-2 billion could be saved through targeted

treatment of these patients' undernourishment, and that this saving would be more than

sufficient to cover the cost of such a treatment intervention. These calculations also suggest

that there may be socioeconomic benefits to be gained by focusing more actively on diet and

nutrition during the treatment of undernourished hospital patients (within the provisions of the

Healthcare Act), rather than "consigning" them to the normal older care and meal services too

early.

Allison (1995) studied the importance of diet for the rehabilitation of hospitalised older

people. He found that encouraging the older to eat and offering them diets with high energy

content promotes rehabilitation. He also calculated the costs of different types of diet:

standard hospital food cost GBP 20 per week, and high-energy hospital food could be

delivered at a limited additional cost. The addition of snacks or energy and protein drinks for

oral ingestion (1 MJ per day) increased the daily cost by 12-18%.

Tube/enteral feeding and intravenous/parenteral feeding (8 MJ per day) were, respectively, 3-

4 and 15-25 times as expensive as standard hospital food. These figures suggest that an early

intervention in relation to undernourishment could be cost-effective if it reduced the need for

enteral or parenteral nutrition.

9.2.4 Good examples

In Denmark, Herlev Hospital has experimented with restructuring its central kitchen to

provide healthy and delicious Nordic cuisine with menus composed by a gourmet chef.

Reportedly, the food costs the same to make as regular hospital food (Munk T., Politiken, 31

March 2014).

9.2.5 Barriers

According to section 83 of the Act on Social Services, municipal councils must offer

"personal care and assistance, assistance or support for necessary practical activities in the

home and meals services" to "persons who are unable to carry out the said activiti es due to

temporary or permanent impairment of physical or mental function or special social

problems". However, for patients who have diseases or are undergoing rehabilitation after

disease, the Healthcare Act's provisions apply. According to these provisions, the benefits

should be provided by authorised healthcare staffs that are independently responsible for

ensuring that the treatment conforms to generally accepted professional standards.

If patients who have diseases or are undergoing rehabilitation after disease receive meal

service in accordance with the Health Act's provisions, they have access to the health

service's appeal and compensation schemes, which entail greater obligations for service

providers than for meal services in normal older care. Such obligations could give providers

more incentive to provide nutritious meals. However, the cost of providing meals for patients in

a treatment context is likely to be somewhat higher than regular meal services pursuant to the

Social Services Act, which may be a barrier to prescribing special diets in accordance with the

healthcare legislation.

There may also be a financial incentive problem for individual agencies – for example

between the health sector and the individual municipalities – if one agency reaps the financial

benefits of improving the older's diet while another has to bear the cost. Such incentive

problems can affect the agencies' mutual coordination of the effort to include nutritional

interventions in the rehabilitation of undernourished older patients.

9.2.6 Areas where more research is needed

As mentioned, more attractive food offers and mealtime situations can help improve the

nutritional status – and thus the general status of health and the degree of independent living –

of many older people, which is likely to lead to financial gains for the public sector and for

society as a whole. However, there is a need for scientific studies of how big these financial

gains will be in the areas of residential care, home care and hospital care.

In addition, there is a need for more research into the incentive structures for ensuring the

quality of meals for the older to ensure that the providers of meal services have enough

financial incentives to supply meals that the users want to eat.

9.2.7 Moving forward

We propose a systematic collection of existing data on the direct and indirect costs associated

with older people's diet and nutrition in nursing homes, home care and hospitals. This will

help determine the financial incentives of the various actors.

It should also enable a preliminary assessment of the financial potentials of improving meals

for the older.

New research can then be initiated with a view to examining the actual cost factors and

determinants in a Danish context.

9.2.8 References

See section 9.3.8

9.3 THE SIGNIFICANCE OF HOW THE MUNICIPALITIES USE THEIR BUDGETS

FOR OLDER MEAL SERVICES

The administration of the food production in the individual municipalities reflects the

overriding financial, organisational and political conditions. This section highlights the

municipalities' and hospitals' options for producing food for the older under these conditions

and within the framework of specific organisational units with independent budgets.

9.3.1 Why it is important

Costs are seen as a significant barrier to delivering nutritious and appetising meals to the

older. At the same time, there are considerable differences in the costs of producing and

distributing the food, for example between municipalities. A better understanding of these

cost differences is key to reducing the financial barriers to providing good meal services to

the older.

9.3.2 The financial significance of the organisation

In nursing homes

Meals for older people in nursing homes can be supplied in three forms: frozen food,

chilled/vacuum-packed food and hot food. Chilled/vacuum-packed food is the most

expensive, with DKK 4,090 in monthly production costs, compared to DKK 3,615 per month

for hot food and DKK 3,866 per month for frozen food, according to Local Government

Denmark and Ministry of Welfare, 2008. Hot food is thus cheapest.

A study carried out by the Danish Broadcasting Corporation (www.dr.dk, published 30

September 2014) indicated that approximately 40% of municipal nursing homes cook each

day's hot main meal from scratch, and that approximately 25% of nursing homes have stopped

cooking hot food themselves over the past 10 years. The trend towards a more centralised

production of meals for the older could indicate that financial economies of scale are being

exploited in food production.

In home care

Among 88 Danish municipalities in 2008, frozen food was provided to the older in 16

municipalities, 67 municipalities used chilled/vacuum-packed food and 58 municipalities

provided food that was kept warm (see Table 1). 37 of the municipalities only used one of

these three forms of production, and among these, the average costs were DKK 1,589 per

month for frozen food, DKK 1,773 per month for chilled/vacuum-packed food and DKK

2,041 per month for food that was kept warm. While the meal services in nursing homes

usually consist of full-day meal plans, the meal services in home care as a starting point only

provide one warm meal a day (Local Government Denmark and the Ministry of Welfare

2008).

Quality control and optimising sensory quality

As Table 1 shows, most meals are delivered chilled/vacuum-packed or kept warm. This

despite the fact that there is a great deal of understanding of the chemical and physical

changes in the quality of food that is reheated or kept warm for a long time. In particular,

cooked and fried chicken and turkey quickly change or lose their flavour (Byrne and Bredie

2002). In addition, many flavours will tend to diffuse across the meal's ingredients if meals

are assembled before delivery. It is not always clear whether there is a systematic quality

control of the food's flavour either when it is produced or when it is eaten with the older in

nursing homes. But relatively large differences between the desired sensory quality and the

sensory quality on the "customer's" table should be expected.

It should also be noted that delivered food that is kept warm gives the user relatively little

flexibility when it comes to choosing eating times. The times when it is practical for the

suppliers to bring out the food (and help the older to eat, if appropriate) may be inconvenient

for some users or may not be times when they are hungry.

Table 9.1 Distribution of food production forms in the municipalities

- - - - - - - - - - - - - No. of municipalities - - - - - - - - - - - - -

Source: Local Government Denmark and the Ministry of Welfare 2008

Despite the fact that frozen food is the cheapest, the municipalities only use this form of

production to a relatively limited extent to provide food for the older. Approximately 40% of

municipalities use chilled/vacuum-packed food in more than half of their delivered servings,

and 35 % of municipalities do not deliver warm food; see Table 9.1 (Local Government

Denmark and the Ministry of Welfare 2008).

As a starting point, meal services consist of a warm meal with a starter or dessert. Not all

users choose to use the meal service every day. There is a lack of systematic research into

where these users receive the rest of their food from and what they eat, e.g. whether they cook

for themselves, whether they get food from family and friends, whether they are part of meal

groups, etc. In other words, there is no solid knowledge about their overall diets.

Mindel et al. (1986) investigated the use of personal services by older Americans living at

home (Ohio), distributed across formalised/professional providers (public sector,

organisations, etc.) and informal providers (family, neighbours, etc.). This study measured

users of a variety of services, including food-related services such as meal services or help

with shopping, but also home care, transport assistance, personal care and healthcare in

monetary units, which allows for some comparisons across services. The study also broke

down the users according to race (white/black) and income level. According to the study, 20-

30% of the older received food-related services, though the majority received these from non-

formalised "suppliers" such as family and friends, and about as many received help with

grocery shopping. Black Americans received more food-related services than white

Americans, but they also received more non-formalised help. The study thus suggests that

non-formalised services such as cooking by relatives may be quite significant – and also that

there may be considerable variation between different population groups in this area. Here, of

course, it is important to be aware of the institutional differences between the US and

Denmark, where presumably there are more formal social services for the older.

In hospitals

In the summer of 2014, the auditing and consultancy firm BDO produced a relatively detailed

financial account of hospital kitchens in the Capital Region of Denmark (BDO 2014). The

report shows that the total costs per meal unit (a normal menu consisting of three main meals

and three snacks makes up a total of 1.6 meal units per day) in the hospitals where the highest

and the lowest costs vary by up to 65%. The price varies from around DKK 55 per day to

around DKK 90 per day (BDO 2014). These cost differences can be attributed to a number of

factors, including diet concepts, levels of service, production methods and production

efficiency. For example, when providing 24-hour meal plans to patients, the hospital kitchens

supplement their meals with ready-processed food to varying degrees, which helps reduce

costs per meal unit. But even taking this into account, the report finds quite significant

differences between the cost levels at the different hospitals.

9.3.3 Interventions for cost-efficient food ordering and meal services

In home care

Aberg (2006) outlines a meal-planning system for the older that allows them to plan their

own diets taking into account taste, price, cooking requirements, dietary variation, dietary

restrictions, nutritional needs and food availability. The system seems to be primarily intended

for older people who cook for themselves, but might also serve as a basis for more flexible

meal delivery schemes and thus enable more targeted and cost-efficient meal services that

respond better to the users' needs and wishes.

Siira and Häikiiiö (2007) described an IT-based ordering system for meals for the older

(Near-Field Communication). However, their system appears to have been developed before

the proliferation of smartphones, ipads, etc., so may not be altogether appropriate for

Denmark.

Various studies, including several from the Nordic countries, have tried to develop concepts

to solve some of the logistical challenges of delivering meals for the older. Bräysy et al.

(2009a, 2009b) developed an optimisation model for minimising the costs of meal services

for the older and applied it to a municipality in Finland. In 2005, the municipality had 827

users and delivered an average of 262 meals per day, or 95,625 meals per year. The price of a

meal was EUR 8. The deliveries were organised into nine delivery lines, and in 2006 the total

delivery cost was EUR 174,999. As a starting point the food was delivered warm, but it could

also be delivered cold, though this did not make a difference in delivery costs, since warm and

cold meals were delivered at the same time. The authors developed an optimisation model to

determine the cheapest delivery routes in terms of labour costs and transport distance. The

analyses suggest that optimising the transport routes can result in savings of between 20% and

50% of the transport costs. Since warm meals have to be delivered within two hours for food

safety reasons (according to the Finnish authorities), the biggest savings are made if the food is

delivered cold and is then heated in the user's home, since this allows for more route flexibility

and thus makes it easier to organise the deliveries. In addition, there are the costs of the carers'

meal assistance for the older, when needed.

The above three intervention types represent different technological and organisational

("bottom- up") solutions to increase cost-efficiency in food production and delivery. There

have also been experiments with more "top-down" interventions designed to create increased

efficiency by regulating the financial or political production frameworks. Putting public meal

services out to tender or regulating the prices of meal services are examples of such "top-

down" interventions.

In the 2009 Finance Act, the Danish Parliament adopted an upper limit on the price of food in

nursing homes and home care. In 2010, the upper limit was DKK 3,000 per month for food in

nursing homes and DKK 45 for one delivered main course. The upper limit is adjusted

annually and in 2014 the rates were DKK 3,324 and DKK 49 respectively. In addition,

municipalities may not charge more than it costs to produce the food. According to the

municipal figures of the Ministry of Economic Affairs and the Interior, these price limits have

meant that a number of municipalities, which before 2010 charged prices above the limits,

have reduced their prices for meal service. At the same time, there have been speculations

that other municipalities, which used to operate with rates that were lower than the upper

limits, have used them to raise their rates (Jyllandsposten 17.10.2014). However, a preliminary

study of the Ministry of Economic Affairs and the Interior's municipal figures does not

suggest that this tendency to raise rates has been particularly widespread. Admittedly, from

2009 to 2010, the municipal charges for food in nursing homes increased in half of the

country's municipalities (and in 10-12 municipalities for meal services in the older's own

homes), but given the general wage and price developments in society, this increase has been

modest in most of these municipalities. The number of municipalities with rates below the

upper limits has remained relatively stable since their introduction.

The price limit for delivered food only applies to a main course; no price limits have been set

for starters, desserts or snacks. The structure of the price limits thus means that separate prices

have to be specified for main dishes and the other courses. As a result, people with low

appetites may be inclined to opt out of the other courses to save money. On the one hand, the

separate pricing of the different dishes gives the user the flexibility to choose between side

courses from the meal service provider and other sources, e.g. family visitors, that is if the user

has access to such sources. On the other hand, since the meals are often composed based on

the nutritional value of the combination of a main course and a starter or dessert, these opt-outs

can be disadvantageous, especially for frail and undernourished older users. For example, a

dessert could provide a valuable calorie boost for an underweight user with a low appetite.

According to a survey by Local Government Denmark and the Ministry of Welfare (2008),

the type of contract behind the meal delivery service can affect costs. For instance, when the

contract states that the user can choose one of the suppliers approved by the municipality

within a set price range, the monthly costs are about 3% lower (user fee plus subsidy) than

average and about 4% lower than the type of contract where the municipality chooses the

suppliers. However, it should be pointed out that not many municipalities used the former

contracts, so these cost differences are very uncertain.

There are different challenges associated with delivered food, both as regards keeping

delivery costs down (which makes demands on the organisation of deliveries), and supplying

food that lives up to the users' wishes and expectations (which makes demands on the

communication between users and suppliers and the organisation of deliveries). Putting meal

services out to tender appears to be a means to create a better relationship between price and

quality in some municipalities. So far, tendering seems mainly to have resulted in lower costs

without a significant lowering of quality (according to the municipalities), but it remains to be

seen whether tendering could also be used to enhance meal quality within the given cost

frames.

Food safety is also an important factor in meal deliveries. A high level of food safety is

essential, especially for underweight older people and those with low appetites and weakened

immune systems, for whom infections from food-borne pathogens can be very serious, even

life-threatening. Food safety also plays a role in relation to the trade-off between costs and the

quality of the meal solutions – perhaps especially when it comes to the costs of delivered

food. Ensuring food safety places financial and logistical demands on the transport facilities,

and may thus affect the types of meal solutions that are offered (warm, chilled, frozen).

In nursing homes

The auditing and consultancy firm Deloitte investigated the financial rationalisation potentials

of centralising or outsourcing the food production in large production centres, and found that

such measures could result in cost savings of 20-45% compared to the average cost level at the

time of the report (Deloitte, 2013). The report focuses mainly on the costs of food production

and only to a limited extent on the quality of the food and the users' influence on the food.

Increased centralisation of food production would likely mean more meals delivered

chilled/vacuum-packed or frozen and fewer meals delivered warm and ready to eat. The

Deloitte study focuses mainly on how to save money in the municipalities, but the identified

potential for saving 20-45% of the current production costs might alternatively be used to

improve the quality of the food, for example by choosing different ingredients or cooking

methods.

Kristensen (2014) provides an overview of experiences of providing services for the older

based on data from the tenders portal www.udbudsportalen.dk. This overview gives a mixed

picture of the experiences. In most of the case studies, the municipalities indicate that they

saved money as a result of putting the services out to tender. Some municipalities (e.g. Høje-

Taastrup, Ballerup) have completely or partially phased out warm food in favour of chilled

food; others (e.g. Fredericia) have achieved savings after the tendering without changing their

delivery forms.

Most of the municipalities included in the study indicate that the quality and delivery of the

food have been at least as good after the tendering process as before.

In hospitals

According to the above-mentioned report by the Capital Region of Denmark (2014), a

number of the region's hospital kitchens are focusing on improving the quality and cost-

effectiveness of food production. In terms of costs, this report mentions the reduction of food

waste as a focus area in 2014 in the hospitals in Gentofte, Glostrup, Herlev, and as an indirect

focus area through optimised allocation in other hospitals. "Efficiency" or "optimised

operation" is also mentioned as a focus area at two hospitals, and "more cooking from

scratch" was a focus area in 2014 in several of the capital region's hospitals – though it is not

clear from the report whether this is based on financial motives. There is no available follow-

up information on the effects of the measures taken within these focus areas.

General financial challenges regarding interventions

Food waste is a recognised problem when it comes to meals for the older. A certain amount

of food waste cannot be avoided. However, some factors in the meal services can contribute

to increasing food waste, and interventions in these areas could help reduce waste. Firstly, if

the food does not live up to what the users expect in terms of taste, consistency, appearance,

temperature, etc., they may not want to eat as much of it as they would if there were a better

match between their requirements and expectations and the actual meals.

It is essential, wherever possible, to apply general knowledge about the physiological and

sensory aspects of older people's food experience, and at the same time develop delivery

systems that take individual preferences into account as much as possible.

The system of user fees per meal probably also contributes to the relatively large amounts of

food waste. When users pay for a meal, they will usually expect to become satiated and get

value for money. To avoid such problems and resulting dissatisfaction and bad reputations

while at the same time keeping management costs low, providers presumably have an

incentive to offer "one size fits all" portions, which are large for the average user.

9.3.4 Good examples

Given that the quality of meals for the older is to some degree subject to budgetary

constraints, improving the quality will probably entail additional costs for ingredients and

preparation. Studies carried out as part of the OPUS project (funded by a grant from the

Nordea Foundation) suggest that the costs of ingredients for a New Nordic Diet, based on

Nordic, organically produced ingredients and meeting the Nordic Nutrition

Recommendations for adults, are around 15% higher than ingredients for an average Danish

diet (Jensen, Poulsen 2013). Although the nutritional recommendations for the older may

differ from the general nutritional recommendations, 15% is considered a slight overestimate

of the additional cost of ingredients for a full diet, since a large proportion of these additional

costs can be attributed to the choice of organic rather than conventional ingredients.

In addition, improving the nutritional and culinary quality of the meals will require modified

cooking methods and working patterns, and taking into account the individual needs and

desires of the users will require more work. However, lessons learned from the Copenhagen

House of Food and Herlev Hospital suggest that large kitchens can be reorganised to make

more meals from scratch without increasing costs dramatically.

9.3.5 Barriers

Warm food is more expensive to produce and deliver than chilled/vacuum-packed or frozen

food, probably because keeping the food warm requires insulating packaging, which takes up

more space in the vans and thus requires more trips, and because warm food has to be

delivered at certain times every day, unlike chilled or frozen food, which does not have to be

delivered daily.

Thus, the delivery of food to the older seems to be a significant barrier, especially if the food

has to be delivered close to the users' desired eating time.

Even if the delivery logistics are optimised, the capacity costs in connection with warm meal

services are likely to be higher.

Food safety is likely to be less of a challenge as regards distributing chilled/vacuum-packed

or frozen food than distributing warm food, provided that it is delivered without interrupting

the cold chain. The delivery costs for chilled/frozen food are presumably also lower, because

it does not have to be delivered on a daily basis. However, delivering chilled/vacuum-packed

or frozen meals with low frequency (e.g. once a week) may involve food safety challenges if

the users do not eat them before the use-by dates. There is a need for more research into the

relationship between delivery costs and food safety for alternative types of meals and

delivery.

9.3.6 Areas where more research is needed

Questions are sometimes asked about the nutritional, culinary and sensory quality of the

meals offered to the older. However, there is a need for real analyses of the link between the

production costs and the quality, variation and individualisation of meal services for the

older. In addition, there is a need to develop quality assurance syst ems to improve the meals'

freshness and taste throughout the distribution chain, from the production unit to the

"customer's" plate.

A key challenge in relation to the problem of food waste is the trade-off between the

advantages of greater flexibility in the payment and delivery systems (in relation to individual

appetite and preferences) and the extra costs. For example, a changed payment structure

whereby the user does not pay the full price in user fees might make it more legitimate to

differentiate between portion sizes, because users would not "pay for something they don't

get".

Informal meal services for the older, e.g. help with shopping and cooking from family,

neighbours or friends, might be used to develop new concepts to improve food and mealtime

quality (e.g. by providing grants for shopping to both the older and their family in return for

helping with the cooking). In this connection, we need to know more about the extent and

cost of these kinds of informal meal services for older people in Denmark, both currently and

in the future. We also need to know more about the development of the societal conditions for

such models, including retail developments and the local shopping facilities in the areas

where the older live.

There is a need for more up-to-date and systematic knowledge about the costs of meal

services for older people in Denmark. More knowledge is needed about costs, cost factors

(raw ingredients, kitchen staff wages, delivery costs, premises, equipment, means of

transport, etc.) in connection with alternative production and delivery models for food

deliveries to the older; for example, models based on a more centralised production, more

food preparation by the users, alternative diet types, organic food, alternative delivery models

(warm, chilled or frozen), transport of older people to communal dining rooms, etc.

There is a need for more research into the strengths and weaknesses of alternative models for

the management and financial governance of food production and delivery, such as trust-

based models, incentive-based models, retail management models, etc.

There is a need for more research into the diet of the older who are assessed for meal service

but who apparently are partially able to do without it. There is also a need for knowledge

about what motivates these users not to use meal services fully, e.g. whether it is due to the

price; the food's quality; portion sizes (for example, they may divide one day's portion and

make it last several days); practical circumstances such as not needing food on certain days of

the week due to activities; attractive alternatives (e.g. ready-meals from supermarkets); the

desire to decide on one's own menu once in a while; and so on.

As a starting point, meal services only provide one warm meal a day, so users need to

arrange for their cold meals in other ways, either by shopping for themselves or getting help

with the shopping. The older are likely to shop in various ways, e.g. depending on whether

they live in a town with grocery stores or in rural areas. However, there is a need for more

research in this area.

There is also a need for more research into the options and habits of older people who are too

self-reliant to be assessed for meal services, but who live in sparsely populated areas and do

not drive, and therefore have limited opportunities to shop.

9.3.7 Moving forward

Above, we have suggested a number of alternative solutions to the cost-related issues related

to the quality of meal services for older people. These alternative solutions include:

 Rationalising the production in a more targeted way to achieve quality improvements

rather than just savings, by changing workflows, organisation, etc.

 Developing new mechanisms for the public financing of meal services for the older so

that, for example, the financial gains achieved by improving the older's nutritional status

are channelled back to the meal service providers.

 Developing new and more flexible concepts for producing food for the older, e.g. making

it more financially attractive for neighbours, friends and family to help with cooking and

eat with the older.

 Developing quality control systems for meal delivery. These kinds of tools should be used

to monitor the quality of the food made in large kitchens before it is brought out, as well

as the sensory quality of the food when it is eaten by the older in their homes, in order to

create a basis for ensuring optimal quality throughout the distribution chain.

9.3.8 References (for sections 9.2 and 9.3)

Aberg J. Dealing with Malnutrition: A Meal Planning System for Elderly, AAAI Spring

Sympos ium: Argumen tation for Co nsu mers of Healthcare, page 1-7. AAAI, 2006

Allison S.P. Cost-effekt of nutrition al support in the elderly , Pr oc Nutr Soc 1995; 54, 693-699

Arla, Kost - og Ernæ ringsf orbund et. Underernæring – det skjulte samfundsprob lem . Arla,

Kost - og Ernæ ringsforbund et 2014

(https://www.kost.dk/sites/default/fil es/uplo ads/ public/underernaer ing- publikati on.pdf)

Bräysy O. , Nakari P., Dullaert W., N eittaanmä ki P. An op timi zation approach for communa l

home meal delivery service: A case study, J Computation al Applied Mathematics 232, 46-53

(2009a)

Bräysy O. , Dullaert W., Nakari P. The potential of optimization in communa l rou ting

problems: Case studies from Finland, JTrans port Geog raphy ,2009; 17, 484-490 (2009b)

Byr ne, D. V. a nd Bredie, W.L.P. Sensory m eat quality and warmed-over flavor - a review. In:

Research advances in the quality of meat and meat products, Toldra, F. (ed.). Research

Signpost, 2002; 95-121.

Deloitte Foranalyse af stordrif tspotentiale i komm unerne, januar 2013

Freijer K, Nuijten MJ, Schols JM. The budget impact of or al nutr itio na l supplement s for

dise ase related malnutrition in el derly in the community setting. Front Pharmacol 2012; 4; 3:

Freijer K, Tan SS, Koop ma nscha p MA, Meijers JM, Halfens RJ, Nuijten MJ. The econo mi c

costs of disease related malnutrition. Clin Nutr 2013; 32 : 136-41

Freijer K, Bours MJ, Nuijten MJ, Poley MJ, Meijers JM, Halfens RJ, Schols JM. The

economic value of enter al med ical nutrition in the manag ement of disease-related

malnutrition: a systematic review. J Am Med Dir Assoc 2014 ; 15 : 17-29

Inden rigs- og Sundhe dsministeriet. Ve jled ning om kommunal rehabilitering. 2011

Jensen J.D., Poulsen S.K. The New Nordic Diet – Co nsu mer Expenditures and Economi c

Incentives Est ima ted fr om a Controlled Interven tion, BMC Public Health, 2013 ; 13 : 1114

Johansen M. Flere kommuner kræver toppri s for ældrema d. Morgenavisen Jyllandsposten.

17.10.2014 http://jyll ands-posten.dk/indland/ECE7121618/Fl ere-komm uner- kr%C 3%A6ver-

toppris-for-%C 3%A6ldremad/

Kommuner nes Landsforening og Velfærdsministeriet (2008) Kortlæ gning af egenbetaling,

produktionso mk ostninger, organisering mv . af madservice ordninger ef ter §83 i serviceloven

(http://www.kl.dk/Im ageVaultFiles/id_28432/cf_202/Kor tl- gning_af_madservice omr-

det.P DF)

Kretser A.J., Vos T., Kerr W.W., Cavadini C., Friedma nn J. Effects of two models of

nutrition al interven tion on homebound older ad ults at nutr itional risk. JAD A 2003, 103, 329-

336

Kristensen N. Øk onomisk effektivitet blandt private og of fen tlige udbydere af ældrepleje:

Metodiske overvejelser og emp irisk e r es ultate r, Det Na ti onale Institut for Kommuners og

Regioners Analyse og Forskning 2014

Lass en K.Ø. , Olsen J., Grinderslev E., Melchiorsen H., Kruse F., Bjerrum M. ( 2005 )

Medicinske patien ters ernæringspleje – en medicinsk tekno logivurd ering, Sund hedsst yr elsen

Living ston G. , Manela M., Katona C. Costs of comm unity care for older people, Br J

Psychiatry, 1997; 171: 56-59

Meijers JM, Halfens RJ, Wi lson L, Schols JM. Es tima ting the costs associated with

malnutriti on in Dutch nursing homes. Clin Nutr 20 12 ; 31 : 65-8.

Mindel C.H., W right R., St arret R.A. In for mal and Formal Health and So cial Support Systems

of Black and White Elder sly : A Comparativ e Cost Ap proach , The Gerontologist, 1986; 26 :

279-285

Offen tlig kostforplejning i Da nmark , bind I – Betænkning fr a udvalget om offentlig

kostfor plejning 1997

Region Hovedstaden Afdækning af økonomi samt service- og kostkoncept for

hospitalskøkkener i Region Hovedstaden 2014

Sahyoun NR, Va udin A. Ho me-Del ivered Mea l s and Nu trition Statu s am ong Older Adults,

NCP , 2014 ; 29 : 459-465

Siira E., Häikiö J. Experiences from Near-Field Communi cation (NFC) in a Meal Service

System. RFID Eurasia, 2007 1st An nual

Socialstyr elsen. Cost- effektivenss studie af tværfa glig er næringsinterven tion blandt skrøbelig e

underernærede ældre. So cialst yrelsen 2014

Økonomi- og In denrigsministeriet, Kommunale Nøgletal (http://w ww.noegl etal.dk/, he ntet d.

10. decemb er 2014)

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vildts auce«. Pol itiken 31. marts 2014. http://pol.dk/2250090

9.4 FOOD AND MEALTIME POLICY

9.4.1 Why it is important

A food and mealtime policy can form the basis for a municipality's initiatives to ensure high-

quality meal services for its older residents. The benefits of establishing a food and mealtime

policy are:

 Having a clear framework for food and mealtimes for the older

 Defining standards for the quality of meal services.

 Creating coherence between political aims, quality standards and agreements with suppliers.

By prioritising food, mealtimes and nutritional interventions, municipalities can create the right

framework to ensure that older people who need meal services have their nutritional needs met.

By setting out key targets for food, mealtime and nutrition interventions for the older who need

meal services, municipalities can achieve a consensus on the direction they need to take.

This reduces the risk of decisions being taken based on individual views. In addition, a policy

creates more clarity among the various staff groups about the general framework for the

interventions. It can also result in the area being given political priority (National Board of

Social Services 2013).

9.4.2 The importance of a food and mealtime policy for older people's nutrition

All three settings

In 2002, the Council of Europe described five main barriers to ensuring nutritional care in

European hospitals (Council of Europe 2002):

 Lack of clearly defined responsibilities in planning and managing nutritional care

 Lack of sufficient education with regard to nutrition among all staff groups

 Lack of influence and knowledge among the patients

 Lack of cooperation between different staff groups

 Lack of involvement by the hospital management

In 2009 the Council of Europe pointed out the same barriers to ensuring nutritional care for

older people in nursing homes and home care (Arvanitakis et al. 2009).

All of these areas are better dealt with by formulating a food and mealtime policy.

In hospitals

In a Danish health-technology assessment of older patients' nutritional care, various staff groups

and management representatives in three wards in a university hospital, a hospital under the

Copenhagen Hospital Corporation and a local hospital were interviewed about their work with

nutritional care. To provide a background for the interviews, information was gathered about the

hospital owners' and managements' nutritional initiatives and about the operation of the wards

and kitchens. The starting point of the data collection was to compare the nutritional care

practices in the three hospitals with the official recommendations for diets for sick people. The

organisational analysis identified circumstances that both promoted and impaired nutritional

care. The results are shown in table 9.1 below (Lassen et al. 2005).

Table 9.1 Facilitating versus inhibiting factors for optimal nutritional care from the perspective

of the hospital management, ward staff and kitchen staff (Lassen et al. 2005).

Hospital management's perspective

Clear indication from management about

the importance of optimal

nutritional care

Weak or deficient communication from

management about the importance of

nutritional care

Access to management tools for

quality assurance, support and

assessment of nutritional care

Lack of management tools for

obtaining information to assess

nutritional care at department level

Resources to follow up on and support

implementation of

nutritional guidelines

A professionally trained person actively

works with nutritional care and has

time to take on the practical work

Lack of time for nutritional care and a

resulting lower priority

Presence of key/engaged

staff

The responsibility for the practical

nutritional care is collective,

but few are committed

The bed ward offers food 24

hours a day and the staff serve it

to the patients

The overall responsibility is formally

placed with the physicians, who

rarely get involved in

nutritional issues

Multidisciplinary guidelines for

detecting patients at risk of

undernourishment and providing

nutritional care for

different types of patients

The competence of the clinical

dieticians is only used to a limited

extent

The nursing staff are unable to offer food

to patients outside of the set mealtimes

The kitchen's perspective

Frequent contact with the nursing staff

Lack of contact with the nursing staff

Monitor and check the supplied food

right up until it is served to the

patients

No knowledge or influence on how the

food is served

Increased visibility in the organisation of

the kitchen staff's work and thus the

possibility of more awareness

and respect from other staff groups

Not visible in the organisation and

therefore lack of awareness among other

staff about their work

Lack of financial room for manoeuvre

In nursing homes and home care

In a 2014 cost-effectiveness study, the National Board of Social Services conducted interviews

with the nursing staff and management to assess the nutritional interventions by the

participating home carers and nursing homes.

Based on these interviews and the rest of the study's results, the Board made the following

conclusions on ensuring effective nutritional screening and subsequent nutritional

interventions (National Board of Social Services 2014):

 It is an advantage to have key nutritional staff who have taken skills development courses

on using the nutritional assessment form, and who can supervise and guide others on how

to complete it.

 It is also an advantage to include relevant interdisciplinary collaborators in the on-the-job

training courses, e.g. a clinical dietician, physiotherapist, occupational therapist and dental

hygienist.

 The carers can benefit from the assistance of a nutritional expert such as a clinical

dietician, e.g. when preparing action plans.

 When implementing these, a responsible person with an overview should take the initiative

and follow up on whether the relevant residents are screened and weighed as prescribed. In

general, then, it is a prerequisite for a systematic nutritional screening of residents that

there is a coordinator with the necessary influence who takes the initiative and monitors

nutritional screenings and follow-up measures.

 When carrying out systematic nutritional screenings and regular weighing of residents, it is

helpful if the carers understand that these measures will benefit everyone. Making sure that

the staff has enough time to perform the tasks is another significant factor for the success

of the implementation.

The project "Developing a Tool for the Nutritional Assessment and Treatment of the Older "

(National Food Institute and National Board of Social Services 2011) focused partly on the

importance of the organisation of the nutritional interventions. Table 9.2 below compares the

degree of compliance with the recommendations for nutritional interventions in various

"Development of Better Care for the Older" projects (UBÆP) to the percentage of older

people with positive results in terms of weight gain. By comparison, the table shows the

percentage of older people who gained weight without a special effort (National Food Institute

and National Board of Social Services 2011).

Table 9.2 The degree of compliance with the recommendations for nutritional interventions in

various "Development of Better Care for the Older" (UBÆP) projects compared to the

proportion (percentage with weight gain) of older people with positive results in terms of

weight gain. "Standard" is the percentage of people who gained weight without a special effort

(National Food Institute and National Board of Social Services 2011).

On-the -job training (all), snacks, nurse with

nutritional expertise

On-the -job training (all, key staff), diet for people

with low appetites, screening, individual treatment

plans, nutritional expertise (in the kitchen)

On-the -job training (carers), diet for

people with low appetites, screening,

individual treatment plans, nutritional

expertise (in the department)

On-the -job training (key staff), diet for

people with low appetites, screening,

individual treatment plans, nurse with

nutritional expertise

On-the -job training (key staff), snacks,

screening, individual

treatment plans, focus on meal ambience, clinical

dietician (in the department)

On-the -job training (all), snacks, nutritional

expertise – part-time (in the kitchen)

Diet for people with low appetites, individual

treatment plans, clinical dietician (in the

kitchen)

On-the -job training (care), diet for people with low

appetites

Table 9.2 shows that an individually targeted intervention in the form of energy- and protein-

rich meals and snacks is the most effective way to ensure weight gain in older people who are

assessed as undernourished or at risk of undernourishment through nutritional screening. It

also shows that the recommended cooperation with a clinical dietician is most effective when

the dietician is involved in the care (National Food Institute and National Board of Social

Services 2011).

9.4.3 Interventions regarding food and mealtime policies

All three settings

No actual randomised controlled intervention studies were found that focused on measuring

the effect of implementing a food and mealtime policy on older people's physical function and

quality of life.

In hospitals

However, when the above-mentioned health-technology assessment was prepared, an

organisational model was assessed which involved a professionally trained person who was

employed to be exclusively responsible for nutrition-related tasks in the ward and promote

the four facilitating factors set out in Table 9.1. This person's working hours were spent on

individual nutritional care; they were very engaged in and knowledgeable about nutrition;

they were aware of the food that was made in the kitchen; and they were able to make snacks

etc. in the ward (Lassen et al. 2005). After five months, interviews with the staff showed that

problems such as lack of time and passing responsibilities onto others had largely been

eliminated. The organisational model also meant that collaboration was established with the

rest of the caregivers based on accepting and understanding the importance of nutrition in the

care and treatment. At the same time the ward saw a significant reduction of food waste

(Lassen et al. 2008).

In nursing homes and home care

The aim of the National Board of Social Services' background material for a food policy was

to identify the areas that should be included in the policy and examine the documented

significance of these areas for the nutrition of older people (National Board of Social Services

2010).

9.4.4 Official Danish recommendations

The ''Recommendations for Developing Attractive Meal Services for Older People" states

that a food policy should be formulated on the political level; that responsibilities should be

identified and defined; and that measures to ensure and develop the quality of nutritional

practice should be put in place (Beck et al. 2006).

The national action plan for meals and nutrition recommends that every municipality council

establishes a policy on food and mealtimes. The policy should be focused on older people

who need meal services and should contain clear, measurable targets and guidelines for

regular follow-ups on interventions (National Board of Social Services 2013).

The National Board of Social Services has prepared a template for how to prepare a food and

mealtime policy for the older. This template and the related guide can give the municipalities

inspiration for developing their policies.

The template offers suggestions for how the municipalities can carry out the process from the

decision-making basis to content, action plans and implementation of a good food and

mealtime policy. The guide sets out a number of problem areas for which the municipalities

may want to formulate policy objectives (National Board of Social Services 2011).

9.4.5 Good examples

Copenhagen Municipality has learned various lessons from its work on introducing a food

and mealtime policy for the older. Political support has helped create coherence between its

various nutritional interventions. This has meant that more resources have been allocated to

the area. The municipality's experience also shows that the continuous involvement of senior

management in the daily operation is essential to ensure implementation in practice. The

implementation of the policy has led to the development of methods that have helped to

change practice. A key lesson is that the policy must be linked up with other political efforts

and aims in the organisation (e.g. policies on healthcare, inclusion, organic food and care for

the older). The purpose of this is to ensure that food, mealtime and nutritional interventions

become integral parts of the social services for the older (National Board of Social Services

2013).

The Danish Veterinary and Food Administration has compiled various institutions'

experiences of introducing food and mealtime policies for children and young people. The

experiences show that a policy can help to clarify and maintain the attention of staff and

parents on the institutions' practices in this area. One significant experience has been the

municipalities' help and support from the Danish Veterinary and Food Administration's own

travelling team, which has the expertise to give the pedagogical staff the knowledge,

influence and tools to convert municipal policies into daily pedagogical practices with the

children. The Danish Veterinary and Food Administration's experiences are partly based on

the latest nationwide evaluati on of the municipalities' progress with food and mealtime policies.

These experiences are supplemented by studies showing that day care centres with food and

mealtime policies tend to serve more varied diets than centres without such policies. It is likely

that a similar effect can be achieved in older care (National Board of Social Services 2013).

9.4.6 Barriers

The barriers identified by the Council of Europe in 2001 and 2009 probably still exist.

9.4.7 Areas where more research is needed

There is a lack of systematic data on the effect of introducing a food and mealtime policy

concerning older people's physical function and quality of life.

There is also a lack of systematically collected data on the effect of the barriers among staff

and management when it comes to ensuring optimal nutritional interventions for older people

in nursing homes, home care and hospitals.

9.4.8 Moving forward

Studies in the areas where more information is needed, as pointed out above.

9.4.9 References

Arva nitakis M, Co ppens P, Doughan L, Van Gossum A. Clin Nutr . 2009;28:492-6

Beck A, et al. Anbefalinger for udvikling af Den attraktive måltidsservi ce til ældre. Da nmark s

Fødevareforskning, 2006

DTU Fødevareinstituttet og Service styrelsen. Pr ojekt "Udvikling af et redskab til

ernæringsvurd ering og b eh andling af ældre". DTU Fødevareinstituttet og Servicestyrelsen

2011

Lass en KØ, Olsen J, Grinder slev E, Melchiorsen H, Kr use F, Bj errum M. Medicinsk e

patien ters er nær ingspleje – en medicinsk te knologivurder ing, Sundhedsst yr elsen 2005

Lass en KØ, Gr inderslev E, Nyholm R. Effect of changed organi sa tion of nutritional care of

Danish medical inpatien ts. BMC Health Serv Res. 2008;8:168

Service styrelsen. Baggrundsmate riale til kv alificering af en måltidspolitik. Servi cestyrelsen

2010

Service styrelsen. Styr på kvalite ten - kom godt i mål med ma d- og må ltidspolitik .

Service styrelsen 2011

Socialstyr elsen. National handlingsplan for må ltider og er næring til ældre i hjemmep lejen og

plejeboligen. So cialstyr elsen 2013

Socialstyr elsen. Cost- ef fect iveness studi e af tværfa glig ernær ingsindsa ts hos skrøbelige

underernærede ældre. So cialst yrelsen 2014

10. CONCLUSION

More and more older people are becoming dependent on meal services. There are many

factors that need to be taken into consideration to ensure that the older are given good meal

experiences, good quality food, good meal access and good dining and social interactions. A

high proportion of older people in nursing homes, home care and hospitals experiences

decreased appetite and weight loss.

This whitepaper's working group has studied the scientific literature on food and mealtimes

for the older with a focus on randomised controlled studies on the effect of interventions on

the physical function and quality of life of the older. On this basis we have provided an

overview of the current research, current and future challenges, barriers and proposals for

solutions and further research.

Current knowledge

Unplanned weight loss can have serious consequences for older people's physical, mental and

social function. Unplanned weight loss and underweight increase the need for home care and

home nursing, as well as the risk of decreased quality of life, life skills, acute illness,

hospitalisations, long-term rehabilitation, increased expenses and premature death.

Unplanned weight loss is particularly common among hospitalised older people, but also

among older people who receive home care or live in nursing homes. All three groups receive

meal services, which are very important in improving their nutritional status. Currently the

potential of the meal services does not seem to be optimally exploited by the hospitals or

municipalities.

Current and future challenges

Despite official recommendations, idea catalogues and action plans designed to give the

older good meal experiences, many older people who receive meal services are in poor

nutritional condition. Given the increasing numbers of older people, the challenge now and in

the future will be to put these recommendations into practice.

Barriers

The working group has identified many barriers to giving the older good meal experiences.

The main barriers are a lack of staff skills, management support, interdisciplinary

collaboration, sharing of responsibility, financial incentives and the involvement of the older

themselves in improving their life skills.

Solutions and further research

The working group has provided recommendations for how to improve the quality, access

and experience of meals for the older, the skills of care staff, as well as the financial and

political aspects.

Food quality

The quality of the food has an effect on the older's appetite and eating pleasure and thus on

their food intake. With age, appetite tends to decrease, the senses of taste and smell change,

sensory memory fades and the reluctance to try new foods increases. There is a lack of

understanding of what these factors mean, including:

 The significance of taste and smell when it comes to taking pleasure in meals and eating.

 The significance of the weakening of sensory memory for older people's food choices and

quality of life, and what can be done to promote them.

 The reasons for the older person's changed perception of food, and what can stimulate

their food intake.

 What factors create preferences for new foods and products and whether they can be used

to promote food intake.

 How the appetite can be stimulated through appetising gourmet meals and food-nudging.

Meal access

Problems with food intake, swallowing, dental health or other difficulties with eating and

drinking (dysphagia) are associated with weight loss, high morbidity and increased mortality,

and have major social and personal consequences. These problems are often overlooked, and

there is a lack of understanding of how interventions targeting these functions can reduce

weight loss, morbidity and mortality. For example, interventions focused on:

 The taste experiences that are most important for older people with eating problems.

 Whether meals adapted to older people's reduced chewing and swallowing ability have a

positive effect on relevant endpoints.

 The necessary tools to enable staff to identify dysphagia and start interventions.

 The importance of oral and dental care and whether it results in better health.

 Whether staff training and optimal use of eating aids ca n improve food intake among

older people who need assistance with eating.

The mealtime experience

One parameter for good mealtime experiences is that the residents enjoy the social setting of

the meal. The older thrive better when the meal ambience and the social framework of the

meal are in focus, whether it is in their own home, in nursing homes or during hospitalisation.

A good mealtime experience can probably stimulate appetite and food intake and thus reduce

morbidity and mortality. However, documentation is lacking in a number of areas, including:

 Whether optimising the food for older people in nursing homes and home care has a

positive effect on their well-being, quality of life and physical and social function, and on

the national economy as a whole.

 The importance of the social interaction and meal ambience for physical function, quality

of life, etc., especially using randomised, controlled studies.

 The importance of the staff in creating a good meal ambience and social interaction.

 The importance of involving older residents in activities related to the meal, such as

shopping, cooking and setting the table.

 The importance of mealtimes for physical function and quality of life, and of integrating

them with preventive and rehabilitative care.

The resident

A good nutritional status helps maintain physical function and reduce the need for help.

Sarcopenia (loss of muscle mass) and dementia occur frequently among the older. In addition,

even short hospital stays can increase the risk of loss of physical function and thus make

everyday chores more difficult after discharge. There is still a lack of understanding in a

number of areas, including:

 Whether a combined nutritional intervention focused on food, mealtimes and physical

exercise can have an added positive effect on counteracting sarcopenia.

 Whether, like industrially produced energy and protein drinks, an optimised diet has a

beneficial effect on physical and mental function.

 The effect of optimising food and mealtimes on the rehabilitation process, e.g. after

discharge from hospital.

 The effect of involving older people in activities related to food and mealtimes on their

life skills, quality of life and physical, mental and social rehabilitation.

 Whether preparing the meal oneself increases food intake and the pleasure of eating.

 Whether social initiatives and non-food-related activities stimulate appetite and weight

retention among the older.

Staff skills

It is crucial to providing better meals for the older that the staff have the necessary skills to

help maintain and build up the older people' s life skills.

Preliminary studies suggest that providing the staff with nutritional training has a positive

impact on the health of older residents and on detecting those at risk of undernourishment.

More knowledge is required in several areas, including:

 How food and mealtimes are included in the various programmes that train staff to care of

the older.

 The effect on older people's nutritional status, physical function and quality of life of

giving staff in the three settings the necessary training/continuing education.

Finances

Costs are seen as a significant barrier to delivering nutritious and appetising meals to the older.

But there is considerable variation between the municipalities.

A better understanding of these cost differences can reduce the financial barriers to providing

good meal services to the older. More attractive food offers and meal environments can

contribute to improving the nutritional status of older people, which can in turn result in

financial benefits for the public sector and society as a whole. There is a need for scientific

studies in various areas, including:

 The size of the financial benefits of improving the nutrition of older people in nursing

homes, home care and hospitals

 How to create the necessary financial incentives to ensure that providers of meal services

supply meals the users want to eat

 The connection between delivery costs, food safety and alternative types of meals and

delivery

 The actual costs of meal services for older people in Denmark. More knowledge is needed

about costs, cost factors (raw ingredients, kitchen staff wages, delivery costs, premises,

equipment, means of transport, etc.) in connection with alternative production and

delivery models for food deliveries to the older; for example, models based on a more

centralised production, more food preparation by the users, alternative diet types, organic

food, alternative delivery models (warm, chilled or frozen), transport of older people to

communal dining rooms, etc.

 What makes older people who are assessed for meal services choose not to fully use those

meal services.

 What options older people have to supplement the meal services, i.e. opportunities for

shopping for themselves.

Policy

A food and mealtime policy can form the basis for a municipality's initiatives to ensure high-

quality meal services for its older residents. This reduces the risk of decisions being taken

based of individual views.

In addition, a policy creates more clarity among the various staff groups about the general

framework for the interventions. It can also result in the area being given political priority.

However, there is a lack of systematic data on:

 The effect of introducing a food and mealtime policy on the function and quality of life of

older people.

 The effect on the barriers among staff and management when it comes to ensuring

optimal nutritional interventions for older people in nursing homes, home care and

hospitals.

ResearchGate has not been able to resolve any citations for this publication.

Background: Aerobic power declines with age. The degree to which this decline is reversible remains unclear. In a 30-year longitudinal follow-up study, the cardiovascular adaptations to exercise training in 5 middle-aged men previously trained in 1966 were evaluated to assess the degree to which the age-associated decline in aerobic power is attributable to deconditioning and to gain insight into the specific mechanisms involved. Methods and Results-- The cardiovascular response to acute submaximal and maximal exercise were assessed before and after a 6-month endurance training program. On average, VO(2max) increased 14% (2.9 versus 3.3 L/min), achieving the level observed at the baseline evaluations 30 years before. Likewise, VO(2max) increased 16% when indexed to total body mass (31 versus 36 mL/kg per minute) or fat-free mass (44 versus 51 mL/kg fat-free mass per minute). Maximal heart rate declined (181 versus 171 beats/min) and maximal stroke volume increased (121 versus 129 mL) after training, with no change in maximal cardiac output (21.4 versus 21.7 L/min); submaximal heart rates also declined to a similar degree. Maximal AVDO(2) increased by 10% (13.8 versus 15.2 vol%) and accounted for the entire improvement of aerobic power associated with training. Conclusions: One hundred percent of the age-related decline in aerobic power among these 5 middle-aged men occurring over 30 years was reversed by a 6-month endurance training program. However, no subject achieved the same maximal VO(2) attained after training 30 years earlier, despite a similar relative training load. The improved aerobic power after training was primarily the result of peripheral adaptation, with no effective improvement in maximal oxygen delivery.

Anne Marie Beck
Ut Andersen
Eva Leedo
Finn Rønholt

The objective was to test whether adding a dietician to a discharge Liaison-Team after discharge of geriatric patients improves nutritional status, muscle strength and patient relevant outcomes. Twelve-week randomized controlled trial. Geriatric patients (70 + years and at nutritional risk) at discharge. Participants were randomly allocated to receive discharge Liaison-Team vs. discharge Liaison-Team in cooperation with a dietician. The dietician performed a total of three home visits with the aim of developing and implementing an individual nutritional care plan. The first visit took place at the day of discharge together with the discharge Liaison-Team while the remaining visits took place approximately three and eight weeks after discharge and were performed by a dietician alone. Nutritional status (weight, and dietary intake), muscle strength (hand grip strength, chair-stand), functional status (mobility, and activities of daily living), quality of life, use of social services, re-/hospitalization and mortality. Seventy-one patients were included (34 in the intervention group), and 63 (89 %) completed the second data collection after 12 weeks (31 in the intervention group). Odds ratios for hospitalization and mortality 6 months after discharge were 0.367 (0.129; 1.042) and 0.323 (0.060; 1.724). Nutritional status improved and some positive tendencies in favour of the intervention group were observed for patient relevant outcomes, i.e. activities of daily living, and quality of life. Almost 100 % of the intervention group received three home visits by a dietician. Adding a dietician to the discharge Liaison-Team after discharge of geriatric patients can improve nutritional status and may reduce the number of times hospitalized within 6 months. A larger study is necessary to see a significant effect on other patient relevant outcomes. © The Author(s) 2014.

Objective: to examine the clinical evidence reporting the prevalence of sarcopenia and the effect of nutrition and exercise interventions from studies using the consensus definition of sarcopenia proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). Methods: PubMed and Dialog databases were searched (January 2000–October 2013) using pre-defined search terms. Prevalence studies and intervention studies investigating muscle mass plus strength or function outcome measures using the EWGSOP definition of sarcopenia, in well-defined populations of adults aged ≥50 years were selected. Results: prevalence of sarcopenia was, with regional and age-related variations, 1–29% in community-dwelling populations, 14–33% in long-term care populations and 10% in the only acute hospital-care population examined. Moderate quality evidence suggests that exercise interventions improve muscle strength and physical performance. The results of nutrition interventions are equivocal due to the low number of studies and heterogeneous study design. Essential amino acid (EAA) supplements, including ∼2.5 g of leucine, and β-hydroxy β-methylbutyric acid (HMB) supplements, show some effects in improving muscle mass and function parameters. Protein supplements have not shown consistent benefits on muscle mass and function. Conclusion: prevalence of sarcopenia is substantial in most geriatric settings. Well-designed, standardised studies evaluating exercise or nutrition interventions are needed before treatment guidelines can be developed. Physicians should screen for sarcopenia in both community and geriatric settings, with diagnosis based on muscle mass and function. Supervised resistance exercise is recommended for individuals with sarcopenia. EAA (with leucine) and HMB may improve muscle outcomes.

Poor food intake in residents living in long-term care (LTC) homes is a common problem. The mealtime experience is known to be important in the multifactorial causes of food intake. Diverse interventions have been developed, implemented, and/or evaluated to improve the mealtime experience in LTC; it is possible that multicomponent interventions will have a greater benefit than single activities. To identify the range of feasible and potentially useful interventions for including in a multicomponent intervention, this scoping review identified and summarized 58 studies that described and/or evaluated mealtime experience interventions. There were several randomized controlled trials, although most studies used less rigorous methods. Interventions that are multicomponent (e.g., food service, dining environment, staff education) and target multilevel factors (e.g., residents, staff) in LTC appear to be feasible, with a variety of outcomes measured. Further research is still needed with more rigorously designed studies, confirming effectiveness, feasible implementation, and scaling up of efficacious interventions.

The trend among older adults in the United States is to "age in place" instead of opting for institutionalization. To maintain older adults with chronic conditions in their homes and to improve health after hospitalization, comprehensive social, health, and nutrition services are essential. Quality of dietary intake is crucial and yet often underestimated. Calorie needs decrease with age while nutrient needs remain the same, even increasing for some nutrients. This poses difficulties for individuals with functional disabilities who are unable to shop and cook due to physical or mental limitations or on a limited budget. The Older American Act home-delivered meal (HDM) program offers at least 1 healthy meal per day, 5 or more days per week, and targets individuals homebound due to illness, disability, or social isolation and those with greatest economic or social need. This review summarizes the available literature on the relationship between HDM and health outcomes. The HDM program is difficult to evaluate because of the multifactorial effect on health status. However, national surveys and smaller studies show that it is well targeted, efficient, and well liked; provides quality food to needy individuals; and helps individuals remain living independently. Studies show that HDMs improve dietary intake, with greater health benefits when more meals reach the neediest individuals. HDMs also decrease institutionalization of older adults and resulting healthcare expenditures. However, funding has not kept up with increased demand for this program. More studies with improved designs may provide more information supporting the program's impact on nutrition status and decreased health expenditures.

Background and aims: "Good nutritional practice (GNP) that is screening, planning, monitoring and follow-up is mandatory for patients at nutritional risk". In 2012, accreditation in all Danish hospitals had been achieved including measurement of nutritional indicators. This study aimed to investigate GNP in Denmark during an 8-year period, and to discuss the impact of accreditation and barriers in the hospital setting. Methods: A questionnaire-based investigation among doctors and nurses in Danish hospitals were compared to a similar investigation in 2004 and included 65 questions including GNP, knowledge, education, guidelines, organization and barriers. Four questions regarding accreditation by The Danish Healthcare Quality Program were added. Results: Response rate was 25% (925 questionnaires returned). Significant improvements were seen in screening (76% vs40%) (p=0.000), nutrition plan (69% vs46%), and monitoring (29% vs46%) (p=0.000). Lack of knowledge were among the most important barriers (41%). Conclusion: After introduction of quality indicators in clinical nutrition according to the Danish Healthcare Quality Program, GNP improved. However a broad variation of effects might have influenced the improvements.

Background Good nutritional practice (GNP) includes screening, nutrition plan and monitoring, and is mandatory for targeted treatment of malnourished patients in hospital. Aims To optimize energy- and protein intake in patients at nutritional risk and to improve GNP in a hospital setting. Methods A 12-months observational multi-modal intervention study was done, using the top-down and bottom-up principle. All hospitalized patients (> 3 days) were included. Setting: A university hospital with 758 beds and all specialities. Measurements Record audit of GNP, energy- and protein intake by 24-hour recall, patient interviews and staff questionnaire before and after the intervention. Interventions Based on pre-measurements, nutrition support teams in each department made targeted action plans, supervised by an expert team. Education, diagnose-specific nutrition plans, improved menus and eating environment, and awareness were initiated. Statistics Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson Chi square test for nominative data. Results Overall 545 patients participated (287 before/258 after) from 26/22 departments. There were no significant differences regarding sex, age, BMI or previous weight loss before and after the intervention. Result-indicators: Energy intake improved from 52% to 68% (p<0.007), and protein intake from 33% to 52% (p<0.001)(> 75% of requirements). Intake of less than 50% of requirements decreased with 50%. Process-indicators: Screening improved from 56% to 77% (p<0.001), nutrition plans from 21% to 56% (p<0.0001), and monitoring food intake from 29% to 58% (p<0.0001). Conclusions Intake of energy and protein as well as GNP improved using a multi-modal top down and bottom up approach.

Source: https://www.researchgate.net/publication/301779553_Gourmet_Good_Nutritious_Meals_for_All_Older_People_-_Whitepaper_on_providing_nutritious_high-quality_meals_for_older_people

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