Christina Lengyel

Making the most of mealtimes (M3): grounding mealtime interventions with a conceptual model.

In this issue of the journal, Whear and colleagues1 present the results of a systematic review focused on mealtime interventions in long term care (LTC) and their effect on behavioral and psychological symptoms of dementia (BPSD) (e.g., fear, agitation). In a companion article2 these authors focus on nutritional outcomes of mealtime interventions. Key findings from both of these systematic reviews are that: 1) there is the potential to positively influence nutrition parameters and BPSD by changing the mealtime environment, 2) quality of these studies is generally poor due to small sample sizes, lack of randomization, and inadequate control for confounding factors within resident, staff and organizational levels, and 3) interventions are only briefly articulated, limiting understanding of how they work and how they can be replicated in typical LTC homes. The authors recommend that high quality studies be conducted to demonstrate the value of these interventions for improving nutritional health and quality of life of residents.1,2 We would add to this recommendation that intervention research needs to be based on a conceptual framework grounded in current evidence that demonstrates that there are several influences on the varied activities (e.g., arriving, eating, waiting socializing) that occur during a mealtime3 and that there are several intermediate (e.g. BPSD, food intake, strength) and ultimate outcomes (e.g., nutritional status, comorbidity, quality of life, functional ability, mortality) to consider. Mealtime is a complex process with multiple levels of influence including residents, staff, home and government.3 For example, organizational practices around when the dining room is open for meals can result in rushed mealtimes and if staffing is short or staff are drawn away from assisting others to encourage an agitated resident to remain at the table, all meal participants, including staff, are affected. Fully understanding the problem and its determinants is needed to design interventions that have the greatest impact.4

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BackgroundOlder adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.MethodsA conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.DiscussionThis rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.Trial RegistrationClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.

Nutritional risk and 5-year mortality of older community-dwelling Canadian men: the Manitoba Follow-Up Study.

This study examines nutritional risk and 5-year mortality rates of community-dwelling older Canadian men participating in the Manitoba Follow-Up Study. The surviving cohort (n = 690; mean age = 86.8 years) was mailed a self-administered Nutrition Survey consisting of SCREEN II, a validated nutrition risk screening tool and health-related questions. Five hundred fifty-three completed surveys (80% completion rate) were returned, with 522 (94%) containing complete responses necessary to score nutritional risk, comprising the participants for this analysis. Forty-four percent of the 522 respondents were scored as high risk, 24% at moderate risk, and 32% at low risk. Over five years from 2007 to 2012, 212 (41%) of the men died, with 1-year, 2-year, 3-year, and 4-year survival rates of 92%, 86%, 77%, and 66%, respectively. Men in the lowest 40th percentile of the nutritional risk distribution accounted for half of all deaths. Adjusted for other characteristics, Cox proportional hazard models demonstrated that with each unit decline on the nutritional risk scale there was a 4% greater risk of mortality (hazard ratio = 0.96 [95% CI 0.94,0.98]). Early identification of older men at nutritional risk and timely nutrition interventions are essential in delaying the progression of morbidity and mortality.

Changes in food group consumption and associations with self-rated diet, health, life satisfaction, and mental and physical functioning over 5 years in very old Canadian men: the Manitoba Follow-Up Study.

ObjectiveTo identify longitudinal food group consumption trends and the relationship to perceived changes in diet, health, and functioning.DesignA prospective longitudinal study.SettingCanadaParticipantsSeven hundred and thirty-six community-dwelling Canadian men (mean age: 2000=79.4 yrs; 2005=84.5 yrs) participating in the Manitoba Follow-up Study.MeasurementsSelf-reported food consumption, self-rated diet and health, life satisfaction, physical and mental functioning from questionnaires completed in 2000 and 2005.ResultsThe majority of participants did not consume from all four food groups daily, based on Canada’s Food Guide recommendations, with only 8% in 2000 and up to 15% in 2005. However, over a five year period, more men improved their consumption in each food group than declined. An association was found between change in the self-rating of the healthiness of their diet and change in consumption of vegetables and fruit, or grain products. Men whose self-rating of the healthiness of their diet remained high or improved between 2000 and 2005, were 2.15 times more likely (95%CI=1.45, 3.17) to also have increased consumption of vegetables and fruit, and 1.71 times more likely (95%CI=1.51, 2.54) to have increased consumption of grain products, relative to men whose self-rating of the healthiness of their diet declined between 2000 and 2005. Men who consumed more food groups daily had better mental and physical component scores.ConclusionDietary improvements are possible in very old men. Greater daily food group consumption is associated with better mental and physical functioning. Given these positive findings, there is still a need to identify older men who require support to improve their dietary habits as nearly half of the participants consumed two or fewer groups daily.

Body image and body work among older women: a review

Purpose – The purpose of this paper is to review the literature on body image and aging among older women. Using existing qualitative research, this paper explores how aging affects body image and how women respond to body image issues as they age. Design/methodology/approach – Multiple databases were used to locate original and review articles on the topics of body image and aging, with a target population of women ages 60 years and older. The findings of the literature search were compiled, summarized and sorted to create themes. Findings – Women struggle with body image issues throughout their lives. Women tend to perceive age-related changes in appearance negatively, as a threat to their identity and social value. This is due, in part, to the sociocultural environment, which pressures women to “fight” aging and maintain an ideal (young and thin) image at all costs. Some women do come to terms with their aging body and report increased self-acceptance with age. However, others turn to various forms of ...

Nutritional risk in community-dwelling older men: the Manitoba follow-up study.

PURPOSE The role of nutrition in older mens health and successful aging has been inadequately studied. We examined the relationships among nutritional risk, self-rated health, and successful aging in community-dwelling Canadian older men. METHODS The surviving cohort of the Manitoba Follow-up Study (n=690, mean age = 86.8 years) were sent a self-administered nutrition survey in December 2007. The survey consisted of the Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II (SCREEN II), a validated tool for assessing nutritional risk of cognitively intact community-living older adults, and questions about successful aging and health. RESULTS Of the 553 surveys returned (80% response), 522 with complete SCREEN II data were included in the analysis. Forty-four percent of respondents were at high nutritional risk, 24% were at moderate risk, and 32% were at low risk. Significant relationships were found between nutritional risk and self-rated health (P<0.0001) and successful aging (P=0.008), with greater nutritional risk associated with lower self-ratings of health and successful aging. Higher use of prescription medication was related to greater nutritional risk (P=0.004). CONCLUSIONS Nutritional screening programs for community-dwelling older men are warranted as two-thirds of the study participants were at nutritional risk. Identifying older men at nutritional risk is a critical step in the process of nutritional assessment, and subsequent nutrition interventions and follow-up are required to prevent further health decline.

Inadequate fluid intake in long term care residents: prevalence and determinants

ABSTRACT Dehydration is estimated to be present in half of long term care residents, as many do not consume the recommended levels of fluid intake. This study aims to describe fluid intake in long term care residents and identify the factors associated with fluid intake. Data were collected from 622 long term care residents, with a mean age of 86.8 ± 7.8. Total fluid intake was estimated over three non‐consecutive days. Potential resident and unit‐level variables risk factors for low fluid intake were collected, such as dementia status, activities of daily living, and eating challenges. Average daily fluid intake ranged from 311–2390 mL (1104.1 ± 379.3). Hierarchical regression analysis revealed that fluid intake was negatively associated with increased age, cognitive impairment, eating challenges and increased dining room staffing. Being male and requiring more physical assistance were positively associated with intake. Variables identified to predict intake could help inform strategies and targeted interventions to improve fluid intake.

Trajectories of nutritional risk: The Manitoba follow-up study

ObjectivesTo identify patterns of nutritional risk among older men over a four-year period and to project their survival rates over the next two and a half years.DesignA prospective longitudinal study.SettingCanada.ParticipantsThree hundred and thirty-six male survivors of the Manitoba Follow-up Study (MFUS) cohort with an average age of 90 years in 2011.MeasurementsFour years of nutritional risk SCREEN II scores (five waves) from the male survivors of the MFUS cohort. The semi-parametric group-based trajectory approach and survival analysis were used to investigate the trajectories of nutritional risk.ResultsOf the participants, 30% lived alone. Five distinct developmental trajectory groups for nutritional risk score were identified. Significant statistical differences were found among the five trajectory groups for SF-36 mental health (p=.02), SF-36 physical health (p=<.001), perception of aging successfully (p=.04) and living alone (p=<.001). Among the five groups, the most pairwise differences were found in appetite, intake of meat and alternatives, and vegetables and fruit, weight change, skipping meals and eating with others. Men in the poorest nutritional risk trajectory group were two times more likely to die within a 2 1/2 year period compared to men in the best nutritional risk trajectory group (hazard rate = 2.33, p=.07).ConclusionDistinct nutritional risk trajectories were found for older men over a four year period. Poor nutritional risk trajectories are associated with higher risk of mortality for very old men over a short period of time. Timely nutritional assessments by health professionals are needed to identify older men at nutritional risk. Subsequent nutrition education and follow-up may be important in preventing further decline.

Intake and Factors Associated with Consumption of Pureed Food in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

Abstract Residents living in long term care (LTC) who consume a pureed diet tend to have inadequate intake; understanding factors associated with poor intake in this group of residents is not well established. This study examined the adequacy of nutrient intake among LTC residents consuming a pureed diet and the factors associated with this intake (n = 67). Data was collected as part of a cross-sectional study conducted in 32 LTC homes. Weighed food intake was measured on three non-consecutive days and analyzed using Food Processor software. Intake of nutrients were adjusted for intra-individual variability and compared to the Estimated Average Requirement or Adequate Intake for women only. Consumers of a pureed diet had low micronutrient intakes. Multivariate analysis found that the average number of staff assisting with a meal was associated with energy and protein intake. Overcoming eating challenges, careful menu planning and nutrient-dense options for pureed diets in LTC are recommended.

Construct Validity of the Mealtime Scan: A Secondary Data Analysis of the Making Most of Mealtimes (M3) Study

Abstract Long-term care (LTC) physical and psychosocial mealtime environments have been inconsistently assessed due to the lack of a standardized measure. The purpose of this study was to examine the construct validity of a new standardized observational measure, the Mealtime Scan (MTS), using the Making Most of Mealtimes data collected on 639 residents in 82 dining rooms in 32 LTC homes. The MTS includes physical, social, and person-centered care summary scales scored from 1 to 8. Mean ratings on these summary scales were moderate for physical (5.6 SD 0.9), social (5.0 SD 0.9), and person-centered care (PCC; 5.5 SD 0.8). Regression analyses determined which items within the MTS were associated with these summary scales: physical – music (B = 0.27, p = 0.04), number of staff passing food (B = −0.11, p = 0.03), number of residents (B = −0.03, p = 0.01); social – social sound (B =  0.31 p < 0.0001), number of residents requiring eating assistance (B = 0.11, p = 0.02); PCC – lighting (B = 0.01 p = 0.04), and total excess noise (B = 0.05, p < 0.0001). The Mealtime Relational Care Checklist (M-RCC) was associated positively with ratings on all three summary scales. Correlations revealed that the MTS summary scales were associated with other constructs: Dining Environment Audit Protocol functionality scale, resident and dining room level M-RCC, Mini Nutritional Assessment- Short Form, and resident Cognitive Performance Scale. These results demonstrate that the MTS summary scales exhibit construct validity, as the ratings were associated with expected observed mealtime characteristics and correlated with dining room and resident level constructs in anticipated directions.