Nutrition & Aging Think Tank - Research Institute for Aging

Nutrition & Aging Think Tank 2014 Summary Report

Table of Contents 03

Acknowledgements

05

Executive Summary

06

Background & Objectives

08

Invited Attendees

10

Key Determinants of Food Intake in Long-Term Care

12

Potential Interventions to Address Key Determinants

14

Key Considerations & Next Steps

15

References

Nutrition & Aging Think Tank Summary Report 2014 © Agri-food for Healthy Aging, Schlegel-University of Waterloo Research Institute for Aging, Kitchener, Ontario, Canada, 2014

Acknowledgements The Nutrition & Aging Think Tank (May 20-21, 2014) was hosted by the Schlegel-University of Waterloo Research Institute for Aging (RIA) and the Agri-food for Healthy Aging (A-HA) program. Additional support was provided from the International Research Partnerships Grant at the University of Waterloo and Agri-Food and Rural Link, the hub for knowledge translation and transfer for the OMAFRAUniversity of Guelph Partnership. On behalf of RIA and A-HA, sincere thanks to the participants who traveled from near and afar to participate in the Think Tank and share their invaluable expertise to advance research related to nutrition and health for older adults.

For More Information For more information regarding the Nutrition & Aging Think Tank and/or this summary report, please contact A-HA’s program manager, Hilary Dunn, at [email protected]. To learn more about RIA and A-HA, visit www.the-ria.ca and www.aha.the-ria.ca

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Executive Summary Worldwide, malnutrition affects 30-60% of older adults living in long-term care (LTC), and greatly impacts health, well-being and quality of life. Poor food intake is considered the primary cause of LTC malnutrition, yet it is preventable and treatable. The conceptual framework and program of research titled “Making the Most of Mealtimes (M3)”, developed by Heather Keller, PhD, RD, FDC (Schlegel Research Chair in Nutrition & Aging, University of Waterloo) in collaboration with a team of Canadian researchers, proposes that the key modifiable determinants of food intake fall into three categories: Meal Quality (nutrient density; variety, preference; sensory appeal); Mealtime Experience (social interactions; ambiance); and Meal Access (capacity/support to eat; chewing, swallowing). Research to date suggests that targeting a combination of factors across these domains is necessary to make any real change in food intake and nutritional status. Given the complexity of this issue, the Schlegel-University of Waterloo Research Institute for Aging (RIA) and the Agri-food for Healthy Aging (A-HA) program invited international experts and key stakeholders in LTC nutrition and intervention research to participate in the Nutrition & Aging Think Tank on May 20-21, 2014. The purpose of this meeting was to collaboratively identify the key determinates of food intake and suggest potential interventions to address these targets.

Participants engaged in a priority-setting process to identify the key determinants of food intake in LTC: 1. Social interactions 2. Self-feeding ability 3. 5 senses (noise, ambiance, light) 4. Assisting attitude (staff approach to care) 5. Time to eat/provide assistance 6. Sensory properties of food (taste, smell, texture) 7. Mealtime logistics (efficiency in service) 8. Choice 9. Nutrient Density Through round-table and group discussion a number of potential interventions were generated and categorized into 4 themes (Education/Training; Policy; Physical Design/Space; and Food/Mealtime). The proposed interventions have the potential to address multiple key determinants and cross the M3 domains. Despite differences in care practices between North American and European LTC homes, the determinants identified and the proposed interventions were deemed to be relevant across these settings. There is great potential to generalize findings from future research. It is also important to note that the nutritional needs of older adults, and particularly those of frail older adults, remains largely unknown. Research is needed to better understand the nutritional requirements of this population, and how food and nutrition can be better utilized to promote health. By partnering with international experts, research in this much-needed area will be accelerated and the results will have a significant impact on the health and quality of life of residents, and the quality of care in both Canadian and international LTC homes.


Background & Objectives Worldwide, malnutrition affects 30-60% of older adults living in long-term care (LTC), and greatly impacts health, well-being and quality of life1-8. Influencing every system of the body, malnutrition has serious consequences both for older adults residing in LTC (e.g., infections; falls; pressure ulcers; declines in function and cognition; hospital admissions; extended lengths of stay in hospital; and death1,8,11) and the health care system overall. While there are no estimates for Canada, malnutrition is associated with a 20-fold increase in medical complications in Europe12 and a cost of over $7 Billion Pounds per year in the United Kingdom (equivalent to roughly $11 Billion Canadian)13. Poor food intake is considered the primary cause of LTC malnutrition14, and it is preventable and treatable. Research suggests that poor food intake has determinants at multiple levels, including resident (e.g., eating ability), staff (e.g., training), unit (e.g., noise in the dining room), LTC home (e.g., size), and system (e.g., food budget allocation)15. However, there is limited understanding of which determinants have the strongest potential to improve food intake and which strategies are most effective, feasible, and transferable in targeting these factors. The conceptual framework “Making the Most of Mealtimes (M3)” was developed by Heather Keller, PhD, RD, FDC (Schlegel Research Chair in Nutrition & Aging, University of Waterloo) in collaboration with Canadian researchers from University of Guelph (Lisa Duizer, PhD), University of Toronto (Catriona Steele, PhD, SLP), University of Alberta (Susan Slaughter, RN, PhD, GNC(C)), University of Manitoba (Christina Lengyel, PhD, RD), and Université de Moncton (Natalie Carrier, PhD, RD). M3 builds on learnings from the restaurant industry16 and proposes that the key modifiable determinants of food intake in long-term care fall into three categories: 1. Meal Quality (nutrient density; variety, preference; sensory appeal; food safety) 2. Mealtime Experience (social interactions; ambiance; desire to eat; tablemate compatibility) 3. Meal Access (capacity/support to eat; chewing, swallowing; taste, smell) It is hypothesized that targeting a combination of factors across these domains is needed to make any real change in food intake and nutritional health17. Research efforts related to feasible and cost-effective solutions targeting key determinants of food intake are needed to improve nutrition in LTC, promote quality of life and minimize stress on the health care system. Given the complexity of the problem and breadth across disciplines, the Schlegel-University of Waterloo Research Institute for Aging (RIA), through its nutrition research program Agri-food for Healthy Aging (A-HA), invited international experts and key stakeholders in LTC nutrition and intervention research to participate in the Nutrition & Aging Think Tank on May 20-21, 2014.

The meeting had the following objectives: 1. To develop a priority list of determinants of food intake in LTC across the M3 domains (meal quality, meal access, and/or mealtime experience). 2. To propose interventions that address factors identified in Objective 1 and support a multimodal approach. 3. To discuss the challenges/learnings from research to date, including the implementation of complex, multi-factorial interventions in the LTC setting. Prior to the meeting, participants shared and reviewed key publications, creating a shared knowledge base. Day 1 included a site tour of a local long-term care home to provide an example from the Canadian LTC context, and a networking dinner where participants reviewed and discussed the agenda and guiding principles for the full day meeting on Day 2. Participants clarified that “increasing food intake” was not the primary objective, but that “improving food intake” was the ultimate goal (e.g., creating a better mealtime environment to improve quality of life). Day 2 engaged participants in a priority-setting process to identify the key determinants of food intake, followed by round-table and group discussion to generate potential interventions. 2014 Summary Report | Page 6


Invited Attendees Attendees were invited to ensure representation from multiple disciplines, and are leaders in their respective fields. The collective group holds expertise in LTC malnutrition, nutrition screening and assessment, multidisciplinary teams and care practices, multifaceted interventions, implementation science and knowledge translation. Key stakeholders and knowledge users who work in various aspects of the longterm care sector (e.g., clinical, corporate, advocacy, government) were also invited to provide a necessary practice-relevant lens to the discussion. Attendees are listed below in alphabetical order: Elaine Amella, PhD, RN, FGSA, FAAN Professor, Medical University of South Carolina, College of Nursing, Charleston, South Carolina, United States Anne Marie Beck, Dietician, PhD, MSc Gerontology Senior Researcher, Research Unit for Nutrition (EFFECT), Herlev University Hospital, Herlev, Denmark Anne-Marie Boström, RN, PhD Senior Lecturer, Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden Natalie Carrier, PhD, RD Associate Professor, École des sciences des aliments, de nutrition et d’études familiales, Université de Moncton, Moncton, New Brunswick, Canada Josie d’Avernas, MSc Vice President, Schlegel-UW Research Institute for Aging (RIA), Kitchener, Ontario, Canada Carol Donovan, RD Chair, Gerontology Network, Dietitians of Canada, Bellwood, Ontario, Canada Kate Ducak, PhD(c) Aging Health and Well-Being, University of Waterloo, Waterloo, Ontario, Canada Lisa Duizer, PhD Associate Professor, Food Science, University of Guelph; Research Scientist, Agri-food for Healthy Aging, Schlegel-UW RIA, Guelph, Ontario, Canada


Alison Duncan, PhD, RD Professor, Associate Director of Research, Human Nutraceutical Research Unit, Department of Human Health and Nutritional Sciences, University of Guelph; Research Scientist, Agri-food for Healthy Aging, Schlegel-UW RIA, Guelph, Ontario, Canada Hilary Dunn, MSc Program Manager, Agri-food for Healthy Aging (A-HA), Schlegel-UW Research Institute for Aging (RIA), Kitchener, Ontario, Canada Jill Estioko, RD Director of Food & Hospitality, Schlegel Villages Inc, Kitchener, Ontario, Canada Heather Keller, PhD, RD, FDC Schlegel Research Chair in Nutrition & Aging; Professor, Kinesiology, University of Waterloo; Research Scientist, Agri-food for Healthy Aging, Schlegel-UW RIA, Waterloo, Ontario, Canada Ivy Lam, RD, MSc(c) Kinesiology, University of Waterloo, Waterloo, Ontario, Canada Christina Lengyel, PhD, RD Assistant Professor, Human Nutritional Sciences, University of Manitoba, Winnipeg, Manitoba, Canada Ashwini Namasivayam, MHSc, S-LP(C), Reg. CASLPO Speech-Language Pathologist, Research Associate II, Swallowing Rehabilitation Research Laboratory, Toronto Rehabilitation Institute, University Health Network; PhD Student, Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada Anja Saletti, RD, PhD Senior Lecturer, Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden Mike Sharratt, PhD President, Schlegel-UW Research Institute for Aging (RIA), Kitchener, Ontario, Canada Jennifer Sherwood, RD Registered Dietitian, Schlegel Villages, Kitchener, Ontario, Canada Sandra Simmons, PhD Associate Professor, Vanderbilt University, School of Medicine, Center for Quality Aging, VA Medical Center, Geriatric Research Education & Clinical Center (GRECC), Nashville, Tennessee, United States Susan Slaughter, RN, PhD, GNC(c) Associate Professor, Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada Ken Stark, PhD Associate Professor; Canadian Research Chair Nutritional Lipidomics, Kinesiology, University of Waterloo; Research Scientist, Agri-food for Healthy Aging, Schlegel-UW RIA, Waterloo, Ontario, Canada Catriona Steele, PhD, SLP Senior Scientist, Swallowing Rehabilitation Research Laboratory, Toronto Rehabilitation Institute; Professor, Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada Vanessa Vucea, MSc(c) Kinesiology, University of Waterloo, Waterloo, Ontario, Canada


Key Determinants of Food Intake in Long-Term Care The morning sessions of Day 2 engaged participants in a priority-setting process using the Nominal Group Technique, which engages all participants in generating ideas, clarifying and creating rank items, and facilitating anonymous prioritization18. This technique is particularly effective when consensus is needed around a complex issue18. To begin, participants individually completed a fish bone diagram recording all determinants that influence food intake in LTC, grouped under the M3 domains. Participants were asked to use neutral terminology (e.g., lack of smell = smell). Using a round-robin approach, a group fish bone diagram was populated with all possible determinants generated by participants. Through group discussion, the root cause of the concern was teased out (e.g., large portions that result in waste can be drilled down to issues with nutrient density), and similar or duplicate ideas were grouped into one over-arching category where warranted.

List of determinants used for prioritization, in alphabetical order: 1. 5 senses (e.g., noise, light, temperature of room, ambiance) 2. Appetite 3. Assisting attitude (e.g., values that are brought into the workplace; demeanor when interacting with residents/team) 4. Bioavailability of nutrients 5. Choice 6. Dignity (e.g., avoiding use of bibs or trays, medication delivery in the dining room) 7. Dining room arrangement (e.g., small group dining, taking meals in bedroom) 8. Distribution of nutrients (e.g., 3 meals with snacks compared to 6 smaller meals) 9 Dysphagia (e.g., tailoring textures to individual needs) 10. Expectation of food & health (e.g., family expectations re. blood sugar control, diet liberalization vs. diet restriction) 11. Familiarity (e.g., homelike, personalized, familiar traditions) 12. Inclusion (e.g., open dining, family is welcomed and integrated) 13. Mealtime logistics (e.g., efficiency in service) 14. Nutrient density 15. Oral health 16. Preferences (e.g., cultural) 17. Readiness for the meal (e.g., dressed for the meal, opportunity to go to the bathroom prior to meal, proper/safe physical positioning) 18. Recognizing food 19. Resident/Family participation 20. Self-feeding ability (e.g., portions, mobility, memory, matching assistance to capacity, awareness of mealtime) 21. Sensory properties of food (e.g., taste, smell, texture) 22. Social interactions (e.g., with staff, tablemates, family) 23. Staff-resident communication 24. Temperature (of food) 25. Time to eat/provide assistance 26. Timing of meals/snacks 27. Tolerance for diversity (e.g., resident-resident, staff-resident interactions) 28. Underlying conditions (e.g., optimal management of depression, apathy, dementia) 29. Variety (e.g., in food choices, experience) 30. Visual appeal 2014 Summary Report | Page 10

At the outset of the meeting, participants discussed and agreed upon criteria that would guide the prioritization process: Amenable to change: Can be altered using an intervention, for example, eating assistance could be changed by providing staff training, whereas dementia diagnosis is unalterable. Potential: Strong opportunity to directly improve food intake. Magnitude: Opportunity to affect the lives of many residents or the impact will be great, even if only a small number of residents are affected. Originality: Unresearched or novel; Prioritized determinants cross levels of influence on food intake i.e., resident, staff, home, government. Relevance: Aligns with policy priorities, funding opportunities, and applicable across settings. Acceptable: Residents and staff/team members would be open/responsive to change. Measurable: Potential to assess determinant, intermediate and ultimate outcomes. With these points in mind, participants ranked their top 9 selections. Previous work has shown that 9 is the optimal number when prioritizing more than 22 factors19. The following determinants were deemed top priorities and key factors to target with future intervention research:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Social interactions Self-feeding ability 5 senses (e.g., noise, light, temperature of room, ambiance) Assisting attitude (values brought into workplace) Time to eat/provide assistance Sensory properties of food (taste, smell, texture) Mealtime logistics Choice Nutrient Density


Potential Interventions to Address Key Determinants In the afternoon of Day 2, round-table discussions were focused on brainstorming interventions that would target the top determinants. At the outset of the meeting, participants discussed and agreed upon principles that would guide the process of generating intervention ideas: Feasible: Potential to implement in the current LTC context; Compatible with other potential components. Transferable: Readily transferable across nations, settings. Diffusion of Innovation: Relative advantage; Compatibility; Simplicity/Complexity; Trialability; Observability20. Sustainable: Will not overwhelm capacity for change. Acceptable: Residents and staff/team members would be open/responsive to change. Measurable: Potential to assess determinant, intermediate and ultimate outcomes. Evidence-based: Research based or preliminary success in practice. Transformative: Original/novel but opportunity to transform care; Multi-component approach. Collaborative: Supports an interdisciplinary approach to care. The interventions discussed can be grouped into 4 themes: Education/Training; Policy; Physical Design/ Space; and Food/Mealtime. The chart below provides examples of potential interventions identified. In many cases these approaches can influence multiple determinants, and as such, diverse outcomes will need to be assessed. The multi-component nature of these approaches can make it challenging to determine which aspect (or which combination) is driving change, therefore inclusion of multiple outcomes helps to capture these nuances. For example, in addition to assessing routine health outcomes, changes in staff/ team member knowledge, attitudes, retention and/or engagement may provide valuable insight.

Education/Training

Examples of potential interventions to address key determinants of food intake in long-term care: Determinants M3 Domains Interventions Targeted Addressed Training for staff and families about “dignified strategies” to assist with feeding (e.g., letting a resident cut their own food even if it takes more time); train staff about choice and respecting choices; utilize empathy training, have staff feed each other; use resident examples/stories, videos

Assisting Attitude Choice Self-feeding Time to Eat/Provide Assistance

Meal Quality Mealtime Experience Meal Access

Utilize customer service training programs from the restaurant/hospitality industry; Consult with industry about best practices

Assisting Attitude Mealtime Logistics

Mealtime Experience


Determinants Targeted

M3 Domains Addressed

Standardized audits of mealtimes, dining room practices; incorporate feedback cycles and training for improvement

Assisting Attitude Self-feeding Social Interactions Time to Eat/Provide Assistance

Meal Quality Mealtime Experience Meal Access

Allow adequate time for meals; this will vary depending on resident needs

Self-feeding Mealtime Logistics Time to Eat/Provide Assistance

Mealtime Experience Meal Access

Implement family style dining where team members/staff are present at the table and share meals with residents

Social Interactions Time to Eat/Provide Assistance

Mealtime Experience Meal Access

Create ambiance; Provide adequate lighting; Play music (talk to residents and families about preferences); Hang up art/pictures in the dining room

5 Senses Self-feeding Social Interactions

Mealtime Experience

Provide a variety of seating arrangements (e.g., group, couple, and single seatings; quiet/private and more social areas)

Self-feeding Social Interactions

Mealtime Experience

Pay attention to presentation (e.g., not mixing purees together, utilizing food molds for better identification)

Assisting Attitude Sensory Properties

Mealtime Experience

Feature a “Resident Dish of the Day” where residents provide recipes for their favourite meals

Sensory Properties Social Interactions

Meal Quality Mealtime Experience

Set up a Chef station with a variety of options/ condiments so residents can build their own meal

Sensory Properties Social Interactions Nutrient Density

Meal Quality Mealtime Experience

Food/Mealtime

Physical Design/Space

Policy

Interventions


Key Considerations There are many challenges in advancing research related to nutrition and nutritional care practices in LTC, and also in implementing interventions within this environment. Key considerations identified during the meeting are discussed below: Nutritional Requirements: Very little is known about the nutritional needs of older adults, and particularly those of frail older adults. Research is needed to better understand the nutritional requirements of this population, and how food and nutrition can be better utilized to promote health and quality of life. Food waste was identified as a significant issue; providing smaller portions with improved nutrient density and options that are better tailored to resident needs should be explored. There is also a lack of standardization regarding outcome measures to assess older adults’ nutritional health. Future research establishing best practices and/or benchmarks is warranted. Regulations and Policies: Regulations and policies at the federal, provincial/regional, and/or organizational level can often impact nutritional practices in long-term care (e.g., budgetary constraints can affect the ability to provide high quality food and adequate staffing for feeding assistance). There is often a mismatch between regulations and the needs of residents and their families, however in some cases this mismatch is only perceived and is the result of a misinterpretation of the regulation. In conducting future research, it will be important to consider the policies governing LTC nutritional practices and how they might be affecting food intake. Home Culture: The home culture is another key point to consider; this can greatly influence research outcomes. For example, many European LTC homes are already embracing more social models of living, whereas North America still widely experiences the institutional or medical model of care. While the determinants of food intake appear to be consistent regardless of geography, the culture of the LTC home may affect the success of the intervention, and how interventions are implemented. Collaboration: Collaboration in both research and practice is needed to improve food intake in long-term care. Future research should involve a multidisciplinary team, capable of employing a multimodal approach. Stakeholders from the LTC sector should be included in research efforts; their insight will be invaluable in designing research questions and protocols to ensure feasibility, transferability and sustainability. Involvement of staff across departments and/or disciplines in LTC nutritional care practices will support better intake and enhanced mealtime environments. Importance of Food and Nutrition: The importance of food and nutrition in supporting healthy aging needs to be recognized. Improving food intake and the mealtime experience in LTC will translate to better health outcomes and increased quality of life for residents and families.

Next Steps In addition to this publicly available Summary Report, publication in an academic journal is being pursued and the collective group will explore international funding opportunities to advance this research agenda. By partnering with international experts, research in this much-needed area will be accelerated and the results will have a significant impact on the health and quality of life of residents, and the quality of care in both Canadian and international LTC homes.


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