Natalie Carrier

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.

Relationship between eating behaviors and physical activity of preschoolers and their peers: a systematic review.

ObjectivesChildren learn by observing and imitating others, meaning that their eating behaviors and physical activity may be influenced by their peers. This paper systematically reviews how preschoolers’ eating behaviors and physical activity relate to their peers’ behaviors, and discusses avenues for future research.MethodsSix databases were searched for quantitative, peer-reviewed studies published up to July 2015 reporting on the correlates, predictors or effectiveness of peers on eating behaviors and physical activity in preschoolers. Risk of bias was independently assessed by two evaluators using the Quality Assessment Tool for Quantitative Studies.ResultsThirteen articles were included: six measured physical activity, and seven assessed eating behaviors. Four of the six physical activity studies reported that children were more active when peers were present, while large peer group size was negatively associated with physical activity in two cross-sectional studies. All nutrition interventions reported that children’s eating behaviors may be influenced by their peers.ConclusionsAlthough supported by weak evidence, peers appear to influence children’s eating behaviors and physical activity. However, this influence may be moderated by the number of peers, gender, age and the perceived status of the role models. Future obesity prevention interventions should consider involving peers as agents for positive eating behaviors and physical activity in preschoolers.

Correlates, determinants, and effectiveness of childcare educators’ practices and behaviours on preschoolers’ physical activity and eating behaviours: a systematic review protocol

BackgroundWorldwide, approximately 12% of children under the age of 5 are either overweight or obese. As many young children spend 30 h or more per week in childcare centres with childcare educators. Targeting childcare educators as role models may prove an effective strategy for the promotion of healthy eating and physical activity. This manuscript describes the methods to systematically review existing literature relating to how childcare educators influence children’s healthy eating and physical activity behaviours, as well as the links between specific practices and behaviours of childcare educators and children’s healthy lifestyle behaviours.MethodsRelevant peer-reviewed studies will be identified through a computerized literature search in six databases: PubMed, The Cochrane Library, Science Direct, CINAHL, Wiley and SportDiscus. Quantitative studies written in English or French reporting the correlates, predictors or effectiveness of childcare educators’ practices and behaviours on preschoolers’ healthy eating and physical activity behaviours will be included. The quality of retained studies will be assessed using the Quality Assessment Tool for Quantitative Studies. Descriptive summary statistics of study characteristics will be reported as well as the study designs and exposure and outcome measures. Inter-rater agreements for study selection and quality assessments will be reported and unadjusted, and adjusted results will be presented. Reporting of the systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.DiscussionThis systematic review will contribute to a better understanding of the potential of childcare educators as role models for young children, as well as the influence (or impact) of their behaviours and intervention on children’s short- and long-term health. It will provide important information that could be used to improve obesity prevention strategies and initiatives, as well as to guide the improvement or implementation of effective healthy eating and physical activity policies in childcare centres.Systematic review registrationPROSPERO (CRD42014012973)

Dépistage nutritionnel chez les aînés en établissements de soins de santé : comparaison entre les établissements francophones et anglophones

RésuméObjectifsLa malnutrition des aînés est un problème répandu dans les hôpitaux et les foyers de soins. Cependant, la pratique du dépistage nutritionnel dans ces milieux est peu connue, particulièrement dans les établissements francophones de soins de santé. Cette étude avait pour objectifs de comparer la situation du dépistage nutritionnel des aînés dans les établissements de soins de santé francophones et anglophones du Nouveau-Brunswick, ainsi que les perceptions et les pratiques des professionnels de la santé.MéthodesLes données sur les paramètres de dépistage ont été puisées directement dans les dossiers médicaux des patients/résidents âgés. Les perceptions et les pratiques de dépistage nutritionnel des professionnels de la santé (médecins, infirmiers, diététistes) ont été recueillies au moyen de questionnaires.RésultatsCinq hôpitaux et 31 foyers de soins de longue durée du Nouveau-Brunswick ainsi que 421 patients/résidents et 457 professionnels de la santé ont participé à l’étude. Des différences significatives quant à la disponibilité des paramètres de dépistage furent observées entre les patients/résidents francophones et anglophones; les francophones bénéficiant moins de certains paramètres de dépistage dont le poids à l’admission, la perte d’appétit et la fraction des repas consommés. Les perceptions des professionnels quant au dépistage nutritionnel varient selon la profession et la langue de l’établissement. Plusieurs obstacles au dépistage nutritionnel sont relevés.ConclusionLa disponibilité moindre de paramètres de dépistage dans les milieux francophones et la sous-évaluation de la malnutrition par les médecins et les infirmiers sont des barrières pouvant influencer le dépistage nutritionnel en établissements de soins de santé francophones.AbstractObjectivesMalnutrition among the elderly is a widespread problem in hospitals and nursing homes. However, data on the practice of nutritional screening in these facilities are limited, particularly in Francophone establishments. This study aimed to compare nutritional screening practices among the elderly in Anglophone and Francophone health care facilities in New Brunswick (NB), as well as perceptions and practices of health care professionals.MethodsInformation on screening parameters was taken directly from elderly patients’/residents’ medical records. Health care professionals’ (doctors, nurses, dietitians) perceptions and practices of nutritional screening were collected through questionnaires.ResultsA total of five hospitals and 31 nursing homes in NB took part in the study. Of these, 421 patients/residents and 457 health professionals participated. Significant differences in the availability of screening parameters were observed between Francophone and Anglophone patients/residents. Certain screening parameters, such as weight at admission, loss of appetite and meal fractions consumed were less available in Francophone patients’/residents’ records. In addition, health care professionals’ perceptions regarding nutritional screening varied by occupation and language of the establishment. Several barriers to screening were also identified.ConclusionReduced availability of screening parameters in Francophone establishments and the underestimation of malnutrition in elderly patients/residents by doctors and nurses are barriers that can influence nutritional screening in Francophone health care facilities.

Association between childcare educators’ practices and preschoolers’ physical activity and dietary intake: a cross-sectional analysis

Introduction Childcare educators may be role models for healthy eating and physical activity (PA) behaviours among young children. This study aimed to identify which childcare educators’ practices are associated with preschoolers’ dietary intake and PA levels. Methods This cross-sectional analysis included 723 preschoolers from 50 randomly selected childcare centres in two Canadian provinces. All data were collected in the fall of 2013 and 2014 and analysed in the fall of 2015. PA was assessed using Actical accelerometers during childcare hours for 5 consecutive days. Children’s dietary intake was measured at lunch on 2 consecutive days using weighed plate waste and digital photography. Childcare educators’ nutrition practices (modelling, nutrition education, satiety recognition, verbal encouragement and not using food as rewards) and PA practices (informal and formal PA promotion) were assessed by direct observation over the course of 2 days, using the Nutrition and Physical Activity Self-Assessment for Child Care tool. Associations between educators’ practices and preschoolers’ PA and dietary intake were examined using multilevel linear regressions. Results Overall, modelling of healthy eating was positively associated with children’s intake of sugar (β=0.141, 95% CI 0.03 to 0.27), while calorie (β=−0.456, 95% CI −1.46 to –0.02) and fibre intake (β=−0.066, 95% CI −0.12 to –0.01) were negatively associated with providing nutrition education. Not using food as rewards was also negatively associated with fat intake (β=−0.144, 95% CI −0.52 to –0.002). None of the educators’ PA practices were associated with children’s participation in PA. Conclusions Modelling healthy eating, providing nutrition education and not using food as rewards are associated with children’s dietary intake at lunch in childcare centres, highlighting the role that educators play in shaping preschoolers’ eating behaviours. Although PA practices were not associated with children’s PA levels, there is a need to reduce sedentary time in childcare centres.

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.

Availability of nutrition screening parameters in New Brunswick hospitals and nursing homes.

PURPOSE Little is known about dietary intakes in toddlers of Low-German-Speaking Mennonites from Mexico, although some of these toddlers might be at risk for nutritional deficiencies. A 97-item, culturally sensitive, interviewer-administered food frequency questionnaire (FFQ) was developed and validated for health professionals to assess dietary intake in these children aged 12 to 36 months. METHODS Cultural foods on the FFQ were determined via focus groups; a pilot study tested content and formatting. The FFQ was administered to parents/caregivers of 22 toddlers in a southern Ontario community of Low-German-Speaking Mennonites from Mexico. Validity was determined by comparing nutrient intakes from the FFQ and from the 24-hour recalls, using Bland-Altman plots, Pearson correlations, and Students t-tests. Test-retest reliability was compared between two FFQ administrations (n=14) one month apart, via intraclass correlations (ICCs). RESULTS Bland-Altman plots showed good agreement between the FFQ and the 24-hour recall; Pearson correlations between methods were significant for protein, folate, calcium, and caffeine. Students t-tests were not significantly different between methods for 11 of 12 nutrients. Test-retest reliability was good on the basis of acceptable ICC for eight of 12 nutrients. CONCLUSIONS The prevalence of nutrient inadequacies was low, except for folate. These results are promising for implementation of a simple, quick, culturally sensitive FFQ with the potential to provide reliable estimates of mean intakes in toddlers of Low-German-Speaking Mennonites from Mexico.We explored the availability of parameters for a nutrition screening system among elderly people in New Brunswick (NB) health care facilities. Patients aged 65 or older were asked to participate in the study; each participant had been admitted to one of four hospitals or lived in one of six nursing homes. Availability of nutrition screening parameters (weight, height, weight change, serum albumin level, appetite, and food intake record) was assessed by auditing the participants’ medical charts. When data were not available, the feasibility of obtaining them was determined. Additional data related to nutrition screening were also obtained. In total, 421 participants were recruited for the study: 140 (33.2%) who lived in nursing homes and 281 (66.8%) who were in hospitals. Parameters needed to conduct nutrition screening, such as weight upon admission, were available for 83.6% of participants; usual weight was available for 43.0%, height for 86.0%, and serum albumin level for 47.5%. Our findings show that b...

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.

Modified Texture Food Use is Associated with Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

ObjectiveModified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered.DesignMaking the Most of Mealtimes (M3) is a cross-sectional multi-site study.Setting32 LTC homes in four Canadian provinces.ParticipantsRegular (n= 337) and modified texture food consumers (minced n= 139; pureed n= 68).MeasurementsMalnutrition risk was determined using the Mini Nutritional Assessment short-form (MNA-SF) score. The use of MTFs, and resident and site characteristics were identified from health records, observations, and standardized assessments. Hierarchical linear regression analyses, accounting for clustering, were performed to determine if the prescription of MTFs is associated with malnutrition risk while controlling for important covariates, such as eating assistance.ResultsPrescription of minced food [F(1, 382)=5.01, p=0.03], as well as pureed food [F(1, 279)=4.95, p=0.03], were both significantly associated with malnutrition risk among residents. After adjusting for age and sex, other significant covariates were: use of oral nutritional supplements, eating challenges (e.g., spitting food out of mouth), poor oral health, and cognitive impairment.ConclusionsPrescription of minced or pureed foods was significantly associated with the risk of malnutrition among residents living in LTC facilities while adjusting for other covariates. Further work needs to consider improving the nutrient density and sensory appeal of MTFs and target modifiable covariates.