Exploring the mealtime experience in residential care settings for older people: an observational study

Improving the mealtime experience in residential care can be a major facilitator in improving care, well‐being and QoL. Evidence suggests that, despite guidance on the subject of food, nutrition and hydration, there are still concerns. Although there is a range of methods to research and assess the quality of food provision, there is a challenge in capturing the experiences of those residents who are unable or unwilling to describe their feelings and experiences because of frailty, impaired communication or other vulnerability. The aim of this exploratory study was to capture and describe individual residents’ mealtime experience. In spring 2011, a small‐scale, observational study was carried out in seven dining settings in four residential care homes in Manchester. An adapted dementia care mapping tool was used alongside field notes. Observations showed two major differences in the way the mealtimes were organised: ‘pre‐plated’ and ‘family‐style’ (where either bowls of food are placed in the centre of the table or food is served directly from a hotplate by a chef). These two styles of service are discussed in relation to the emerging themes of ‘task versus resident‐centred mealtimes’, ‘fostering resident independence’ and ‘levels of interaction’. Although improving mealtimes alone is not enough to improve quality of life in care homes, findings showed that relatively small changes to mealtime delivery can potentially have an impact on resident well‐being in these homes. Observation is a useful method of engaging residents in care settings for older people who may not otherwise be able to take part in research.     

Food provision for older people receiving home care from the perspectives of home‐care workers

Malnutrition is a significant cause of morbidity and mortality, particularly among older people. Attention has focused on the inadequacies of food provision in institutions, yet the majority suffering from malnutrition live in the community. The aim of this study was to explore barriers and facilitators to food provision for older people receiving home care. It was a qualitative exploratory study using semi‐structured interviews with nine home‐care workers in June 2013 employed by independent agencies in a large city in northern England. Data were analysed thematically, based on the principles of grounded theory. Findings showed that significant time pressures limited home‐care workers in their ability to socially engage with service users at mealtimes, or provide them with anything other than ready meals. Enabling choice was considered more important than providing a healthy diet, but choice was limited by food availability and reliance on families for shopping. Despite their knowledge of service users and their central role in providing food, home‐care workers received little nutritional training and were not involved by healthcare professionals in the management of malnutrition. Despite the rhetoric of individual choice and importance of social engagement and nutrition for health and well‐being, nutritional care has been significantly compromised by cuts to social care budgets. The potential role for home‐care workers in promoting good nutrition in older people is undervalued and undermined by the lack of recognition, training and time dedicated to food‐related care. This has led to a situation whereby good quality food and enjoyable mealtimes are denied to many older people on the basis that they are unaffordable luxuries rather than an integral component of fundamental care.     

Managing food insecurity through informal networks of care: an ethnography of youth practices in the North of England

Food insecurity in the UK is a pressing concern that is associated with poor health outcomes. Research to date has focused on the challenges for adults in providing food for families. However, there is little evidence showing how children and young people experience food insecurity, particularly outside of the home and school. This paper, drawing on 14 months of ethnography in a youth club in the North of England, explores how young people manage food insecurity. In this youth club, the circulation of takeaway food is part of an informal network where boys purchase, share and receive food. This practice allows the boys to participate meaningfully within their peer groups whilst also providing stable access to food. This peer practice, however, was not available to everyone. This was a gendered practice that for the girls held little benefit due to their concerns about eating and pressure to provide for others. Instead, some girls depend on romantic relationships for food provision that is equated with affection and care. The findings will be discussed through a ‘materialities of care’ perspective to explore the complex ways in which food as a practice of care is part of everyday routines embedded within local places.     

Improving the nutritional status of older residents in care – new national minimum standards

Summary On 1st April 2002, national minimum standards for care homes for older people came into force in England and Wales ( Department of Health 2002 ). These were published in accordance with the Care Standards Act 2000 and replaced the Registered Homes Act of 1984. The Care Standards Act also created the National Care Standards Commission (NCSC), an independent non-governmental public body to regulate social and health care services (previously regulated by local councils and health authorities). Meeting the new standards is a core requirement for all care homes providing accommodation and nursing or personal care for older people and will form the basis on which the new NCSC will determine whether homes for older people meet the needs and secure the welfare and social inclusion of those who live in them. Several of the key topics highlighted in the Act relate explicitly to food and food provision (including health and personal care, daily life and social activities and staffing). For example, specifications are made about the type of food that is acceptable, when it should be eaten, the appropriate number of meals per day and their distribution throughout the day. This article outlines the main nutrition related issues in the new standards and highlights some available resources that may help care home owners to meet them.     

Improving opportunities for food service and dietetics practice in hospitals and residential aged care facilities

Aim: Food is a phenomenon that everyone has an opinion on because eating is a frequent, often social occurrence, and as such the importance of mealtimes can be undervalued in healthcare settings. Some staff may not share our concerns about suboptimal dietary intakes as they assume that nutritional status will improve as people feel better. However, the provision and consumption of an appealing and adequate diet is a critical aspect of holistic health care. This review examines the role of dietitians in food services to improve the situation. Methods: A narrative review was formed with reference to the literature. Results: Labelling food service departments as a ‘hotel service’ or a ‘non‐clinical service’ does little to assist the perception of these services by others; to enhance the knowledge and skills needed by others about optimising dietary intake opportunities by the sick and elderly; or to enhance the communication that is needed between stakeholders about food and mealtimes. The issue of addressing malnutrition, reviewing and improving menus, mealtime environments, feeding assistance, communication between staff, and acknowledgement of the important care role of food service providers becomes even more relevant as the population ages and the demand for health care grows. Conclusion: This narrative highlights that the importance of dietitians building links with food services, leading high‐quality research, and improving the profile and recognition of food and mealtimes as integral to care, has never been greater.     

Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents’ nutrition and well-being is required.     

An evaluation of renal inpatient meals against Renal Nutrition Group standards

BACKGROUND: The Renal Nutrition Group (RNG) of the British Dietetic Association has developed standards for the nutritional composition of meals provided to renal patients in hospital. However, no data are available as to whether these are achievable. The purpose of this study was to determine whether renal inpatient meals can meet the standards set by the RNG. METHOD: A prospective 10-day weighed food analysis of hospital meals provided to renal patients was undertaken. Two sample meals were analysed at each mealtime to include (1) the most energy dense choice and (2) the most frequent patient choice (FPC). RESULTS: Energy dense choice meals achieved the standard for protein provision on 90% of days, but provided too little energy on 100% of days (for men) and on 30% of days (for women). Although daily standards for potassium were met on 70% of days, those for sodium and phosphate were exceeded. FPC meals met the daily standards for potassium, sodium and phosphate on at least 80% of days, but provided too little protein on 40% of days and too little energy on 100% of days (for men and women). CONCLUSION: The majority of hospital meals fail to meet the RNG standards. Problems exist in providing sufficient energy and protein whilst restricting sodium, potassium and phosphate.     

Managing routine food choices in UK families: the role of convenience consumption

The paper explores the meaning of convenience food for UK mothers, investigating the relationship between mothers and their families' food. The study examines the role of convenience food within the food strategies of contemporary UK families, and aims to elicit consumption meanings in the broader social context of family relationships with food, their rituals, routines and conventions. The findings reveal convenience has multiple meanings for UK women, and that convenience food has been incorporated into reinterpreted versions of homemade and "proper" meals. A hierarchy of acceptable convenience food is presented by the mothers, who tackle complex and conflicting family routines by introducing convenience solutions. Rules of eating have evolved, yet remain essentially controlled by the mother in terms of nutrition. While the traditional model of "proper" food remains aspirational, contemporary family lifestyles require that convenience food become part of the equation.     

Health and social factors affecting the food choice and nutritional intake of elderly people with restricted mobility

Background: Little is known about the magnitude of social and health factors which affect the food choices and nutritional intake of elderly people with restricted mobility. Design: Semistructured taped interviews were used to capture expressions used in the identification of health and social factors which affect food choices and nutritional intake of 13 female subjects and three male subjects living in the community with restricted mobility. Twenty-four-hour recall assessment was used to establish their dietary intake and meal patterns. Results: There was an inadequate intake of fluid, fruit and vegetables and nonstarch polysaccharide by the subjects. In addition, there was an infrequent consumption of cooked meals. Health and social factors which affect the food choices and nutritional intake of older people were identified as being inadequate money, inadequate food storage facilities, physical disabilities affecting food preparation, poor access to shops, difficulties in undertaking the shopping, type of cooking facilities, loneliness and bereavement. Conclusion: Elderly people living in the community with restricted mobility may be unable to consume an optimum nutritional intake due to the health and social factors identified which affect their food choices and nutritional intake.     

The effect of megestrol acetate on oral food and fluid intake in nursing home residents: a pilot study

OBJECTIVES: The objective of this study was to evaluate the effect of megestrol acetate (Megace OS; Bristol-Myers Squibb, Princeton, NJ) on the oral food and fluid intake of nursing home (NH) residents under two conditions: usual NH care and optimal mealtime feeding assistance. DESIGN AND SETTING: We conducted a prospective, preliminary trial in four NHs. PARTICIPANTS: Participants (n = 17) were recruited from a larger study designed to assess nutritional care quality. Eligibility for the Megace OS trial required participants to consistently eat less than 75% of most meals under both usual NH care and optimal feeding assistance conditions at baseline. INTERVENTION: Megace OS, an oral liquid suspension of megestrol acetate, was given daily in a 400-mg dose for 63 days. MEASUREMENTS: Each participant's oral food and fluid intake was monitored weekly for 1 day (three meals) during which research staff conducted direct observations of usual NH care (weeks 1, 3, and 5 and day 63) or provided optimal feeding assistance (weeks 2, 4, and 6). Average total percent intake was compared from baseline across the assessment weeks of the trial under the two mealtime care conditions. RESULTS: Megace OS had a significant effect on oral food and fluid intake only under the optimal mealtime feeding assistance condition, in which average total percent eaten increased from 50% (+/- 15%) at baseline to 63% (+/- 14%) post-63 days of the trial. There was no change in participants' oral food and fluid intake under the usual NH care condition (average total percent intake at baseline 43% +/- 12% vs. 43% +/- 20% post-63 days). CONCLUSION: The results of this preliminary study suggest that Megace OS is not an effective nutritional intervention to increase oral intake under usual NH care conditions, which is often characterized by inadequate feeding assistance. However, Megace OS in combination with optimal mealtime feeding assistance does significantly increase oral intake in a frail NH sample at high risk for weight loss.     

The School Food Trust: transforming school lunches in England

School food has been provided to pupils in England for many decades. From the mid‐1970s, however, both the number of meals provided and the quality of food have declined. Legislation was introduced in 2001 to ensure that school catering services provided healthy options, but surveys of consumption in 2004–2005 and in 1997 showed that improved availability of healthy options in school had little or no impact on children's eating habits. In February 2005, Jamie Oliver presented a series of television programmes highlighting the poor quality of school food. The government responded by setting up the School Meals Review Panel to make recommendations on how to improve school food and the School Food Trust, a non‐departmental public body to promote the education and health of children and young people by improving the quality of food supplied and consumed in schools. Legislation was introduced in 2006–2008 that set out what caterers could and could not provide for children in schools. At the same time, the Trust worked with caterers, schools, pupils, parents, manufacturers, food distributors, institutions providing further education for catering staff and others in a coordinated programme of change. This paper reports clear evidence of the improvements in provision, choice and consumption of food in schools following the introduction of legislation and a national programme of work to change catering practices and the attitudes of pupils, parents and others to healthier food provision in schools. It also provides objective evidence of the impact of healthier food on children's learning behaviour in the classroom, and overall costs and benefits. It concludes by outlining the future work of the Trust as it moves from being a non‐departmental public body to a not‐for‐profit social enterprise.     

The costs of care: An ethnography of care work in residential homes for older people

The cost of social care, the work conditions experienced by care workers and the quality of care provided by residential homes for older people are all linked, yet we know very little about how this relationship works in practice. Drawing upon an ethnography of two differently priced residential care homes for older people in Southern England, I examine the implications of different financial regimes for care-giving practices. I show how the scheduling and allocation of resources—conveyed, for example, in formal routines and staffing levels—structure the care workers’ time, tasks and activities in each setting. This acts to symbolically demarcate what, or who, is valued. I argue that the availability of resources facilitates and impedes the symbolic culture of care work, shapes care workers’ ability to afford dignity to the individuals in their care and affects how care workers experience, and relate to, their labour. I conclude by discussing how current practices of funding and pricing social care have effects seeping beyond the practical and measurable, and into the realm of the symbolic.     

Rising food bank use in the UK: Sign of a new public health emergency?

The provision of food aid through food banks has recently expanded in the UK. By providing free bags of food to people experiencing financial shortfalls, food banks aim to prevent individuals and families from going without food. A growing body of research has sought to understand this type of provisioning, from what it indicates about social security in the UK to what it indicates about the problem of food insecurity. Here, recent research on the characteristics of people receiving help from food banks is reviewed, highlighting that they serve the most financially vulnerable groups in the UK: people with disabilities, people receiving out‐of‐work benefits and lone parents. The severity and chronicity of food insecurity observed in this population is a public health concern, as is evidence of high rates of poor mental health. Food banks have largely gone unevaluated for how well they do at meeting the needs of people using them, but focusing on building better food banks may also serve to further entrench voluntary and charitable food assistance as part of the social safety net in the UK. Given evidence that policy interventions such as pensions and income transfers reduce food insecurity, the importance of restoring strong social safety nets for reducing the need for food banks and food insecurity is discussed.     

Dynamics of food habits of newly married couples: food-related activities and attitudes towards food

Sixty young couples were interviewed on three occasions—before marriage, after 5 months of marriage and after 21/2 years of marriage. The roles taken by each spouse in food provision and preparation are reported. Expressed attitudes towards food- and health-related factors were also discussed.
Wives took the major responsibility for food purchasing and preparation, although husbands played a significant role. The impact of children on these roles remains to be seen.
After 2 1/2 years of marriage, there was a reduction in the number of shared meals, with the exception of the evening meal which remained the focal meal at which to influence a spouse's eating habits. The opportunity for more individualized meals during the day may lessen potential conflict over who gets their preferred foods in the evening.
There were small but noticeable differences between wives and husbands stated likes and dislikes, and stated concerns about food. These may affect how much and in which way people are prepared to change their eating habits, and should be taken into account when planning nutrition education programmes.     

Older Chinese people's views on food: implications for supportive cancer care

Objectives. As people face cancer and the end of life, the social, cultural and therapeutic role of food takes on an increasing significance. As part of a larger study involving older Chinese people resident in the UK, we investigated their beliefs about the influence of food on cancer and its role in supportive cancer care.

Design. A two-phase qualitative research study involved older Chinese people identified via Chinese community groups. In phase one, 46 older Chinese people participated in seven focus group discussions. In phase two, semi-structured interviews were conducted in Cantonese or Mandarin with 46 different older Chinese people to elicit their understandings of the role of food in health and illness generally and specifically for those with cancer.

Results. The analyses revealed four main themes: (1) food as ‘therapeutic’; (2) food as ‘risky’; (3) food as supportive and comforting; and (4) beliefs about the lack of culturally appropriate and acceptable food in hospitals. Expectations about the lack of Chinese food and the poor quality and perceived unsuitability of ‘western’ food were regarded as major concerns in relation to hospital admission.

Discussion. Understanding the perceived cultural and therapeutic significance of food and its functions in social exchange is one important aspect of promoting supportive and end-of-life cancer care for minority communities. These views helped explain the diversity and salience of food use in illness for older Chinese people resident in the UK.     

Enjoy! Enhancing Meals in the Swedish Public Sector

Public meals in schools, hospitals, social, and elderly care play an important role in Swedish welfare. This article analyzes texts concerning the public catering sector, following up government directives that meals should provide enjoyment. The aim was to study a discernible shift towards enjoyment in the approach to public meals. The method is qualitative, with data from functional texts related to the public meal sector in Sweden, using the Five Aspects Meal Model/FAMM as a qualitative framework used by dietitians to add soft values in the public catering sector to the average nutritional values. The result is described in terms of important meal situations: new values, hospitality and service, environment, experience, and food quality as related to how and in which way to make changes. The question of public meals is important in an international view with elderly and multicultural populations.     

Living on the margin: Understanding the experience of living and dying with frailty in old age

Within policy and practice there is an increasing interest in the care of frail elders. However understanding of the experience and challenges of living and dying with frailty in older age is currently undeveloped. Frailty is often used as a synonym for the increasing infirmities that accompany ageing and the slow dwindling dying trajectory of many elders. However, there is little empirical work on the experience of being frail to inform social gerontological perspectives and welfare provision. Through analysis of repeated in-depth interviews over 17 months (2006-2008) with 17 frail elders living at home in the U.K., key factors that shape elders' experience of being frail emerged. The study argues that the visible markers of functional limitations and the increasing social losses of old age bring finitude to the fore. To retain anchorage in this state of imbalance, frail elders work actively to develop and sustain connections to their physical environment, routines and social networks. This experience can be conceptualised as persistent liminality; a state of imbalance "betwixt and between" active living and clinically recognised dying. This paper highlights the precarious and often protracted dying trajectory of frail older people. Whilst it could be argued that developing into death in older age is part of a normal and successful course after a life long-lived, recognition of and support for older people deemed frail is lacking. Frail elders find themselves living in the margin between the Third and Fourth Age with little recognition of or support for the work of living and dying over time. This experience of frailty contests dominant cultural and welfare practices and policy frameworks that operate in binary modes: social or health; independent or dependent; living or dying.     

Consumers of eldercare in Sweden: the semblance of choice

In Sweden and other countries, the benefits of user choice and market forces are often voiced in relation to the provision of medical care and social services. Policy makers increasingly view people as customers and consumers of care services. Among very old people—the most frequent care users—how many have the capacity necessary to find information and make decisions concerning providers of medical and social services?     

Contrasting approaches to ‘doing’ family meals: a qualitative study of how parents frame children’s food preferences

Family meals, as acts of domestic food provisioning, are shaped by the competing influences of household resources, food preferences and broader cultural norms around dietary practices. The place of children’s food tastes in family meal practices is particularly complex. Food tastes stand in a reciprocal relationship with family food practices: being both an influence on and a product of them. This paper explores how parents think about and respond to their children’s food preferences in relation to family meal practices. A qualitative study was conducted with residents of Sandwell, UK. The results presented here are based on the responses of nine key participants and their families. Photo elicitation methods generated participant food photo diaries that were used to inform subsequent interviews. A thematic analysis revealed two contrasting ways of incorporating children’s tastes into family meal routines: (1) ‘what we fancy’ and (2) ‘regulated’. The former entails repeatedly consulting and negotiating with children over what to cook for each meal. It is supported by the practical strategies of multiple and individually modified meals. The latter relies upon parents developing a repertoire of meals that ‘work’ for the family. This repertoire is performed as a series of ‘set meals’ in which any requests for variation are strongly resisted. Our findings add to the small body of literature on household food provisioning and suggest that achieving the idealised ritual of the family meal is underpinned by a range of values and strategies, some of which may run counter to health messages about nutrition.