Anne Marie Beck

Size makes a difference

OBJECTIVE To elucidate status and trends in portion size of foods rich in fat and/or added sugars during the past decades, and to bring portion size into perspective in its role in obesity and dietary guidelines in Denmark. DATA SOURCES Information about portion sizes of low-fat and full-fat food items was obtained from a 4-day weighed food record (Study 1). Trends in portion sizes of commercial foods were examined by gathering information from major food manufacturers and fast food chains (Study 2). Data on intakes and sales of sugar-sweetened soft drinks and confectionery were obtained through nation-wide dietary surveys and official sales statistics (Study 3). RESULTS Study 1: Subjects ate and drank significantly more when they chose low-fat food and meal items (milk used as a drink, sauce and sliced cold meat), compared with their counterparts who chose food and meal items with a higher fat content. As a result, almost the same amounts of energy and fat were consumed both ways, with the exception of sliced cold meat (energy and fat) and milk (fat). Study 2: Portion sizes of commercial energy-dense foods and beverages, and fast food meals rich in fat and/or added sugars, seem to have increased over time, and in particular in the last 10 years. Study 3: The development in portion sizes of commercial foods has been paralleled by a sharp increase of more than 50% in the sales of sugar-sweetened soft drinks and confectionery like sweets, chocolate and ice creams since the 1970s. CONCLUSIONS Larger portion sizes of foods low in fat and commercial energy-dense foods and beverages could be important factors in maintaining a high energy intake, causing over-consumption and enhancing the prevalence of obesity in the population. In light of this development, portion size ought to take central place in dietary guidelines and public campaigns.

Nutrition in care homes and home care: how to implement adequate strategies (report of the Brussels Forum (22-23 November 2007)

BACKGROUND & AIMS Undernutrition in home care and care home settings is an unrecognized problem with significant consequences. The present work was edited after a forum concerning nutrition in these settings was held in Brussels in order to tackle the problem. METHODS Various aspects of the question were addressed with the participation of scientific experts. The proceedings of the forum were edited and completed by a review of previously published material. RESULTS Prevalence of undernutrition in home care and care home settings varies between 15% and 65%. Causes of undernutrition are various: medical, social, environmental, organizational and financial. Lack of alertness of individuals, their relatives and health-care professionals play an important role. Undernutrition enhances the risk of infection, hospitalization, mortality and alter the quality of life. Moreover, undernutrition related-disease is an economic burden in most countries. Nutritional assessment should be part of routine global management. Nutritional support combined with physical training and an improved ambiance during meals is mandatory. Awareness, information and collaboration with all the stakeholders should facilitate implementation of nutritional strategies. CONCLUSIONS Undernutrition in home care and care home settings is a considerable problem and measures should be taken to prevent and treat it.

Multifaceted nutritional intervention among nursing-home residents has a positive influence on nutrition and function

OBJECTIVE We tested the hypothesis that a multifaceted 11-wk intervention comprising nutrition, group exercise, and oral care would have a significant influence on nutrition and function in elderly (>or=65 y) nursing-home residents. METHODS The study was an 11-wk randomized controlled intervention study with nutrition (chocolate and homemade oral supplements), group exercise twice a week (45-60 min, moderate intensity), and oral care intervention one to two times a week, with the aim of improving nutritional status and function in elderly nursing-home residents. A follow-up visit was made 4 mo after the end of the intervention. Assessments were weight, body mass index, dietary intake, handgrip strength, Senior Fitness Test, Bergs Balance Scale, and the prevalence of plaque. RESULTS A total of 121 subjects (61%) accepted the invitation and 62 were randomized to the intervention group. Six of these dropped out during the 11 wk. At the 4-mo follow-up there were 15 deaths in the intervention group and 8 in the control group. The nutrition and exercise were well tolerated. After 11 wk the change in percentage of weight (P = 0.005), percentage of body mass index (P = 0.003), energy intake (P = 0.084), protein intake (P = 0.012), and Bergs Balance Scale (P = 0.004) was higher in the intervention group than in the control group. In addition, the percentage of subjects whose functional tests improved was higher in the intervention group. Both groups lost the same percentage of weight after the intervention (P = 0.908). The total percentage of weight loss from baseline to follow-up was higher in the control group (P = 0.019). Oral care was not well accepted and the prevalence of plaque did not change. CONCLUSION It is possible to improve nutrition and function in elderly nursing-home residents by means of a multifaceted intervention consisting of chocolate, homemade supplements, group exercise, and oral care.

Oral nutritional support of older (65 years+) medical and surgical patients after discharge from hospital: systematic review and meta-analysis of randomized controlled trials

Objective: To estimate the effectiveness of oral nutritional support compared to placebo or usual care in improving clinical outcome in older (65 years+) medical and surgical patients after discharge from hospital. Outcome goals were: re-admissions, survival, nutritional and functional status, quality of life and morbidity. Data sources: Three recent Cochrane reviews and an update of their literature search using MEDLINE, EMBASE, Web of Science. Search terms included randomized controlled trials; humans; age 65+ years; subset: dietary supplements. Review methods: One reviewer assessed trials for inclusion, extracted data and assessed trial quality. Results: Six trials were included (N = 716 randomly assigned participants). All trials used oral nutritional supplements. A positive effect on nutritional intake (energy) and/or nutritional status (weight) (in compliant participants) were observed in all trials. Two pooled analysis was based on a fixed-effects model. No significant effect were found on mortality (four randomized controlled trials with 532 participants, odds ratio 0.80 (95% confidence (CI) interval 0.46 to 1.39)) or re-admissions (four randomized controlled trials with 478 participants, odds ratio 1.07 (95% CI 0.71 to 1.61)). Conclusion: Although the evidence is limited, we suggest that oral nutritional support may be considered for older malnourished medical and surgical patients after discharge from hospital.

Home-made oral supplement as nutritional support of old nursing home residents, who are undernourished or at risk of undernutrition based on the MNA. A pilot trial

Aims: The aim of this pilot study was to examine the effect of a home-made oral supplement on body weight and energy intake of old people residing in a nursing home. Methods: Sixty-six old (65 + years) nursing home residents were included and divided into three classes according to their Mini Nutritional Assessment (MNA) scores. Participants who scored 17–23.5 MNA points (at risk of undernutrition) and had a BMI <24 kg/m2 were randomly allocated (block randomization) to two groups: B and C. Participants with <17 MNA-points (undernourished) were allocated to group A. The participants allocated to groups A and B received a home-made oral supplement every evening for two consecutive months. Results: The results after two months showed that compliance with the supplement was good and daily intake from the supplement averaged 1.6 MJ. The total energy intake in group A significantly increased (p<0.001), without suppressing the intake of energy from normal food. Group B experienced a decrease in the intake of normal food and hence no overall change in food intake. Body weight was unchanged in all groups. Conclusions: Our limited data suggest that a home-made oral supplement can improve the total energy intake of nursing home residents who are undernourished according to the MNA.

Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge: a randomized controlled trial

Objective: To assess the additional benefits of individualized nutritional counselling by a registered dietitian in geriatric patients’ home after discharge from hospital, in relation to risk of re-admissions, functional status, nutritional status, use of social services and mortality. Design: Twelve-week single-blind randomized controlled study. Setting and subjects: Geriatric medical patients (65+ years) at nutritional risk. Interventions: Participants were randomly allocated to receive a visit in their homes, either three individualized nutritional counselling by a registered dietitian complemented with three follow-up visits by general practitioners or three follow-up visits by general practitioners alone. Main measures: Primary outcome was risk of re-admissions. Secondary outcomes were functional status (hand grip strength, chair stand, mobility, disability and tiredness in daily activities, rehabilitation capacity), nutritional status (weight, BMI, energy and protein intake), need of social services (home care, home nursing, meals-on-wheels) and mortality. Results: One hundred and fifty-two patients were included; 132 (87%) completed the first and 124 (82%) the second data collection after 12 weeks. Ten per cent of the participants had three contacts with their general practitioner, while compliance with the dietetic intervention was almost 100%. Odds ratio for re-admission and mortality after 26 weeks was 1.62 (95% confidence interval (CI) 0.85 to 3.10) and 0.60 (95% CI 0.17 to 2.13). The intervention had a positive effect on functional status (i.e. mobility, P = 0.029), and nutritional status (i.e. weight, P = 0.035; energy intake, P < 0.001; protein intake, P = 0.001) and the use of meals-on wheels was reduced (P = 0.084). Conclusion: Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge.

Physical and social functional abilities seem to be maintained by a multifaceted randomized controlled nutritional intervention among old (>65 years) Danish nursing home residents

The purpose was to test the hypothesis that a multifaceted 11 weeks randomized controlled intervention would have a significant influence of functional abilities in old nursing home residents. Participants were 121 old (>65 years) residents in seven Danish nursing homes. The intervention consisted of nutrition (chocolate, homemade oral supplements), group exercise (moderate intensity) and oral care. Measurements taken were weight, body mass index (BMI), energy and protein intake, and functional abilities (activities of daily living=ADL, cognitive performance, and social engagement). The results showed that the nutrition and exercise were well accepted. After 11 weeks the change in % weight (1.3 vs. -0.6%, p=0.005), % BMI (0.4 vs. -0.2%, p=0.003), energy intake (0.7 vs. -0.3 MJ/day, p=0.084) and protein intake (5 vs. -2g/day, p=0.012) was higher in the intervention group than in the control group. Also, after 11 weeks, social and physical function had decreased in the control group but was unchanged in the intervention group. The difference between groups was significant in relation to social engagement (p=0.009). After the end of the intervention both groups had lost weight and physical function. Cognitive performance did not change, at any time. In conclusion, it seems possible to maintain social (and physical) functional abilities in old nursing home residents by means of a multifaceted intervention.

Do recommendations for institutional food service result in better food service? A study of compliance in Danish hospitals and nursing homes from 1995 to 2002-2003

Background:Since 1995, significant efforts by authorities and researchers have been directed towards addressing the nutritional problems in Danish hospitals and nursing homes.Aim:The purpose of this study was to investigate whether the increased focus on nutritional problems in patients and nursing home residents has resulted in measurable progress.Design:A questionnaire-based study was carried out among foodservice managers in Danish hospitals (n=96) and nursing homes (n=898) in 1995 and 2002/3 (n=90) and (n=682), respectively. The study used compliance with selected issues in the official Danish recommendations for institutional food service as an indicator for progress. The issues included: using nutrient calculated recipes/menus, offering menu choice options, using feedback routines on acceptability of menus, maintaining nutritional steering committees, employing food and nutrition contact persons, employing official recommendations and offering choice between three different menu energy levels.Results:Hospitals had a higher compliance compared to nursing homes. In 1995, this was the case for all questions asked and differences were statistically significant. Also in 2002/3, hospitals had a higher compliance, except in the case of established feedback routines. Differences were statistically significant. The results indicate that nutritional care is higher on the agenda in hospital, than in nursing homes. However, very little progress can be seen in compliance when results are analysed over the 8-year period. The only progress for nursing homes was that more homes had implemented feedback routines on acceptability of food service in 2002/3 than in 1995. The difference was statistically significant. For hospitals, however, no progress was found between 1995 and 2002/3.Conclusion:The attempts to improve the nutritional status of hospital patients and nursing home residents seem to have failed. Still, the initiatives taken to improve the situation seem relevant. Especially the nursing homes might benefit from advantage of these experiences.

Effectiveness of offering healthy labelled meals in improving the nutritional quality of lunch meals eaten in a worksite canteen

Healthier meal selections at restaurants and canteens are often limited and not actively promoted. In this Danish study the effectiveness of a healthy labelling certification program in improving dietary intake and influencing edible plate waste was evaluated in a quasi-experimental study design. Employees from an intervention worksite canteen and a matched control canteen were included in the study at baseline (February 2012), after completing the certification process (end-point) and six month from end-point (follow-up) (total n=270). In order to estimate nutrient composition of the consumed lunch meals and plate waste a validated digital photographic method was used combining estimation of food intake with food nutrient composition data. Food satisfaction was rated by participants using a questionnaire. Several significant positive nutritional effects were observed at the intervention canteen including a mean decrease in energy density in the consumed meals from 561kJ/100g at baseline to 368 and 407kJ/100g at end-point and follow-up, respectively (P<0.001). No significant changes were seen with regard to food satisfaction and plate waste. In the control canteen no positive nutritional effects were observed. The results of the study highlight the potential of using healthy labelling certification programs as a possible driver for increasing both the availability and awareness of healthy meal choices, thereby improving dietary intake when eating out.

Individualised dietary counselling for nutritionally at-risk older patients following discharge from acute hospital to home: a systematic review and meta-analysis.

BACKGROUND Many older patients are undernourished after hospitalisation. Undernutrition impacts negatively on physical function and the ability of older patients to perform activities of daily living at home after discharge from acute hospital. The present study aimed to evaluate the evidence for an effect of individualised dietary counselling following discharge from acute hospital to home on physical function, and, second, on readmissions, mortality, nutritional status, nutritional intake and quality of life (QoL), in nutritionally at-risk older patients. METHODS A systematic review of randomised controlled trials was conducted. The overall quality of the evidence was assessed according to Grading of Recommendations Assessment, Development and Evaluation system (GRADE) criteria. RESULTS Four randomised controlled trials (n = 729) were included. Overall, the evidence was of moderate quality. Dietitians provided counselling in all studies. Meta-analyses showed a significant increase in energy intake [mean difference (MD) = 1.10 MJ day(-1), 95% confidence interval (CI) = 0.66-1.54, P < 0.001], protein intake (MD = 10.13 g day(-1), 95% CI = 5.14-15.13, P < 0.001) and body weight (BW) (MD = 1.01 kg, 95% CI = 0.08-1.95, P = 0.03). Meta-analyses revealed no significant effect on physical function assessed using hand grip strength, and similarly on mortality. Narrative summation of effects on physical function using other instruments revealed inconsistent effects. Meta-analyses were not conducted on QoL and readmissions as a result of a lack of data. CONCLUSIONS Individualised dietary counselling by dietitians following discharge from acute hospital to home improved BW, as well as energy and protein intake, in older nutritionally at-risk patients, although without clearly improving physical function. The effect of this strategy on physical function and other relevant clinical outcomes warrants further investigation.