Project Summary
MG Food Solutions Pty Ltd in partnership with Aged Care and Housing Group (ACH) and Flinders University has been awarded an ARIIA grant for their project ‘Measuring consumer’s health and outcome benefits of switching from clinical dietary supplements to a food first approach to address malnutrition’.
This research is designed to explore if serving a nutrient-enriched (fortified) food product improves nutritional outcomes and food satisfaction for residents whilst reducing food service resource utilisation in aged care homes compared to serving separate food and dietary supplement products. Specifically, the research will investigate the performance of the fully integrated Food Imperative fortified dairy dessert product compared to using a combination of standard ice cream in meals and then addressing nutrient intake deficiency with a separate clinical dietary supplement (CDS), most likely in the form of a liquid supplement.
The use of a CDS is often very expensive, and if not consumed by the consumer, it can be a significant waste of money whilst failing to achieve the desired clinical outcomes. Therefore, switching from CDS to a food-first approach will also allow economic savings not only for the aged care providers but also for the healthcare system.
By undertaking this research, we will determine whether replacing standard ice cream and a CDS with a nutrient-fortified dairy desert results in improved outcomes for residents and aged care homes.
Project Outcomes
Background and Aims
Malnutrition is highly prevalent in residential aged care homes (RACHs). Findings from the Royal Commission into Aged Care Quality and Safety indicated that 68% of residents across 60 RACHs in 2017 were diagnosed with malnutrition or at risk of malnutrition.
Malnutrition
- Develops from prolonged poor dietary intake that does not meet the individual’s needs.
- It results in weight loss, which reduces strength and energy levels, increasing the risk of falls and fractures in older adults.
- Further, malnourished individuals are at greater risk of hospital admissions and poorer recovery outcomes.
The aged care population is at risk of malnutrition, due to several physiological changes that coincide with aging and environmental factors.
Clinical dietary supplements (CDS) are a nutrition intervention frequently used in RACHs to address malnutrition with the aim of increasing dietary intake of energy and protein. CDS are administered in the form of a liquid supplement and routinely prescribed by a dietitian to supplement oral intake. If administered according to the regime, CDS can have positive outcomes for individuals with malnutrition, particularly in clinical settings.
Aged care food service staff require time-saving interventions to improve the nutritional status of malnourished residents. It is common for aged care homes to manually fortify food items, such as soups and custards, increasing the workload and training requirements of staff. Interventions need to be feasible and should consider the perspectives of aged care food service staff.
Studies have demonstrated that enriched food products and menu items can be effective in increasing energy and protein intake. Food-first interventions are well-received by individuals due to their improved taste, familiarity, and palatability. Fortification of a familiar dessert product, such as ice cream, can be used to replace standard ice cream, and increase energy and protein intake for malnourished individuals.
Food Imperative Frozen Dessert is an ice cream product that has been developed in collaboration with nutrition professionals to specifically address the nutritional needs of aged care residents with malnutrition, inclusive of residents with dysphagia.
The aims of this study were:
- To determine the acceptability and tolerability of Food Imperative Frozen Dessert product compared to CDS currently used at ACH.
- To compare the intake of Imperative frozen dessert compared to CDS within residents of ACH.
- To explore the impact of using the frozen dessert product on resident body weight compared to standard/usual CDS.
- To determine the feasibility of providing a high protein and energy frozen dessert in place of CDS within the food service.
What We Did
The study was conducted in November 2024 and January 2025 involving aged care residents across ACH Site 1 (November) and ACH Site 2 (January). All residents provided informed written consent prior to participating and were able to withdraw at any time. Only residents who were in receipt of CDS were eligible to participate. Residents unable to provide informed consent and/or unable to fulfil the study requirements were excluded.
Participants were involved in the project for 4 weeks in total. During weeks 1 and 2 (Days 1-14), residents received their usual CDS prescription. CDS were administered in the usual format, by nursing staff during the medication rounds. Provisions and wastage/left over CDS were recorded by the nursing staff on the project data forms.
During weeks 3 and 4 (Day 15-28), participants had their CDS prescription replaced (with an equivalent energy / protein with up to 2 serves of the Food Imperative Frozen Dessert, delivered at morning and afternoon tea by ACH staff. To ensure that participants continued to receive adequate nutrition support, a modified CDS prescription was provided to residents who had a shortfall in energy and protein despite the prescription of the full 2 serves of the dessert. The ice cream provision was recorded, and the leftovers were collected and weighed by research staff to determine resident intake of the dessert.
The Food Imperative Frozen Dessert has been formulated with a unique blend of whey, caseinate and soy protein to facilitate increase in lean muscle mass, compared to individual proteins or other protein combinations. Additionally, the Food Imperative Frozen dessert is suitable for all levels of the International Dysphagia Diet Standardisation Initiative 2019 (IDSSI) 1,2 and 3 whereas standard ice cream and CDS are not suitable for IDSSI levels 1,2,3 and 4 (fluids).
To address aims 1 and 2, daily intake of both the CDS and Frozen dessert were measured each day. Participants also completed a resident food service satisfaction survey (FSS) at the end of each 2-week period and daily symptom charts were completed for tolerability. The FSS was an 11-item questionnaire with 5-levels of response, ‘none of the time’, ‘some of the time’, ‘most of the time’, ‘all of the time’ and ‘unsure’. Questions relate to the resident choice, taste/appeal, timing, appearance of staff knowledge and understanding and resident perception of health benefits. The questionnaire was administered by research staff.
To address aim 3, resident body weight was collected by ACH staff at baseline, day 15 and day 28 to determine any changes in body weight and to compare changes between the two time periods.
To address aim 4, aged care staff involved in the project were asked to complete an aged care staff food service satisfaction survey at the end of each two-week period (day 15 and day 28). The aged care worker survey was a 23-item questionnaire with the same 5-level response as the resident questionnaire. The questions relate to the workers satisfaction with the provision of CDS (day 15) or the Imperative Frozen Dessert (day 28).
Outcomes
At the time of recruitment at each site, there were a total of 123 and 137 residents at ACH Site 1 and ACH Site 2 respectively. Thirty-nine residents across the two sites met eligibility and inclusion criteria and 31 residents consented to take part. Four residents withdrew from the study leaving a total of 27 participants (4 at ACH Site 1, 23 at ACH Site 2) who completed the 4-week study. Reasons for withdrawing from the study included: concerns about impact of frozen dessert on lactose intolerance, dislike of ice cream and no longer wishing to participate.
Daily intake of CDS and the frozen dessert was recorded as a percentage of prescribed amount consumed due to the differing prescriptions across residents. There were significant differences between the % intake of CDS and the dessert, with intake of CDS being higher. This amounted to 995kJ additional energy and 8g additional protein consumption on average from the CDS compared with the dessert. However, the mean total satisfaction scores were significantly higher for the frozen dessert compared with the CDS. When patterns of intake of CDS and Frozen Imperative Dessert were explored, there were no clear patterns within the time periods or between the two time periods.
A statistically significant negative correlation was observed between % CDS intake and % satisfaction (r – 0.470, p=0.04), whereas no significant correlation was observed between frozen dessert intake and % satisfaction scores (r 0.291, p=0.385).
Aim 3 of the study was to examine the impact of using the frozen dessert instead of CDS on resident body weight. Table 3 shows the body weight data for residents at the 3 timepoints. Overall, there was no significant difference in mean body weight across the 4 weeks of the study. Comparing the use of frozen dessert with CDS, there was no significant difference in the mean weight change between baseline and day 15 vs between day 15 and day 28.
The final aim of the study was to determine the feasibility of providing a high protein and energy frozen dessert in place of CDS within the food service. Four responses were received from staff however three of these were from members of the research team who were involved in delivery of the intervention hence not valid. With only one response we are unable to address aim 4 with any clarity or certainty.
Impact on Aged Care and Workforce
Traditionally, clinical staff have been serving and managing supplements. However, switching from CDS to the food first approach should not be difficult to implement, as this aligns with the Strengthened Quality Standards.
Workforce planning and staff training will be necessary to implement a food-first approach rather than CDS on a larger scale. Workforce planning will require more food services staff on the floor and a reduction in clinical staff. The current practice for the CDS approach is that CDS are delivered by clinical staff whereas with the food-first approach, these tasks will be undertaken by food services staff.
Workforce, workload and time management
- Workforce availability during the post-intervention period. There were many overlaps between the residents' activities and the distribution of the fortified dessert, which sometimes made the logistics of delivering the fortified dessert to the residents challenging.
- Staff had to focus on providing normal care to residents, and additionally, they had to assist residents who required assistance with their meals. In some areas, 4 participants required assistance with their meals.
- Sometimes, care staff were busy in the morning during ADLS, which made the post-intervention phase harder. For example, there were many occasions when the participants were still having breakfast at 9.30 am, and serving the Food Imperative Dessert at 10 am resulted in many participants not feeling like having any morning tea, as there were only 30 minutes between the two meal services.
Logistic issues
- The challenge was the lack of freezer capacity at ACH Site 2 to keep the Food Imperative Frozen Dessert stock; therefore, additional freezer had to be purchased to allow for additional storage capacity.
Facility layout and landscape
- ACH Site 2 is spread out into 8 different areas/units, and residents from 7 areas participated in the study. It was very challenging to deliver the food imperative fortified dessert during morning and afternoon tea, and ensure that participants who required assistance with their meal received the required assistance in a timely manner. There was a need for constant communication between the data collection staff and the staff working on the floor.
- There was a challenge where participants had to go to church, visit their families, or attend social engagements. As the post-intervention was only at morning and afternoon tea time, this restricted/limited the flexibility of the participant to have the dessert at a different time in comparison with the pre-intervention, the participant could have the CDS at a later time or keep the CDS for a more extended period of time in their rooms.
The project has highlighted the need for additional training of the aged care workforce at ACH Group, as well as additional capacity and equipment in order to implement a food-first approach. ACH have started working on an alternate delivery method of ice cream – aimed at promoting social engagement by making the delivery eventful, including use of a purpose-built ice cream trolley (with freezer) / Greensleeves music, etc. The Fortified ice cream will be utilised as a Food First Approach.
The following could be key areas of focus when implementing a food first approach:
- Increasing food service staff may not be feasible, however, there may be an opportunity to reduce RN clinical workload through reduced supplement delivery requirements.
- Food first approach requires collaboration between clinical, food service staff and workforce (carers). Often it is the care staff fortifying food at point of service i.e. cream on cake from tea trolley. This relies upon effective communication from RNs regarding who needs it and what they like.
- The challenges highlight a need for ‘Person directed’ nutritional support - allowing flexibility in what residents like to eat, when, where and with whom. This aligns with strengthened standard 6 - dining experience guidelines.
- Staff training for all staff involved with food production / delivery and social engagement is required. The change in ‘mindset’ is a move from a task orientated workforce towards a shared goal of prioritising residents’ meal time enjoyment.
Next Steps
MG Food aims to conduct further experimental studies to further validate the outcome that a food first approach is a better approach than CDS to tackle malnutrition in aged care, as it would provide a better quality of life. MG Food is also planning to measure the wastage between CDS and the Food First approach and perform a cost comparison.