Ekta Agarwal

Role of domiciliary and family carers in individualised nutrition support for older adults living in the community

Protein-energy malnutrition is common amongst people aged 65 years and older, has a multifactorial aetiology, and numerous negative outcomes. Domiciliary carers (non-clinical paid carers) and family carers (including family, friends and neighbours) are required to support the increasing demand for in-home assistance with activities of daily living due to the ageing population. This review provides insight into the role of both domiciliary and family carers in providing individualised nutrition support for older, community-dwelling adults with malnutrition. Four electronic databases were searched for intervention studies from database inception to December 2016. Both domiciliary and family carers are well placed to monitor the dietary intake and nutritional status of older adults; to assist with many food-related tasks such as the sourcing and preparation of meals, and assisting with feeding when necessary; and to act as a conduit between the care recipient and formal nutrition professionals such as dietitians. There is moderate evidence to support the role of domiciliary carers in implementing nutrition screening and referral pathways, and emerging evidence suggests they may have a role in malnutrition interventions when supported by health professionals. Moderate evidence also supports the engagement of family carers as part of the nutrition care team for older adults with malnutrition. Interventions such as group education, skill-development workshops and telehealth demonstrate promise and have significantly improved outcomes in older adults with dementia. Further interventional and translational research is required to demonstrate the efficacy of engaging with domiciliary and family carers of older adults in the general community.

Medical nutrition therapy and simple interventions can improve intake in patients who eat poorly in hospital

This study aimed to determine the career and study paths that University of Wollongong (UOW) graduates take once they complete their qualifications in either nutrition, dietetics, exercise science or exercise physiology and to establish how prepared they and their employers felt they were. Three online surveys (December 2012 graduates, July 2007-July 2012 graduates and employers) were conducted via Survey Monkey® in late 2012 that asked about work and study experiences pre and post-graduation, strengths and weaknesses of programs, ideas for further curriculum development and experiences employing UOW graduates. 23 responses were received from the December graduating students, 96 from earlier graduates and 11 from employers.The Australasian Nutrition Care Day Survey (ANCDS) reported two-in-five patients in Australian and New Zealand hospitals consume ≤50% of the offered food. The ANCDS found a significant association between poor food intake and increased in-hospital mortality after controlling for confounders (nutritional status, age, disease type and severity)1. Evidence for the effectiveness of medical nutrition therapy (MNT) in hospital patients eating poorly is lacking. An exploratory study was conducted in respiratory, neurology and orthopaedic wards of an Australian hospital. At baseline, 24-hour food intake (0%, 25%, 50%, 75%, 100% of offered meals) was evaluated for patients hospitalised for ≥2 days and not under dietetic review. Patients consuming ≤50% of offered meals due to nutrition-impact symptoms were referred to ward dietitians for MNT with food intake re-evaluated on day-7. 184 patients were observed over four weeks. Sixty-two patients (34%) consumed ≤50% of the offered meals. Simple interventions (feeding/menu assistance, diet texture modifications) improved intake to ≥75% in 30 patients who did not require further MNT. Of the 32 patients referred for MNT, baseline and day-7 data were available for 20 patients (68±17years, 65% females, BMI: 22±5kg/m2, median energy, protein intake: 2250kJ, 25g respectively). On day-7, 17 participants (85%) demonstrated significantly higher consumption (4300kJ, 53g; p<0.01). Three participants demonstrated no improvement due to ongoing nutrition-impact symptoms. “Percentage food intake” was a quick tool to identify patients in whom simple interventions could enhance intake. MNT was associated with improved dietary intake in hospital patients. Further research is needed to establish a causal relationship.

An investigation into the nutritional status of patients receiving an Enhanced Recovery After Surgery (ERAS) protocol versus standard care following Oesophagectomy

PurposeEnhanced Recovery After Surgery (ERAS) protocols have been effectively expanded to various surgical specialities including oesophagectomy. Despite nutrition being a key component, actual nutrition outcomes and specific guidelines are lacking. This cohort comparison study aims to compare nutritional status and adherence during implementation of a standardised post-operative nutritional support protocol, as part of ERAS, compared to those who received usual care.MethodsTwo groups of patients undergoing resection of oesophageal cancer were studied. Group 1 (n = 17) underwent oesophagectomy between Oct 2014 and Nov 2016 during implementation of an ERAS protocol. Patients in group 2 (n = 16) underwent oesophagectomy between Jan 2011 and Dec 2012 prior to the implementation of ERAS. Demographic, nutritional status, dietary intake and adherence data were collected. Ordinal data was analysed using independent t tests, and categorical data using chi-square tests.ResultsThere was no significant difference in nutrition status, dietary intake or length of stay following implementation of an ERAS protocol. Malnutrition remained prevalent in both groups at day 42 post surgery (n = 10, 83% usual care; and n = 9, 60% ERAS). A significant difference was demonstrated in adherence with earlier initiation of oral free fluids (p <0.008), transition to soft diet (p <0.004) and continuation of jejunostomy feeds on discharge (p <0.000) for the ERAS group.ConclusionA standardised post-operative nutrition protocol, within an ERAS framework, results in earlier transition to oral intake; however, malnutrition remains prevalent post surgery. Further large-scale studies are warranted to examine individualised decision-making regarding nutrition support within an ERAS protocol.

Disease-related malnutrition in the twenty-first century: From best evidence to best practice

Malnutrition is a syndrome that results from the intake of nutrients that do not conform to physiological requirements. Malnutrition indiscriminately affects individuals across various stages in life, right from infants and children to adolescents and older adults, and includes underand over-nutrition. Whilst under-nutrition was once associated with developing countries and over-nutrition with developed countries, many parts of the world experience a dual burden. Three landmark papers on malnutrition published in the twentieth century include: • ‘Human starvation and its consequences’ by Ancel Keys (1946), that demonstrated when deprived of adequate nutrition, healthy volunteers developed severe physiological and psychological disorders, which improved with the reintroduction of adequate feeding; • ‘The skeleton in the hospital closet’ by Charles Butterworth (1974), that was the first to highlight that, despite a noticeable prevalence, hospital-based medical teams failed to identify malnutrition in patients; • ‘What supports nutritional support’ by Ronald Koretz (1984), that highlighted the knowledge deficit in making evidence-based decisions regarding when acute care patients should be offered nutrition support. These works led to the inception of a huge body of clinical research into malnutrition. Depending on the method of assessment, malnutrition is prevalent in approximately 20–50% of adult acute care patients, 20–70% of nursing home residents and 5–30% of community-dwelling adults. Research has provided compelling evidence associating malnutrition with frequent readmissions to hospitals; prolonged length of hospital stay; increased risk of infections, falls and pressure ulcers; delayed convalescence; increased health-care costs; and mortality. Nutrition screening and assessment tools have been developed and validated to identify and diagnose malnutrition across the continuum of care, with research informing the development of nutrition support and care strategies to manage malnutrition. Working parties and task forces from around the world have compiled, collated and summarised evidence into guidelines to inform best practice amongst clinical staff for the management of malnutrition, which have been endorsed by dietetic associations and societies. The basic premise of evidence-based practice guidelines is to improve and ensure best practice for patient care. Guidelines emerging from clinical research are usually accepted by practitioners at an academic level. Therefore, it is logical that practice would align with evidence-based guidelines. On the contrary, substantive data reflect that practice diverges from evidence-based guidelines. So, where lies the problem?

Protein-Energy malnutrition exists and is associated with negative outcomes in morbidly obese hospital patients

Prevalence of protein-energy malnutrition (PEM), food intake inadequacy and associated health-related outcomes in morbidly obese (Body Mass Index ≥ 40 kg/m2) acute care patients are unknown. This study reports findings in morbidly obese participants from the Australasian Nutrition Care Day Survey (ANCDS) conducted in 2010. The ANCDS was a cross-sectional survey involving acute care patients from 56 Australian and New Zealand hospitals. Hospital-based dietitians evaluated participants’ nutritional status (defined by Subjective Global Assessment, SGA) and 24-hour food intake (as 0%, 25%, 50%, 75%, and 100% of the offered food). Three months later, outcome data, including length of stay (LOS) and 90-day in-hospital mortality, were collected. Of the 3122 participants, 4% (n = 136) were morbidly obese (67% females, 55 ± 14 years, BMI: 48 ± 8 kg/m2). Eleven percent (n = 15) of the morbidly obese patients were malnourished, and most (n = 11/15, 73%)received standard hospital diets without additional nutritional support. Malnourished morbidly obese patients had significantly longer LOS and greater 90-day in-hospital mortality than well-nourished counterparts (23 days vs. 9 days, p = 0.036; 14% vs. 0% mortality, p = 0.011 respectively). Thirteen morbidly obese patients (10%) consumed only 25% of the offered meals with a significantly greater proportion of malnourished (n = 4, 27%) versus well-nourished (n = 9, 7%) (p = 0.018). These results provide new knowledge on the prevalence of PEM and poor food intake in morbidly obese patients in Australian and New Zealand hospitals. For the first time internationally, the study establishes that PEM is significantly associated with negative outcomes in morbidly obese patients and warrants timely nutritional support during hospitalisation.Abstract of an oral paper that was presented at the Dietitians Association of Australia 31st National Conference. Incorporating: 2nd World Forum on Nutrition Research Translating the Principles of the Mediterranean Diet, 15-17 May 2014, Brisbane Convention and Exhibition Centre, Brisbane, Queensland, Australia. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Needham, A., Beck, E. & Tapsell, L. (2014). Does a standardised dinner meal consumed the evening prior to testing add methodological integrity to an acute meal test study design?. Nutrition and Dietetics, 71 (Suppl. S1), 26-26. This journal article is available at Research Online: http://ro.uow.edu.au/smhpapers/2739 Does a Standardised Dinner Mealconsumed the Evening Prior to Testing add Methodological Integrity to an Acute Meal Test Study Design? Anita Needham, Eleanor Beck, Linda Tapsell University of Wollongong, NSW Sorghum is an ancient, gluten-free cereal grain that has slow digestibility in vitro and high polyphenol content that may attenuate blood glucose and insulin responses and potentially increase satiety and antioxidant potential in humans. A randomised, double-blind meal test study was conducted to determine the acute effects of different sorghum-based breakfast meals on measures of acute satiety, prospective food intake and antioxidant capacity. The aim of this paper is to discuss whether a standardised pre-test dinner meal added mechanistic value and research quality to this study design. Using a within-subjects, repeated measures design, 40 healthy subjects (20 men and 20 women), aged 20-50 years attended a Clinical Trials Unit on 4 occasions after a 12-hour overnight fast. The evening before the testing day, each subject consumed a frozen dinner meal of energy value stratified to his or her usual intake. The key rationale for this condition was to standardise the level of polyphenolic compounds, and therefore potential antioxidants, present in the plasma of subjects at baseline on each test day. Standardisation of energy, macroand micronutrients was a secondary effect. This paper reviews evidence on standardisation of intake before meal test studies, particularly reviewing the baseline plasma antioxidant capacity in the current study, after consumption of the standardised meal on the evening prior to testing. These results may inform the design of future meal test studies that specifically investigate food intake and antioxidant outcome measures.words: 248 58

Patient perspectives of factors contributing to inadequate dietary intake in acute care patients in hospital

Up to 30% of acute care patients consume less than half of the food provided in hospital. Inadequate dietary intake can have adverse clinical outcomes, including a higher risk of in-hospital mortality. This study aimed to investigate the reasons for poor intake among acute care patients in hospital. Patients with an observed intake of ≤50% of the food provided at lunch were approached to participate in the study. Thirty-two patients participated in semi-structured interviews over a three week period, to provide their perspective of food and mealtimes in hospital and discuss the reasons and factors influencing inadequate intake. Responses were coded and analysed thematically using the framework method. Patients reported both individual and organisational factors contribute to their inadequate intake. Half the patients reported the size of the meals were too large, with some patients reporting that large meal sizes puts them off their food and reduced their intake. ‘Not important to eat all the food provided’, and ‘do not need to eat much food in hospital’ were common attitudes among the patients. Half the patients reported that nurses did not observe their intake and were not concerned if all the food was not eaten. Identifying the reasons for poor intake can assist with the development of suitable interventions to improve dietary intake and reduce the risk of adverse clinical outcomes. Further investigation of suitable interventions to reduce portion sizes and improve both staff and patient perceptions of the importance of food in hospital is recommended.Despite being commonly prevalent in acute care hospitals worldwide, malnutrition often goes unidentified and untreated due to a lack in the implementation of a nutrition care pathway. The aim of this study was to validate nutrition screening and assessment tools in Vietnamese language. After converting into Vietnamese, Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA) were used to identify malnutrition in the adult setting; and the Paediatric Nutrition Screening Tool (PNST) and paediatric Subjective Global Nutritional Assessment (SGNA) were used in the paediatric setting in two acute care hospitals in Vietnam. This cross-sectional observational study sampled 123 adults (median age 78 years [39–96 years], 63% males) and 105 children (median age 20 months [2–100 months], 66% males). In adults, nutrition risk and malnutrition were identified in 29% and 45% of the cohort respectively. Nutrition risk and malnutrition were identified in 71% and 43% of the paediatric cohort respectively. The sensitivity and specificity of the screening tools were: 62% and 99% for the MST compared to the SGA; 89% and 42% for the PNST compared to the SGNA. This study provides a stepping stone to the potential use of evidence-based nutrition screening and assessment tools in Vietnamese language within the adult and paediatric Vietnamese acute care setting. Further work is required into integrating a complete nutrition care pathway within the acute care setting in Vietnamese hospitals.Abstract of a poster presented at 32nd DAA National Conference, 13-16 May 2015, Crown Perth Conference Centre, Perth, Western Australia. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Ryman, S., Bell, A., Walton, K. & Jenkins, E. (2015). Exploring the impact of two different food and beverage packaging conditions on the dietary intakes of older adults in a simulated hospital environment. Nutrition and Dietetics, 72 (Suppl. 1), 63-63. This journal article is available at Research Online: http://ro.uow.edu.au/smhpapers/2781 Abstract of a poster presented at 32nd DAA National Conference, 13–16 May 2015, Crown Perth Conference Centre, Perth, Western Australia.of a poster presented at 32nd DAA National Conference, 13–16 May 2015, Crown Perth Conference Centre, Perth, Western Australia. Exploring the impact of two different food and beverage packaging conditions on the dietary intakes of older adults in a simulated hospital environment SARAH RYMAN, ALISON BELL, KAREN WALTON, EMMAJENKINS School of Medicine, University of Wollongong, NSW This study aimed to determine the impact of food and beverage packaging on the dietary intakes of older adults. Malnutrition is a common issue in hospitals that can be often overlooked. In the literature food and beverage packaging has consistently been identified as negatively impacting dietary intakes of older inpatients. All 31 participants (aged 65 years and over) experienced two conditions which included unopened packaging and pre-opened packaging in the Nursing Simulation Laboratory at the University of Wollongong. A food waste audit was conducted, post meal questionnaire, meal time observations and malnutrition screening. Data were analysed through paired t-tests, independent t-tests and descriptive statistics using the Statistical Package for Social Science (SPSS). There was no significant difference in participants’ dietary intakes between the two packaging conditions. Cheese and biscuit packaging were found to be the most difficult to open. The average attempts to open the cheese packaging was 5.6 and took 28.5 s. The average attempts to open biscuits was 5.8 and took 16.4 s. It was found that there was a significant difference between malnutrition status and attempts to open cheese packaging. There was no significant difference in dietary intake, malnutrition status or gender. Although no statistical significant difference in dietary intakes was found, these results may reflect a clinically significant finding for a person who is malnourished. The study did find that some packaging was more difficult for participants’ to open and any barriers to dietary intake should be minimised to prevent malnutrition. Funding source: Global Challenges and University International Collaboration Grants from the University of Wollongong supported this research Contact author: Sarah Ryman – sjr659@uowmail.edu.au

Validating adult and paediatric nutrition screening and assessment tools in Vietnamese language in two acute hospitals in Ho Chi Minh City, Vietnam

Up to 30% of acute care patients consume less than half of the food provided in hospital. Inadequate dietary intake can have adverse clinical outcomes, including a higher risk of in-hospital mortality. This study aimed to investigate the reasons for poor intake among acute care patients in hospital. Patients with an observed intake of ≤50% of the food provided at lunch were approached to participate in the study. Thirty-two patients participated in semi-structured interviews over a three week period, to provide their perspective of food and mealtimes in hospital and discuss the reasons and factors influencing inadequate intake. Responses were coded and analysed thematically using the framework method. Patients reported both individual and organisational factors contribute to their inadequate intake. Half the patients reported the size of the meals were too large, with some patients reporting that large meal sizes puts them off their food and reduced their intake. ‘Not important to eat all the food provided’, and ‘do not need to eat much food in hospital’ were common attitudes among the patients. Half the patients reported that nurses did not observe their intake and were not concerned if all the food was not eaten. Identifying the reasons for poor intake can assist with the development of suitable interventions to improve dietary intake and reduce the risk of adverse clinical outcomes. Further investigation of suitable interventions to reduce portion sizes and improve both staff and patient perceptions of the importance of food in hospital is recommended.Despite being commonly prevalent in acute care hospitals worldwide, malnutrition often goes unidentified and untreated due to a lack in the implementation of a nutrition care pathway. The aim of this study was to validate nutrition screening and assessment tools in Vietnamese language. After converting into Vietnamese, Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA) were used to identify malnutrition in the adult setting; and the Paediatric Nutrition Screening Tool (PNST) and paediatric Subjective Global Nutritional Assessment (SGNA) were used in the paediatric setting in two acute care hospitals in Vietnam. This cross-sectional observational study sampled 123 adults (median age 78 years [39–96 years], 63% males) and 105 children (median age 20 months [2–100 months], 66% males). In adults, nutrition risk and malnutrition were identified in 29% and 45% of the cohort respectively. Nutrition risk and malnutrition were identified in 71% and 43% of the paediatric cohort respectively. The sensitivity and specificity of the screening tools were: 62% and 99% for the MST compared to the SGA; 89% and 42% for the PNST compared to the SGNA. This study provides a stepping stone to the potential use of evidence-based nutrition screening and assessment tools in Vietnamese language within the adult and paediatric Vietnamese acute care setting. Further work is required into integrating a complete nutrition care pathway within the acute care setting in Vietnamese hospitals.Abstract of a poster presented at 32nd DAA National Conference, 13-16 May 2015, Crown Perth Conference Centre, Perth, Western Australia. Disciplines Medicine and Health Sciences | Social and Behavioral Sciences Publication Details Ryman, S., Bell, A., Walton, K. & Jenkins, E. (2015). Exploring the impact of two different food and beverage packaging conditions on the dietary intakes of older adults in a simulated hospital environment. Nutrition and Dietetics, 72 (Suppl. 1), 63-63. This journal article is available at Research Online: http://ro.uow.edu.au/smhpapers/2781 Abstract of a poster presented at 32nd DAA National Conference, 13–16 May 2015, Crown Perth Conference Centre, Perth, Western Australia.of a poster presented at 32nd DAA National Conference, 13–16 May 2015, Crown Perth Conference Centre, Perth, Western Australia. Exploring the impact of two different food and beverage packaging conditions on the dietary intakes of older adults in a simulated hospital environment SARAH RYMAN, ALISON BELL, KAREN WALTON, EMMAJENKINS School of Medicine, University of Wollongong, NSW This study aimed to determine the impact of food and beverage packaging on the dietary intakes of older adults. Malnutrition is a common issue in hospitals that can be often overlooked. In the literature food and beverage packaging has consistently been identified as negatively impacting dietary intakes of older inpatients. All 31 participants (aged 65 years and over) experienced two conditions which included unopened packaging and pre-opened packaging in the Nursing Simulation Laboratory at the University of Wollongong. A food waste audit was conducted, post meal questionnaire, meal time observations and malnutrition screening. Data were analysed through paired t-tests, independent t-tests and descriptive statistics using the Statistical Package for Social Science (SPSS). There was no significant difference in participants’ dietary intakes between the two packaging conditions. Cheese and biscuit packaging were found to be the most difficult to open. The average attempts to open the cheese packaging was 5.6 and took 28.5 s. The average attempts to open biscuits was 5.8 and took 16.4 s. It was found that there was a significant difference between malnutrition status and attempts to open cheese packaging. There was no significant difference in dietary intake, malnutrition status or gender. Although no statistical significant difference in dietary intakes was found, these results may reflect a clinically significant finding for a person who is malnourished. The study did find that some packaging was more difficult for participants’ to open and any barriers to dietary intake should be minimised to prevent malnutrition. Funding source: Global Challenges and University International Collaboration Grants from the University of Wollongong supported this research Contact author: Sarah Ryman – sjr659@uowmail.edu.au

OP008 THE IMPACT OF MALNUTRITION AND DECREASED FOOD INTAKE ON LENGTH OF STAY, READMISSION, AND MORTALITY IN ACUTE CARE PATIENTS

Rationale: The Australasian Nutrition Care Day Survey (ANCDS) evaluated if malnutrition and decreased food intake are independent risk factors for negative outcomes in hospitalised patients. Methods: A multicentre (56 hospitals) cross-sectional survey was conducted in two phases. Phase 1 evaluated nutritional status (defined by Subjective Global Assessment) and 24-hour food intake recorded as 0, 25, 50, 75, and 100% intake. Phase 2 data, which included length of stay (LOS), readmissions and mortality, were collected 90 days post-Phase 1. Logistic regression was used to control for confounders: age, gender, disease type and severity (using Patient Clinical Complexity Level scores). Results: Of 3122 participants (53% males, mean age: 65±18 years) 32% were malnourished and 23% consumed�25% of the offered food. Median LOS for malnourished (MN) patients was higher than well-nourished (WN) patients (15 vs. 10 days, p<0.0001). Median LOS for patients consuming �25% of the food was higher than those consuming �50% (13 vs. 11 days, p<0.0001). MN patients had higher readmission rates (36% vs. 30%, p = 0.001). The odds ratios of 90-day in-hospital mortality were 1.8 times greater for MN patients (CI: 1.03 3.22, p = 0.04) and 2.7 times greater for those consuming �25% of the offered food (CI: 1.54 4.68, p = 0.001). Conclusion: The ANCDS demonstrates that malnutrition and/or decreased food intake are associated with longer LOS and readmissions. The survey also establishes that malnutrition and decreased food intake are independent risk factors for in-hospital mortality in acute care patients; and highlights the need for appropriate nutritional screening and support during hospitalisation. Disclosure of Interest: None Declared.