Krassie, Jacqueline Gail (2021) Strategies to improve nutritional intake across a hospital and a Meals on Wheels service: The time is now. PhD thesis, Victoria University.

Abstract

The impact of an ageing population and growing levels of chronic disease in the community are increasing demands across all sectors of the health care industry globally. Malnutrition impacts health outcomes, healthcare costs, and quality of life for individuals across health care sectors, and is acknowledged nationally and internationally as reducing the ability of older adults living in the community to retain their independence. The reasons for malnutrition involve a complex set of internal and external influences, including ageing, appetite, oral health, social and environmental factors. This thesis investigated the impact of interventions targeting the energy and protein intake within two healthcare sectors - hospital patients and Meals on Wheels (MOW) clients - in the Australian context. The first study (Chapter 3) investigated the impact of a change from a traditional to a room service food service system, on energy and protein intake for patients. The study was conducted at a private, acute care hospital in Brisbane, Australia. The majority of patients were in hospital less than 4 days, and were on a normal diet. The risk of malnutrition was less than 12% for both groups. With room service, patients received their meal within 45 minutes of ordering their meal, compared with a traditional hot plating system where patients order their meals one day in advance. An analysis of meals consumed over a 24-hour period, by 50 patients pre-, and 47 patients post-room service, demonstrated an overall reduction in plate waste of 7 % (p < 0.05) post-room service. This outcome was observed at lunch, and dinner meals and, with respect to food categories, soup, hot starch, and vegetables (p < 0.05). In spite of these operational efficiencies, a reduction in plate waste, whether assessed as an absolute value or against a threshold of estimated energy and protein requirements, energy and protein intake was unchanged following the implementation of room service. The second study investigates the impact of a social intervention on the nutritional intake of a cohort of eighty-three clients from MOW services in North and West Metropolitan Region of Melbourne, and Macedon and Geelong regions of Victoria. The results of this study are presented in three separate chapters. Participant characteristics and meal utilisation patterns are detailed in Chapter 4, variables associated with nutritional intake in Chapter 5, and the impact of the social intervention on intake in Chapter 6. Results from the initial interviews with participants, including demographic details, meal ordering and utilisation information, and dietary intake data from three 24-hour recalls are reported in Chapter 4. While a single 24-hour recall has been utilised in other studies, this study expanded the food recall to 3 days for each participant, allowing for the variations in eating patterns, including weekdays and weekends, to be reflected in the assessment of intake. Participants were mainly well-nourished (84.3%), relatively independent with respect to making meals and shopping for groceries, and had regular social contact. All participants in the study ordered the main MOW meal, 93% ordered dessert, and 70% ordered soup, with meals frequently consumed over two or three meals. Over half of the participants reported throwing out meals (56.6%), with 14.9% of these giving MOW meals to a pet. In contrast to the level of discarding meals, the positive and negative feedback from participants was similar suggesting the need for further investigation to clarify the participant expectations regarding meal quality and service levels. Nevertheless, in this study, MOW meals contributed 30% of energy and 38% of participants’ protein intake, and the total daily intake for participants met 82% of energy and 98% of protein requirements. These results provide valuable insight into existing issues, expectations, and have the potential to inform future system interventions. Working with the participants profiled in Chapter 4, Chapter 5 investigated associations between the participant characteristics and nutrient outcome variables, and the participants understanding of MOW delivery as a social experience. Nutritional intake was higher for male participants, while the contribution of intake to energy requirements was greater for those who were with MOW for a longer time period increased (p = 0.033). The contribution of MOW to intake increased as the number of MOW meals per week increased, but declined with age. Interestingly, total energy and protein intake, and the contribution of energy to requirements, declined as the number of positive comments from participants increased. The vast majority of participants chatted with the delivery person (89%), and considered MOW meal delivery social (82%). Further research is needed to understand client perceptions across a range of MOW groups, including those that are less healthy, independent and socially connected. Chapter 6 reported on the impact of a 3-month program of social visits on energy and protein intake. Participants included in the initial stage of this study (Chapter 4), were randomly assigned to either the control group or one of two intervention groups, receiving six social visits every 2 weeks, or 3 social visits each month. During the three months of the project, for a variety of reasons, 10 of the original 83 participants (12%) withdrew. Dietary intake data from three 24-hour recalls was collected during interviews with each participant. Chapter 6 reported an increase in energy intake on MOW days compared with non-MOW days of 938 kJ (p = 0.003). This outcome is consistent with the observation reported in Chapter 5 where intake increased with the number of MOW meals received per week. However there was no impact on total intake of energy or protein for either intervention groups. As the study design did not require participants to consume a MOW meal on each day, participants varied their frequency of consumption of MOW meals, reducing the potential impact on the overall intake of energy and protein. The relatively well-nourished, independent and socially connected profile of this group of participants, in combination with small group sizes, may have impacted the results of this study. An important step in exploring the potential for social connection to impact nutritional intake, this study provides a baseline from which future studies can scaffold targeted strategies that explore the impact on quality of life and nutritional intake. CONCLUSION While the interventions reported in this thesis did not demonstrate an increased nutritional intake for hospital patients or MOW clients, the results extend our current understanding of the characteristics and behaviours related to meal consumption and utilisation necessary to inform the development of targeted interventions across these two health care sectors. The time is right to expand the focus of malnutrition research. There is an opportunity to undertake studies across the health care sectors, to develop interventions that acknowledge, identify and address the needs of the individual, and service provider, and ultimately contribute to a continuum of nutritional care for the individual across the sectors.

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