BMJ  2006;332:1165-1166 (20 May), doi:10.1136/bmj.332.7551.1165

Editorial

Improved food intake in frail older people

Sociable meal times may combat malnutrition in long term care

Concerns about obesity underlie much of the current emphasis on the importance of good diet. For older people, however, insufficient protein and energy intake is the main concern. Recent guidelines and policy initiatives on treating and preventing malnutrition have been developed in Europe and the United Kingdom for older people in hospitals and institutions for long term care and in the community.^1-3

On p 1180 Nijs and colleagues report a trial of family-style meals in Dutch nursing homes, an encouraging study for all those interested in the wellbeing of our increasing population of frail older people. ⁴ In our recent systematic review of 55 trials evaluating protein and energy supplementation in older people at risk of malnutrition in different settings, we found modest reductions in mortality and morbidity, but only in the undernourished groups in hospital.⁵ The evidence did not support routine dietary supplementation for all older patients in long term care or in community settings.

Poor long term compliance with nutritional supplements in older people living in the community is common. The "anorexia of ageing" associated with gradual weight loss in older people is partly due to social factors, especially isolation.⁶ Organizations providing round the clock care determine the food provided and the social context of meal times, and residents and patients are given limited choice and even limited time to eat each meal.⁷

The eating environment and fellowship at meal times are important factors affecting appetite in retirement home residents.⁸ Older acute care patients in hospital who ate in a supervised dining room improved their food intake but not their weight in comparison to those eating from a tray at the bedside.⁹ Remsburg and colleagues found in the US that buffet-style dining in long term care improved older residents' satisfaction with meals but yielded no significant difference in weight or biochemical markers of nutritional status.¹⁰

The cluster quasi-randomised trial by Nijs and colleagues examined the impact of family-style dinners instead of tray service on quality of life, physical performance, body weight, and energy intake in nursing home residents without dementia in five Dutch nursing homes.⁴ For six months the intervention group had meals that included table dressing to improve ambience, choice of food at the table, and a minimum of one member of staff sitting at each table of typically six residents. All ate together with no outside interruptions during meals.

The control group received individual pre-plated food chosen up to two weeks before (including sandwiches). They were assigned seats at the table on the basis of availability but could choose to stay in their rooms, and they routinely received medication during the meal. When staff thought no one needed help, they left to eat their own meals elsewhere.

Nijs and colleagues report statistically significant improvements in quality of life, physical functioning, energy intake, and body weight in the intervention group compared with the control group.⁴ Potential sources of bias in the study design may have influenced the results, however. These include problems with the method of randomisation and allocation concealment and lack of blinding of the care providers and outcome assessors. Intention to treat analysis was not carried out for all patients recruited to the trial: patients who were discharged home were excluded (and more were discharged home in the intervention group). The average age of 77 and the discharge of patients to their homes indicate that this population may be less frail and more mobile than some nursing home populations.

It is not possible to say which aspects of the intervention probably had the most impact on appetite and wellbeing. Perhaps an assistant, nurse, or volunteer at the table to provide help and encouragement was particularly important, although the evidence for this from hospital based studies is equivocal.^{11 12} It seems natural that a family-style eating environment would enhance the general ambience of the care environment and improve mood and social interaction.

The trial was not accompanied by an economic analysis, an important omission which limits the ability of this study's results to influence routine care in nursing homes. Such a homely environment may not be practical for the sick patient in hospital, where sip feeds may be a simple if less sociable solution. None the less, the important message is that increasing energy intake in older patients who are likely to be undernourished may yield many benefits. The way to achieve this will vary depending on the environment.

Health Services Research Unit, University of Aberdeen, Aberdeen AB25 2ZD
(a.c.milne{at}abdn.ac.uk)

Health Services Research Unit, University of Aberdeen, Aberdeen AB25 2ZD

University of Wollongong, Sydney, NSW 2521, Australia

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Research p 1180

Competing interests: None declared

References

1. National Institute of Clinical Excellence. Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. 2006. www.nice.org.uk/pdf/CG032NICEguideline.pdf (accessed 1 May 2006).
2. NHS Quality Improvement Scotland. Food, fluid and nutritional care. Clinical Standards. Glasgow: NHS Quality Improvement Scotland. 2003. http://www.nhshealthquality.org/(accessed 1 May 2006).
3. Council of Europe. Food and nutritional care in hospitals: how to prevent under-nutrition. Report and recommendations of the Committee of Experts on Nutrition, Food Safety and Consumer Protection. Strasbourg: Council of Europe Publishing; 2002.
4. Nijs KAND, de Graaf C, Kok FJ, van Staveren WA. Effect of family-style mealtimes on quality of life, physical performance, and body weight of nursing home residents: cluster randomised controlled trial. BMJ 2006:332: 1180-3.[Abstract/Free Full Text]
5. Milne AC, Avenell A, Potter J. Meta-analysis: protein and energy supplementation in older people. Ann Intern Med 2006;144: 37-48.[Abstract/Free Full Text]
6. Morley JE. Pathophysiology of weight loss in older persons. In: Lochs H, Thomas DR, eds. Home care enteral feeding. Basel: Karger, 2005: 103-25. (Nestlé nutrition workshop series clinical and performance program, vol 10.)
7. Sydner YM, Fjellström C. Food provision and the meal situation in elderly care—outcomes in different social contexts. J Hum Nutr Dietet 2005;18: 45-52.[Medline]
8. Wikby K, Fägerskiöld, A. The willingness to eat. Scand J Caring Sci 2004;(18): 120-7.
9. Wright L, Hickson M, Frost G. Eating together is important: using a dining room in an acute elderly medical ward increases energy intake. J Hum Nutr Dietet 2006;19: 23-6.[Medline]
10. Remsburg RE, Lukin A, Baran P, Radu C, Pineda D, Bennett RG, et al. Impact of a buffet-style dining program on weight and biochemical indicators of nutritional status in nursing home residents. J Am Dietet Assoc 2001;101: 1460-3.[Medline]
11. Duncan DG, Beck SJ, Hood K, Johansen A. Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward. Age Ageing 2006;35: 148-53.[Abstract/Free Full Text]
12. Hickson M, Bulpitt C, Nunes M, Peters R, Cooke J, Nicholl C, et al. Does additional feeding support provided by health care assistants improve nutritional status and outcome in acutely ill older in-patients? A randomised control trial. Clin Nutr 2004;23: 67-9.

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