Food fortification and oral nutrient supplements play a role in reducing malnutrition and unintentional weight loss, however effectiveness can depend on how well programs are monitored, writes Sandy Cheu.

Research shows that some aged care residents are malnourished and receiving inadequate amounts of protein. While food fortification and oral supplements can reduce malnutrition among residents, their intake has to be monitored to be successful, says dietitian Lisa Sossen.

Sossen, a PhD candidate at Monash University, is researching food fortification in aged care and methods to increase current energy and protein on current menus. She says the biggest challenge, and an area of her interest, is implementing sustainable effective programs.

Her study recently published in the Journal of Nutrition in Gerontology and Geriatrics, investigated whether a structured high-energy high-protein diet (SHEHP) incorporated into the standard menu could reduce unintentional weight loss in aged care residents.

“The SHEHP looked at how we put something in that is structured that the kitchen staff can do, and that nursing staff can follow and that they can encourage. And if we put that in, will it actually work, rather than us asking the kitchen to add in more cream or extra butter, which doesn’t always work,” Sossen tells Australian Ageing Agenda.

Lisa Sossen

The study involved 67 residents on a SHEHP diet and 55 residents taking oral nutrient supplements at five residential aged care facilities in Melbourne, Victoria.

The SHEHP diet involves fortifying foods and beverages for meals and snacks. That includes milk used for breakfast cereals and porridge milkshakes and fruit juice as well as adding five grams of butter to lunch and evening meals.

“The diet involved making a milkshake, or having cheese and biscuits for those who don’t have milkshakes, for morning and afternoon tea,” she says.

For residents who chose not to have porridge or cereal for breakfast, an additional milkshake was provided at breakfast or during the day.

The SHEHP fortification provided an additional average energy intake of 701 calories or 2,932 kilojoules and 27 grams of protein, she says.

During the trial, Sossen says kitchen staff knew how to make the fortified foods and the staff were good at encouraging residents to eat.

“The nursing staff were more on alert to the foods that were boosted up so by doing that, they were able to encourage it more often. They knew the porridge was important, so they would encourage the porridge more than leaving and thinking it’s not very nutritious,” she says.

The study found better outcomes for residents on the SHEHP diet compared to those taking the oral supplements.

“In the group with the high energy high protein diet, we found that it did improve malnutrition scores and we did find that they didn’t have any weight loss,” Sossen says. “They actually gained 0.56 of a kilogram compared to the others who lost 1.64 kilograms on average in their old nutritional supplement group.”

Five grams of butter or margarine were added to lunch and dinner meals during the study.

Sossen says they found that residents receiving a SHEHP diet but not eating their entire meals still had either a stable weight or slight weight gain.

“Those who had about 80 per cent meal waste were still on the positive side of the weight change scale,” she says.

Missed supplements was the key issue for participants in the oral supplement group, says Sossen.  

“It usually was near the end of the day, the afternoon or evening dose that was not given. Or the residents were sleeping and the staff would just leave it, so it wasn’t always the best time to give the oral nutrient supplement,” she says.

“With the nursing staff in the evening, there are less staff and they are pushed to get the medication done. So there is not as much patience to stand there and make sure they drank it,” Sossen says. “They were taking it okay, but they weren’t actually getting it all the time.”

While the SHEHP diet had better outcomes, neither programs are sustainable without someone driving it, Sossen says.

“The SHEHP is more sustainable in many ways because the kitchen is providing it and you’ve got the kitchen staff doing it,” she says. “However, both of them are not sustainable to a point if someone isn’t checking it. Similarly, if there is a change of staff and if new staff come in and they don’t know, that’s where anything will fall down.”

It all comes down to how programs are managed, she says.

“If we can empower our staff to look at food as the first line of nutrition and have dietitians more involved to check and monitor the program and come up with something new before it’s too late if something isn’t working, the programs can be sustained.”

Sossen expects to complete her PhD by the end of 2020.

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