In search of the best added-nutrient model

Fortified food can reduce malnutrition among residents but there is still no best-practice sustainable model for residential aged care, writes Sandy Cheu.

Food fortification is the process of adding micronutrients or macronutrients into common foods to improve nutrition. It plays an important role for older people who require nutritional support, says Danielle Cave, a dietitian who is researching food fortification strategies.

“Food fortification is an effective food-first nutrition support strategy to prevent and treat malnutrition,” Cave tells AAA.

“The biggest issue, and what I’m trying to focus on in my PhD, is getting a food fortification model implemented into an aged care home’s food service system, and having that work long term,” says Cave, a PhD candidate at the University of Queensland’s School of Human Movement and Nutrition Sciences.

The main methods of fortifying food include adding common high protein and energy ingredients like butter, cream, cheese and milk powder into foods such as porridge, milkshakes, yoghurt, custard and soups. Many fortified foods are mixed into dairy-based products, says Cave.

As part of her PhD research, Cave looked at 17 studies exploring food fortification strategies and the relationship between delivery and sustainability in aged care facilities. The research, which was published in the International Journal of Food Sciences and Nutrition in August this year, found there is uncertainty around whether food fortification strategies continue in aged care facilities after research interventions finish.

“They’re going great for the intervention period when there are researchers there and they’re making sure everything is happening. But we don’t really know if food fortification strategies are maintained long-term following the completion of these studies.”

In one of the studies, a researcher followed up with a facility a couple of years after a food fortification strategy was implemented and found the nutritional status of residents had declined, and the program was no longer in place.

“The whole idea is if you want to boost residents’ intake and nutritional status, it does need to keep happening,” Cave says.

“Future research should look at enablers for sustainability of food fortification strategies for maintaining the improvement seen in both intake and nutrition status.”

Food fortification strategies

On-site fortification is more commonly used in residential aged care than pre-fortified methods, says Cave. It is also most likely the cheapest approach, she says.

“You also get more choice in what ingredients you’re adding. For example, for a resident who needs extra energy, you could just be adding more butter or cream into their food. But if you’re concerned about getting more protein as well, you could add a milk or supplement powder to their food.”

On-site fortification allows the chef to pick which foods are fortified. This method decreases the chance of residents experiencing taste fatigue, which is when a person tires of eating or drinking the same food or beverage over time, says Cave.

“If you’re popping it in a milkshake and the person gets sick of it, you have the ability of putting it in something else.”

While on-site fortified food offers more choice, it needs more preparation time. “It requires extra staff time in the kitchen and from what I’ve seen kitchen staff don’t have a lot of time. Whereas if you’re getting something pre-made, you can just get something and deliver it straight to the resident,” Cave says.

However, pre-fortified food options are limited in Australia, which can make purchasing difficult, Cave says. An issue with on-site food fortification is that not all chefs are trained or aware of how to use ingredients to maximise nutrition, she says.

“It’s more difficult when you have chefs coming in from other industries, because when chefs get trained, they don’t get trained in food fortification, it’s something that is quite specific to aged care or a hospital,” says Cave.

“You need to make sure you’re putting enough of this extra ingredient in to make a proper difference. There is no point adding in a couple scoops of milk powder if the soup is going to 100 residents. That’s barely going to bump up the nutrition by anything,” she says.

Aged care facilities can improve their strategies by serving a variety of fortified foods and beverages throughout the day. They can also work with a dietitian and allocate a champion for nutrition and food fortification, Cave says.

“Enablers for the sustainability of food fortification include choosing low cost ingredients that are easy for staff to use.”

Cave’s PhD is looking into a sustainable best-practice food fortification model and associated costs for residential aged care. She expects to complete it in December 2020.

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