Dietitians advocate for measuring malnutrition risk

The quality and quantity of food being served in aged care facilities has been a topic of conversation for a while.

The Final Report of the Royal Commission into Aged Care Quality and Safety expressed the importance of good quality food and nutrition for older people.

It is well known that there are significant consequences of poor nutrition on older people and they can be associated with other health risks, including an increased incidence of falls and fractures, pressure injuries taking longer to heal, and higher risk of infection.

All of which can put an extra strain on an aged care provider and delivering quality care.

Julie Dundon, Advanced Accredited Practising Dietitian at Nutrition Professionals Australia (NPA), said improving food and nutrition in aged care has been a process over the last decade.

Working in the aged care sector for almost three decades as a residential site manager and managing aged care kitchens, Ms Dundon said food in aged care facilities needed to be both nutritious and appetising to best cater to older residents.

“Good food and good nutrition is a human right, no matter who we are and no matter where we live,” she said.

“We need to put ourselves in the shoes of the person we are caring for – if you plate it and you wouldn’t eat it, don’t serve it.”

Having recently been appointed to the Aged Care Quality and Safety Advisory Council, Ms Dundon said that since the Royal Commission, moves have been made to improve food and food delivery in aged care facilities, and she would like this focus on food to grow within the sector.

Ms Dundon has provided easy and research-proven tips for aged care facilities to implement to improve food quality and delivery.

Malnutrition in aged care facilities

With aged care facilities required to report the overall weight loss across the facility every quarter to mitigate the risk of malnutrition for aged care residents, it is very important to improve your food quality and nutrition so you can provide better weight loss data to the Government.

In the last quarter of 2019-20, residential aged care providers recorded that 8% of residents had experienced significant unplanned weight loss and 7.94% of residents had experienced consecutive unplanned weight loss under the Quality Indicators (QI) Program.

However, this number has increased to 10.9% of aged care residents having significant unplanned weight loss and 11.2% of residents experiencing consecutive unplanned weight loss in the January to March 2022 quarter.

Ms Dundon said while documenting weight loss is important, dietitians advocate for measuring malnutrition risk instead of measuring weight loss, as someone can remain the same weight but become malnourished and would then not be picked up in these figures. 

She encourages aged care providers to also consider how they measure malnutrition within their facilities, rather than just weight loss.

“I’d expect those numbers would jump significantly if we were measuring malnutrition,” she said. 

Since the first of July last year, the Government has given aged care facilities that spend less than $10 a day on each resident with an additional $10 per resident per day to be spent on food and nutrition called the Basic Daily Fee supplement. 

Ms Dundon said this supplement should really be utilised to improve on food and nutrition delivery and overall resident meal experience. 

“The Government is measuring money spent on food and staff, but if you’re putting down a plate of something that no one likes, it all goes in the bin and they’re still not getting any nutrition,” Ms Dundon explained.

Food quality and quantity 

While three main meals a day are considered important for nutrition, Ms Dundon noted the importance of providing mid-meal snacks like morning tea, afternoon tea and supper. 

An older person needs at least 30g of protein, equating to about 100g of meat, at every main meal of an adequate serving size to fulfil the amount of protein needed in a day. 

Ms Dundon explained if an older person was served inadequate foods as a main meal – such as party pies, pizza and fish fingers – someone would need to eat about six party pies, two-and-a-half cups of tinned spaghetti and 29 spring rolls to meet their daily protein requirement. 

“You can use these types of foods to get protein, but the amount necessary to meet that target far exceeds our residents’ appetites,” she said. 

“They’re things to have in between meals.”

Ms Dundon adds it is important that providers balance enjoyable or nostalgic food for residents with nutrition-packed meals. 

Delivery of texture modified foods

When a resident has swallowing problems, facilities need to appropriately access the appropriate level of nutrition, food texture and fluid consistency needed to make eating easier and safer, without losing that food enjoyment. 

According to Ms Dundon some providers focus on the texture of foods – in terms of safety for the resident – but neglect how they taste, with soft and bite sized foods often being the most poorly presented and executed. 

“We need to be careful of how we are plating [food], and it comes down to the taste as well,” she said. 

“Using moulds [to set modified foods] isn’t new, and they certainly make modified foods look better, but it comes down to staff knowing what they’re doing, how to reheat food, and how it should look when it is plated.

“There are times we obsess over the textures so we don’t put the person at risk of choking, for good reason, but the purpose of food is for enjoyment and nutrition.”

How to improve

Ms Dundon said the very first thing providers should do is hire a dietitian to assess their menu and mealtime experience to provide them with a map of where their shortcomings are and how they need to improve. 

Once a provider is aware of what the priorities are to work on, they can choose to either utilise a dietitian or implement the changes themselves if they have enough resources.

The Aged Care Quality and Safety Commission released guides for providers to help improve the eating experience and standard of nutrition for aged care residents.

Some recommendations include:

• Consider the dining room atmosphere – the table layouts, lighting, decorations, table coverings and settings. Ventilation, glare, and background noise are also important factors to consider in a resident’s eating environment. 
• Ensure all meals look appetising and served at an appropriate temperature, regardless of texture.
• Support independence and dignity by empowering residents to eat and drink using modified tables, cutlery and aids, if required. Provide mealtime assistance only if needed or requested. 

• Ensure residents have adequate time to eat, drink and socialise and do not remove food before checking if the person has finished. 
• Avoid using clothing protectors to maintain residents’ dignity unless they are requested or they are absolutely necessary for excessive food spillage. 
• Involve residents in the planning and assessment of their dining experience by asking for suggestions and feedback.

• When serving texture modified foods, explain to residents what the food is.
• Avoid stirring and/or mixing the food and don’t mix texture modified meals all together, as it is undignified. 
• Provide culturally-appropriate food and cutlery including chopsticks, spoons, forks and handwashing bowls for those who want to use their hands to eat. 
• Provide time for cultural prayer or traditions during mealtime. 
• Encourage all staff to sit down with residents during mealtimes.

Nutrition Professionals Australia also has online training modules for all aged care workers and providers about food and nutrition, to equip staff with information and skills on how to provide older people living in care with easy access to good food.