Menu planning guidelines for Aged Care Homes - Missing in action

Aged Care Accreditation Standards are demanding increasing levels of excellence and facilities are coming under ever increasing scrutiny around the provision of nutrition and hydration. Food Service Managers are struggling with tighter budgets and needing to do more with less. Anne Schneyder asks where are the Nutrition and Menu Planning Standards for aged care facilities?
Many older people have multiple medical problems, poor appetites, increased nutrient requirements and special dietary needs, meaning that it can be difficult to achieve an adequate nutritional intake. Studies have reported the rate of malnutrition among residents in residential care homes can be as high as 70%^1,2,3,4,5. ‘Malnutrition is both a cause and a consequence of ill-health. It interferes with an individual’s ability to benefit from health treatments and affects every domain of their well-being’¹, it impacts on quality of life and increases the cost of care⁷. Weight loss in the elderly population generally results in loss of skeletal muscle mass and strength (sarcopenia)⁶. Sarcopenia has huge personal and financial costs and remains largely unrecognised.
There are multiple factors that may contribute to weight loss and malnutrition. These may include:

• financial problems


• social difficulties


• multiple medical problems


• respiratory difficulties (for example dyspnoea)


• dysphagia


• poor dentition


• adverse effects of drugs


• polypharmacy


• depression, bereavement


• dementia


• reduced taste and smell


• poor appetite.

The above factors are ‘individual specific’, but there are numerous ‘system specific’ causes of malnutrition:

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“Access to adequate food and nutrition in a form that is enjoyable and without imposition of unnecessary or arbitrary restrictions is a fundamental right for all residents in our aged care homes.”
ANNE SCHNEYDER

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The food supply

• Does the menu provide adequate nutrients even if the resident’s appetite is good? How do we know?


• Do the serves sizes meet guidelines? What guidelines are used?


• Are there enough opportunities to eat during the day? How many hours are there between breakfast and the evening meal?


• Are residents placed on unnecessary special diet restrictions?  e.g. low cholesterol, low salt, weight reduction, low fat diets)


• How is the food cooked?


• Is the food cooked fresh or are there a large number of commercial processed options?


• Are the textures correct? Are there lumps or skins in the puree foods leading to fear of eating?


• Are necessary special diets adhered to correctly? (e.g. allergies, gluten free diets)


• Are staff available to feed the residents? Do they have sufficient time?


• Where and with whom do they share a meal?

Communication issues

• Do the residents always receive the correct meal?


• Where are the details documented?


• Is documentation referred to when plating the meals?


• Do the residents enjoy their meals? How do we know?


• Do they have a real choice?


• What is provided when an item is disliked?

We must identify and treat malnutrition on an individual basis1, but a ‘food first’ approach to adequate nutrition and nutrition support plays an integral role in ensuring residents have sufficient nutrition and energy to meet their needs without the need for expensive supplements or interventions. Good menu planning is an essential component of good nutrition care⁹.
So, where are the food service and menu planning guidelines we can turn to that are specific to aged care?
The newly revised Australian Dietary Guidelines9 include guidelines regarding the dietary needs of individuals over 70 years of age but specifically exclude the frail elderly and are not intended to be a guide for food service.
Aged Care Accreditation Standards include nutrition and hydration standards¹¹, however these are very general and outcome based; standards addressing actual menu planning are limited or non-existent.
The Best Practice Food and Nutrition Manual for Aged Care Facilities by Bartl and Bunney¹⁰ is an excellent Australian manual describing the various nutrition issues in aged care homes. It provides practical advice and examples for care facilities. It is now ten years old, with a new version having been developed in early 2012 but not yet released by the Department of Health. It addresses a variety of nutrition, hydration and catering issues but is not intended to be a catering guide and does not address menu planning in depth.
Most Australian states have developed a set of Nutrition Standards for food service in hospitals^12,13,14,15. Some were designed as specifications for recipes for catering organisations to ensure that dishes have a minimum nutrient profile. The Queensland and Victorian documents discuss aged care facilities and catering but are not specifically focussed on the needs of the frail aged population. In practice the frail elderly often do not eat the quantity of foods recommended (personal observation).
In October 2011, Dr Peter Williams was contracted by the Dietitians Association of Australia to conduct a scoping project to review literature and documentation relevant to nutrition and menu planning standards in Australia and New Zealand²⁰. Dr Williams reviewed all known Australian and New Zealand nutrition or menu standards, guidelines or checklists for their applicability for use in the aged care sector. He also compared key standards from the USA and UK.
Key recommendations from Dr Williams’ report included:

• there is strong support for the development of aged care specific menu planning guidelines


• guidelines should not be mandatory but should provide a ‘best practice’ approach


• guidelines should be simply and clearly written, practical and understandable by non-dietitians


• development of guidelines should involve not only dietitians in Australia and New Zealand, but also representatives of the Institute of Hospitality in Health Care, major companies providing food services to RACFs, the Aged Care Standards and Accreditation Agency, and peak bodies such as the Aged Care Associations of Australia and New Zealand.

To date there has been no action or follow-up from this report. There are excellent documents from the US, UK and Europe^8,17,18,19 that can be referred to but there are no up-to-date Australian standards.
The Accreditation Agency calls for menus to be reviewed on a regular basis. Aged care homes may contract a dietitian to review their menu.
But what standards should be used to audit against?
Dietitians will most commonly refer to The Best Practice Food and Nutrition Manual for Aged Care Facilities¹⁰ despite the fact that it is now ten years old and out of date, and the New Zealand Menu Audit Tool for Aged Care Facilities developed by Dietitians New Zealand¹⁶. In practice dietitians, food service managers, and care staff use a combination of the available guidelines and their own experience, together with input from a variety of sources (including the resident and their families) to plan and assess menus for aged care homes.
The quality of a menu review can vary greatly, from a review of food groups in the written menu only, to a comprehensive assessment of nutrition care within a facility. It is not sufficient to fax the menu off for a quick tick. An assessment needs to be made on how the menu integrates into care. Audits of serve sizes, documentation, malnutrition assessments and pathways of care should be assessed. The food should be viewed and tasted: without a site visit the menu review does not provide a complete picture of what really happens in a facility! A comprehensive assessment is far more than a review of paperwork.
Access to adequate food and nutrition in a form that is enjoyable and without imposition of unnecessary or arbitrary restrictions is a fundamental right for all residents in our aged care homes. Menu Planning Guidelines that are specific to aged care are required to ensure that all residents receive quality nutrition care. A minimum standard for menu reviews is needed so that the review has meaning and so that the advice is consistent.
“Organisations have to deal with so many competing priorities and may ask: ‘Why should we prioritise nutrition and hydration care?’ The answer is simple. Without food and water, people will die.”
Janine Roberts, Programme Director, Malnutrition Taskforce, UK
Anne Schneyder is a director of Nutrition Professionals Australia
Anne Schneyder is a director of Nutrition Professionals Australia. She has over 30 years experience in a variety of clinical settings. Anne has been involved in the private sector for most of her professional life, conducting a successful private practice and consultancy service. Anne, together with Julie Dundon established Nutrition Professionals Australia in 2001, and the business has now grown to be one of the largest providers of nutrition and dietetic services in Australia. Anne has been awarded Advanced Accredited Practising Dietitian status by the Dietitians Association of Australia.
References:
1. Dietitians Association of Australia. Evidence-based guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet 2009;66 Suppl 3:51.
2. Australian and New Zealand Society for Geriatric Medicine. Under-Nutrition and the Older Person. Position Statement No 6 2007 www.anzsgm.org/documents/PositionStatementNo6Under-NutritionintheElderly.pdf
3. Marilyn Banks et al. Prevalence of malnutrition in adults in Queensland public hospitals and resdential aged care facilities. Nutrition and Dietetics 2007.
4. Gaskill D, Black L, Isenring E, Hassall S, Sanders F, and Bauer J. Malnutrition prevalence and nutrition issues in residential aged care facilities. Austral J Ageing 2008; 127: 189-194.
5. Woods J, Walker K, S I-B, and Strauss B. Malnutrition on the menu: nutritional status of institutionalised elderly Australians in low-level care. J Nutr Health Aging 2009; 13: 693-698.
6. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis. European Working Group on Sarcopenia in Older People. Age Ageing 2010;39:412-23.
7. Karen Freijer et al. The economic costs of disease related malnutrition. Clinical Nutrition 32 (2013) 136-141
8. Pioneer Network Food and Dining Clinical Standards Task Force: New Dining Practice Standards 2011.  http://www.pioneernetwork.net/Data/Documents/NewDiningPracticeStandards.pdf
9. National Health and Medical Research Council. Australian Dietary Guidelines. 2013 www.eatforhealth.gov.au/
10. Bartl R and Bunney C. Best practice food and nutrition manual for aged care facilities: addressing nutrition, hydration and catering issues. Gosford: Central Coast Health, 2004.
11. Aged Care Accreditation and Standards Agency Accreditation Standards. http://www.accreditation.org.au/site/uploads/30985_AgedCare_ASENGLISHV1_3.pdf
12. Nutrition Standards for adult inpatients in NSW hospitals (NSW Agency for Clinical Nutrition) http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0004/160555/ACI_Adult_Nutrition_web.pdf
13. Nutrition Standards for Menu Items in Victorian Hospitals and Residential Aged Care Facilities (Department of Human Services (Victoria) http://www.health.vic.gov.au/ archive/archive2011/patientfood/nutrition_standards.pdf
14. Nutrition Standards for Meals and Menus (Queensland Health) http://www.health.qld.ov.au/nutrition/resources/hphe_nutritionstd.pdf
15. WA Health. Nutrition Standards for Adult Inpatients in WA Hospitals http://www.health.wa.gov.au/circularsnew/attachments/811.pdf
16. Dietitians New Zealand. Menu audit tool for aged care facilities. Wellington, 2010. http://bit.ly/1nn2IcS
17. National Association of Care Catering Malnutrition Taskforce. Malnutrition in Later Life: Prevention and Early Intervention- Best Practice Principles & Implementation Guide. 2013. http://www.malnutritiontaskforce.org.uk/downloads/other_resources/prevention_Early_Intervention_Of_Malnutrition_in_Later_Life_Hospital.pdf
18. Council of Europe Committee of Experts on Nutrition, Food and Consumer Health. Nutrition in care homes and home care Report and recommendations: from recommendations to action
19. The Caroline Walker Trust. Eating Well Resources http://www.cwt.org.uk/pdfs/EWOld-Dementia-Practical-Resource.pdf
20. Williams, P. Scoping Project: Development of Nutrition and Menu Planning Standards for Residential Aged Care Facilities in Australia and New Zealand- Literature Review and Final report. http://daa.asn.au/for-health-professionals/daa-projects/nutritionand- menu-planning-standards-in-residential-aged-care-facilities-in-australia-andnew- zealand/