Heather Keller, RD, PhD, FDC, is a Professor in the Department of Family Relations and Applied Nutrition at the University of Guelph and is an expert in nutrition and older adults. Her comprehensive research program includes nutrition risk screening, nutrition and aging well in older adults, and nutrition and dementia.
(www.drheatherkeller.com)
What are the psychosocial and physical aspects of mealtime, and how do they impact appetite and food intake in
older adults? What are your tips for healthy mealtimes?
I’ve been doing research around the psychosocial aspects of meals. Even if you put excellent food on the plate and give people what they need to eat well, if they don’t feel like eating, they’re still not going to eat. This led me to try to understand what is it—specifically in the case of dementia—that might be leading people into not eating well. There is certainly the physiological side of that, and there is a huge social side. The physical side of course is that as we age, we tend to move less and we have less muscle mass and we tend to have a smaller appetite. The second, social side of it is that as people get older, their appetite isn’t as good automatically and they tend to get into a vicious cycle of not eating well. That can even reduce appetites further and they lose weight, so it’s a negative cycle that they don’t seem to get over. That led me to think—is there a social thing you can do to stimulate appetite?
Meals are really about connecting for folks. They’re about the social interaction that happens at mealtime. We try to stimulate interaction at mealtime, starting with the older person with dementia actually taking part—things like drying the dishes, setting the table, bringing other residents to the room that are in wheelchairs, all those sorts of things. Everybody needs to feel needed. We need to have an identity and a role. If we can give people a sense of who they are in the eating environment, that’s going to promote a better eating experience.
Having a role is one way to be engaged. Another is having one’s preferences identified and supported. So one of the things we do is ask people what they want to eat in long-term care—preferences for the meal. For us, making the most of the mealtime experience is honouring that preference, honouring that identity, and where we can, supporting them to consume food efficiently to meet their nutritional needs. So it’s really about honouring the person, not just getting nutrients into the body.
How does the psychosocial aspect of mealtime apply to retirement communities?
Our preferences say a lot about who we are as people. It’s our identity. In long-term care or retirement residences, preferences would mean a person gets what they want in the way that they want. In a retirement community, it would be ensuring that your menu is actually responsive to the desires of the clientele that you have. If you’re honouring the identity, it would be having a menu that they want, a menu that they consider is ideal for them to eat. That might be meals that they consider traditional to their culture or foods that are comforting, that sort of thing. So what we can do as people who work in that setting is to make sure that we are open to their suggestions and identifying menus, working with the clientele about that. And we do that with residents’ councils and truly honouring clientele in our menus. I’ve been to retirement residences that say, “We have a residents’ council” and nothing ever happens. So on the one hand, they do the residents’ council, but they don’t follow through and change the menu or they don’t change it in a way that most people feel like it’s meeting their needs. That’s a challenge that we have—to truly honour identity. I think that when people actually complain about the food, what it’s saying is that their honour is being jeopardized in some way. When you have complaints, it’s actually a good thing because it demonstrates that people are still trying to live, and when they give up on complaining, then you have a problem because they’ve given up on their identity.
It’s one of the few things they have control over, right? Even if they are well, they move into a place where they have a room, someone else cleans it, someone else prepares their food. They’ve lost many of the pieces of their identity. They may not have a car anymore; they don’t have their own home anymore; they may have a few pictures on the wall and a few pieces of their furniture they’ve taken from home. But what daily supports their identity is what they can do, so one of the key things they do is eat. And in their activities, their hobbies, what they do with their families, even if those things aren’t happening as much, food plays a huge part.
What factors are typically present when nutritional problems occur among residents and is nutrition screening something staff should undertake on a regular basis?
I think for everybody that goes into retirement, long-term care or assisted living, there is a potential for nutrition risk. Is that really the answer—screening that group? Probably not. I think that the issue is having quality care already in place and that care coming when they need it. I am very glad we have dieticians in long-term care. I think retirement residences also have to have some sort of oversight by a dietician to pick up problems around weight loss and changes in appetite and nutrition status sooner than later. And screening in that case helps identify people at risk. One of the key things, I think, is having nutritionists in retirement residences.
There has to be a nice middle ground. The chefs are wonderful because they can actually provide you with good-quality food. However, they may not know that some of the nutrient needs are greater for older adults, for example, or about what we call pre-dysphasia, which happens in about 20 to 30 per cent of people in retirement homes. They may not be aware of some of the food behaviour issues that need to be taken into account for a long-term care or retirement residence. Chewing difficulty, swallowing difficulty: those are two of the things that need to be thought about in planning the menu. I think that it’s wonderful that chefs are there because the quality of food is increasing, but it needs to be paired with the nutritional needs of that group. And then finally as well, the residents’ preferences. You can have wonderful French-style dining, but if the residents don’t want it—they want roast beef and potatoes, they want turkey and potatoes. They don’t want something Florentine that they’ve never heard of. So it’s really a combination of really knowing your residents and truly building a menu around their needs. And it’s having a dietician who knows the nutritional needs and can work collaboratively with the chef, who has the incredible skill and knowledge base around food, to bring those together.
What is the most important thing that retirement residences can do to improve the dining experience for their residents?
Training the food staff. Even if the food isn’t great, even if the food isn’t as appealing, or isn’t exactly what they want, if you have a great staff member who delivers that food, chats with the residents, it changes the entire social experience of the meal. I was in a retirement residence, and a woman came in one day with her grandchild who was nine months old. Before she came into the dining room, it was the typical dining room conversation, a little bit of this, a little bit of that. People were sharing, you know, but it wasn’t really animated. She walked in with the baby and went from table to table, and you could see the interaction change at the table even after she left. If people are engaged socially, interacting at that table, they’re going to eat the food, they’re going to stay at the table. We know that ourselves. If you go to dinner, even if the turkey’s dry, it’s still wonderful because the social interaction is there. So I think if you can train your staff to be that socially engaging person, that when they deliver that meal they can talk, ask the impression of people at the table and include everybody at the table. Even if residents don’t participate that well, that engages them.
Another example. Another staff member came up and talked to only one person at the table. The faces of the people who were not being included, they looked away and they disengaged from what was happening at the table. That was a lost opportunity, when that staff member could have greeted everybody, said something to everybody, and then did a little bit of business with that other individual. So I think it’s staff training. If there’s one thing that could be done right now without changing the building’s structure, without changing the physical plan, it’s changing how staff approach people.
What advice do you have for retirement residence executives as they plan their food service operations for the next five years?
I think we have to take account of the social environment, the physical environment and then the food environment itself. So some things are being done right, but it’s bringing those things together that we’ve talked about and having a flexible and responsive approach to providing food.
Your population is going to continue to change, and you have to be able to flex around that and figure out what is the group that you have today. What are their needs for the next six months or a year in terms of food preferences, etc? And work collaboratively with the chef and the dietician. I think that we often put in place things like, say, music, and it’s often thought to fix everything because we put in this wonderful classical music. Well, walk through that dining room and see. Are people talking? If they’re not talking, maybe the music’s too loud, maybe it’s not the music they’d like. So I think that when you put in an intervention or an idea, think about, “Did it actually do what you wanted it to do?” And it may not have. You can change it up, be flexible and move forward, progressing toward food that’s better care than you were giving.
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