Journal of Human Nutrition and Dietetics
NUTRITIONAL SCIENCE
Improving the dietary intake of under nourished older
people in residential care homes using an energy-enriching
food approach: a cluster randomised controlled study
W. S. Leslie,* M. Woodward,† M. E. J. Lean,* H. Theobald,‡ L. Watson* & C. R. Hankey*
*Life-course, Nutrition and Health, Centre for Population Health, University of Glasgow, Glasgow, UK
†Epidemiology and Biostatistics, The George Institute for Global Health, The University of Sydney, Sydney, Australia
‡GlaxoSmithKline, Nutritional Healthcare Future Group, GlaxoSmithKline, Brentford, UK
Keywords
aged, care home, food enrichment,
undernutrition.
Correspondence
C. R. Hankey, Life-course, Nutrition and Health,
University of Glasgow, School of Medicine, 4th
Floor Walton Building, Glasgow Royal Infirmary,
Glasgow G4 0SF, UK.
Tel.: +44 (0)141 211 5443
Fax: +44 (0)141 211 4844
E-mail: [email protected]
How to cite this article
Leslie W.S., Woodward M., Lean M.E.J.,
Theobald H., Watson L. & Hankey C.R. (2012)
Improving the dietary intake of under nourished
older people in residential care homes using an
energy-enriching food approach: a cluster
randomised controlled study. J Hum Nutr Diet.
26, 387–394
doi:10.1111/jhn.12020
Abstract
Background: To examine whether the nutritional status of aged undernourished residents in care could be improved through dietary modification to
increase energy intake but not portion size.
Methods: A 12-week cluster randomised controlled trial was carried out in
21 residential care homes. Participants comprised undernourished residents
with a body mass index (BMI) <18.5 kg m–2. All menus were analysed to
evaluate nutrient provision. Energy and macronutrient intakes of undernourished residents were estimated using 3-day weighed food intake diaries.
Those resident in homes randomised to intervention had their usual meals
enriched with energy-dense foods to a maximum of +1673 kJ day 1.
Results: Of 445 residents screened, 41 (9%) had a BMI <18.5 kg m–2 and
entered the study. Despite adequate food provision, energy and macronutrient intakes were below UK dietary reference values. Mean (SEM) energy
intake increased [+556 (372) kJ, P = 0.154] in residents allocated to intervention but fell in those residents in ‘control homes’ receiving usual care
[ 151 (351) kJ, P = 0.676]. Weight change [+1.3 (0.53) kg, P = 0.03] was
seen in intervention residents but not in controls [ 0.2 (1.5) kg,
P = 0.536]. Between-group differences for changes in weight and energy
intake were not significant (P = 0.08 and 0.20, respectively). Six residents
allocated to the intervention increased their BMI >18.5 kg m–2 (P = 0.018).
Conclusions: Achieving weight gain in frail older people is difficult. These
results suggest that enriching food could help address undernutrition and
slow chronic weight loss. Interventions of a longer duration are needed to
confirm or exclude the value of food enrichment.
Introduction
Undernutrition, a persistent problem (Suominen et al.,
2005), is associated with increased risks of morbidity and
mortality (Margetts et al., 2003). The UK National Diet
and Nutrition Survey of those aged 65 years found that
16% of men and 15% of women in long-term care were
undernourished [body mass index (BMI) 20 kg m–2]
(Finch et al., 1998). The UK population aged >65 years is
rising (United Nations, 2009) and an increased need for
care home places is likely.
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
Identifying those who are at risk of undernutrition is
problematic because measurements of weight/BMI are not
always routinely made (Leslie et al., 2006). Unintentional
weight loss requires serial measurements to quantify change
and facilitate the prompt identification of changes in nutritional status. Addressing undernutrition effectively can benefit quality of life and health (McMurdo & Witham, 2007).
Nutritionally complete supplements are often used first
to address undernutrition. These costly supplements have
undergone only limited evaluation in community settings
(Edington et al., 2004), although their effects on body
387
W. S. Leslie et al.
Diet enrichment for under nourished older people
weight are now quantified: +2.05% [95% confidence
interval (CI) = 1.63–2.49] (Potter et al., 1998). Taste
intolerance is known to limit the effectiveness of supplements, with attrition rates of up to 25% after 2 weeks
(Price et al., 2005).
Food enrichment could improve nutritional status by
increasing the energy density of meals with the addition of
energy rich foods. This may suit older people, who often
have small appetites (Odlund Olin et al., 2003). Food
enrichment may be more economical, without taste fatigue, allowing the continuation of usual eating patterns.
Although advocated in clinical guidelines (NICE, 2006),
few trials have evaluated this approach (Odlund Olin et al.,
2003; Smoliner et al., 2008). The need for further studies
aiming to examine whether energy intake can be increased
by food enrichment is pertinent (Milne et al., 2006).
This 12-week study of undernourished older people in
care aimed to determine:
• If daily energy intake could be increased using food
enrichment without increasing meal sizes?
• Whether nutritional status of those whose BMI was
<18.5 kg m–2 could be improved?
weight was measured using chair scales without shoes
(SECA, Birmingham, UK). Adult height was determined
using knee height (Han & Lean, 1996) and the BMI
was calculated.
Assessment of dietary intakes
Three-day weighed intake diaries were completed by the
study researcher at baseline and week 12. Dietary data
were analysed using WINDIETS (Robert Gordon University,
Aberdeen, UK).
Intervention homes
Undernourished residents in homes randomised to intervention had usual meals enriched with standard quantities of energy dense foods. Double cream (50 mL) was
added to cereal, porridge, soup and desserts, and butter
(8 g) was added to potatoes. A 250-mL malted milk
drink made with whole milk was offered each evening.
The maximum potential increase in daily energy intake
was 1673 kJ. The daily cost of additional foods to
provide enrichment was estimated at 97 pence (as of
January 2011).
Materials and methods
A cluster randomised trial design was used with homes as
the unit of randomisation. Allocation was made, postrecruitment and baseline screening, using a random permuted block design, stratified by home type (dementia/not)
by a study statistician who had no contact with the homes
(MW). The primary outcome was the delta difference in
energy intake between those given enrichment or usual care.
Settings and participants
Twenty-one residential care homes for older people run
by a charitable organisation were invited to participate.
All residents, not acutely unwell, were invited to take
part. Consent for anthropometric measurements was
secured from residents, or a relative/guardian for residents with mental incapacity. Inclusion criteria were BMI
<18.5 kg m–2 without acute disease.
Food provision
Food provided in all homes was evaluated by the CORA
menu planner (Caroline Walker Trust, London, UK).
Anthropometric measurements
Mid upper arm circumference (MUAC) and body
weight were recorded at baseline and week 12. Body
388
Control homes
Home managers were requested to maintain usual care
with unaltered catering provision.
Sample size calculation and statistical analysis
A range of reasonable estimates for intra-cluster correlation coefficients, the number of residents available for
study per home, and a standard deviation of difference
in energy intake taken from a small pilot study (Leslie
et al., 2006) indicated a required sample size of 58 to
detect a delta difference in energy intake of 1673 kJ
with 95% power, using a two-sided 5% significance test
(Woodward, 2005). Primary analyses used linear mixed
models to allow for the cluster design. Because 2.3
undernourished residents per home participated in the
study, the clustering had little effect on estimates or
SEs (e.g. ignoring clustering changed the estimate and
SE of the primary endpoint by <5%). Thus, further
analyses ignored clustering. Descriptive statistics analysed
changes in MUAC, macronutrients and micronutrients.
Fisher’s exact tests analysed between-group differences
in those experiencing acute illness or a change of BMI
category.
Ethical approval was secured (on 16 September 2004)
from the Multi-centre Research Ethics Committee
Scotland.
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
W. S. Leslie et al.
Diet enrichment for under nourished older people
Results
Nutritional analysis of menus
All 21 homes that were invited to participate did so (four
dementia units). A total of 445 residents (83.6% female,
85 from dementia units) were screened. No residents were
undernourished in three homes. In 18 homes (nine intervention, nine control), 41 residents (9%) were undernourished (six from dementia units).
Mean (SD) age was 91 (7) years (range 77–105 years)
(Table 1). Thirty-one residents completed the study
(three from dementia units), 10 subjects withdrew: seven
died (mean BMI 17.5 kg m–2), two were hospitalised
(BMI 16.2 and 15.5 kg m–2) and one retracted consent
(Fig. 1).
Nutritional analysis of menus (CORA menu planner; Caroline Walker Trust), showed that food provision achieved
UK reference values with the exception of vitamin D
(COMA Department of Health, 1991). No menu alterations were required.
Baseline anthropometric measurements
Mean BMI was 17.3 (range 15.5–18.4) kg m–2 for intervention participants and 17.1 (range 13.3–18.5) kg m–2 in
controls (Table 1).
Baseline energy requirements and dietary intake
Study power
The intra-cluster correlation coefficient for difference in
energy intake was low (0.04). Together with the lower
than expected degree of clustering, the achieved sample
size of 31 meant that the study was well powered to
detect the clinically important delta difference in energy
intake (1673 kJ). Accounting for the design effect, missing
values and a disproportionate allocation to treatment
group, the study had 90% power to detect the prespecified difference in the primary outcome.
Food provision at baseline
Food provision in all homes comprised three meals daily
plus snacks mid-morning, mid-afternoon and evening.
Breakfast was continental style, with nine homes offering
cooked Sunday breakfasts. A three-course lunch was the
main meal of the day with dinner a light meal or snack.
Between meal snacks comprised drinks and biscuits. Some
homes routinely offered residents a malted milk drink
but reconstituted it with water. Externally sourced foods
provided negligible dietary energy.
Table 1 Anthropometric measures at baseline for control and
intervention subjects
Female (n)
Male (n)
Age (years)
MUAC (mm)
Body weight
(kg)
BMI (kg m–2)
Controls (n = 19)
Intervention
(n = 22)
Mean (SD)
Range
Mean (SD)
Range
17
2
90.3 (6.8)
20.0 (2)
39.9 (4.4)
70–100
15–22
32.6–53.3
19
3
90.9
20.0 (2)
40.2 (5.1)
77–105
16–23
28.7–51.5
17.3 (1.4)
15.5–18.4
17.1 (1.5)
13.3–18.5
BMI, body mass index; MUAC, mid upper arm circumference.
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
In male residents, mean estimated basal metabolic rate
(BMR) was 6393 (range 6146–6627) kJ and mean energy
intake was 6397 (range 3866–9288) kJ (Schofield et al.,
1985). Mean BMR for female residents was 5506 (range
5008–5778) kJ and mean energy intake was 5435 (range
2200–8999) kJ.
Mean macronutrient intake was lower than UK dietary
reference values for males and females (COMA Department of Health, 1991). Nonstarch polysaccharide consumption was one-third of that recommended for females
and less than half for male residents (Table 2). Mean
intakes of some micronutrients were also considerably
lower than the Reference Nutrient Intake (Table 2).
Dietary and anthropometric measures at 12 weeks
Dietary intakes
Mean changes in energy intake in intervention and control
subjects were not significant (Table 3). Fat intake increased
significantly in intervention participants (P = 0.014), indicating that the intervention was consumed. Between-group
analyses showed no statistically significant difference in
changes in energy and nutrient intake (Table 4).
Weight change
Weight increased significantly in intervention subjects
(Table 3). Of those who gained weight, six gained more
than 2 kg. Six residents allocated to intervention achieved
a BMI >18.5 kg m–2 and were no longer undernourished
(P = 0.018). Increases in body weight and BMI were
reflected in MUAC changes (Table 3).
Close to 50% of control residents lost weight, whereas
one remained weight stable. Mean weight change was not
significantly different from baseline. Those who did gain
weight, gained <1 kg. MUAC was unchanged (Table 3).
Between-group differences in body weight change were
nonsignificant (Table 4).
389
W. S. Leslie et al.
Diet enrichment for under nourished older people
514 residents eligible
for screening in 21
homes
69 residents refused
screening
445 residents screened
in 21 homes
3 homes had no eligible
undernourished residents
18 homes randomised
41 undernourished
residents eligible for
entry to study
9 homes assigned to
9 homes assigned to
control group 22
participants
intervention group
19 participants
2 died
1 hospitalised
5 died
1 hospitalised
16 reviewed
at 12 weeks
1 withdrew
16* reviewed
at 12 weeks
Figure 1 Trial profile. *One participant did not have
body weight and height repeated at week 12.
Table 2 Comparison of underweight subject’s mean recorded intake at baseline with current dietary reference values
Mean (SD) recorded intake
COMA
recommendations
(75+ years)
Nutrient
Male (n = 5)
Female (n = 35)
Male
Female
Male
Female
Energy (kcal)
Energy (kJ)
Fat (g)
Carbohydrate (g)
Fibre (g)
Protein (g)
Thiamine (mg)
Riboflavin (mg)
Niacin (mg)
Folate (lg)
Vitamin C (mg)
Vitamin A (lg)
Vitamin D (lg)
Calcium (mg)
Iron (mg)
1528
6393
62
208
8
49.4
1.1
1.4
21
147
40
928
1.8
713
7.2
1299
5435
54
166
6
43
0.8
1.2
17
114
39
651
1.5
628
6.7
2100
8786
82
218
18
53.3
0.9
1.3
16
200
40
700
10
700
8.7
1810
7573
70
188
18
46.5
0.8
1.1
12
200
40
600
10
700
8.7
73
73
76
95
44
93
122
101
131
74
100
132
18
101
83
72
72
77
82
33
92
100
101
142
57
98
101
15
90
77
(475)
(1987)
(22)
(60)
(4)
(20.5)
(0.3)
(0.4
(7)
(30)
(25)
(359)
(0.6)
(220)
(2)
(339)
(1418)
(22)
(40)
(2)
(15)
(0.3)
(0.5)
(7)
(53)
(23)
(416)
(1.2)
(220)
(2)
Mean recorded
intake as percentage
of DRV
COMA, UK committee on medical aspects of food policy; DRV, UK dietary reference value.
Acute illness
Acute illness occurred in seven residents, causing weight
loss across the groups. Mean weight change for interven390
tion residents was 0.2 (range 3.2 to +2.9) kg, whereas,
in controls, it was 1.5 (range 3.2 to +0.3) kg. No
between-group differences were seen in the proportion of
acutely unwell residents (P = 0.16).
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
W. S. Leslie et al.
Diet enrichment for under nourished older people
Table 3 Change in energy intake and anthropometric measures in control and intervention subjects between baseline and week 12
Control subjects
(n = 16)
Measurement
Weight (kg)*
MUAC (mm)
BMI (kg m–2)*
Energy (kcal)
Energy (kJ)
Fat (g)
Protein (g)
Carbohydrate (g)
Nonstarch
polysaccharide (g)
Thiamin (units)
Riboflavin (units)
Niacin (units)
Folate (units)
Vitamin C (mg)
Vitamin A (units)
Calcium (mg)
Iron (mg)
Potassium (units)
Zinc
Vitamin D
Change
(SEM)
Intervention subjects
(n = 16 except for those values* where n = 15)
95% CI
P
Change
(SEM)
95% CI
P
0.2
0.1
0.1
36
151
1.3
0.1
12
0.2
(1.5)
(0.3)
(0.4)
(84)
(351)
(4.6)
(3.5)
(14.7)
(0.6)
1.1 to 0.6
0.7 to 0.5
0.5 to 0.2
212 to 141
887 to 590
11.2 to 8.6
7.3 to 7.5
43 to 19.1
1.1 to 1.5
0.536
0.691
0.517
0.676
0.676
0.783
0.983
0.417
0.702
1.3
0.4
0.5
133
556
16.7
0.1
5.7
0.1
(0.53)
(0.16)
(0.25)
(89)
(372)
(5.9)
(3.6)
(10.7)
(0.4)
0.14 to 2.41
0.08 to 0.78
0.02 to 1.07
57 to 323
238 to 1351
3.9 to 29.5
7.6 to 7.7
28.7 to 17.2
0.9 to 0.9
0.03
0.019
0.042
0.154
0.154
0.014
0.980
0.600
0.952
0.1
0.2
2.6
20
5
498
19
0.9
1237
0.1
0.6
(0.1)
(0.1)
(2.5)
(8.6)
(5.4)
(373)
(40)
(0.8)
(358)
(0.4)
(0.3)
0.2 to 0.3
0.1 to 0.4
8.0 to 2.8
12.3 to 51.7
16.3 to 7.2
298 to 1294
66 to 104
2.6 to 0.8
1999 to 474
1.0 to 0.8
1.2 to 0.1
0.551
0.243
0.324
0.210
0.422
0.202
0.648
0.275
0.243
0.854
0.067
0.1
0.2
0.2
6.2
0.3
471
57
0.3
778
0.1
0.2
(0.1)
(0.1)
(0.1)
(8.6)
(5.4)
(274)
(56)
(0.4)
(118)
(0.6)
(0.4)
0.1 to 0.2
0.1 to 0.3
2.7 to 3.2
24.6 to 12.2
11.3 to 12.0
115 to 1058
64 to 177
1.3 to 0.6
1032 to 523
1.1 to 1.4
0.9 to 0.6
0.576
0.082
0.875
0.483
0.950
0.107
0.329
0.501
0.047
0.820
0.610
*Refers to the weight and height measures in the left hand column.
BMI, body mass index; CI, confidence interval; MUAC, mid upper arm circumference.
Discussion
The risk of undernutrition among older people, aged
65 years, living in the UK has been reported at 14%
(Finch et al., 1998; Margetts et al., 2003). For those in
care, this equates to one in six residents, whereas, for older
free-living people, the risk is 5% (Finch et al., 1998).
Although undernutrition in older people results in poor
health status (Finch et al., 1998; Margetts et al., 2003) and
even death (Mattila et al., 1986), scant evidence exists that
nutritional management is a defined part of care. Food
enrichment is advocated by dietititans and clinical guidelines and thus further evaluation is justified (Thomas,
1994; National Diet Resource, 2001; NICE, 2006).
Recruitment
The number of residents identified as undernourished
and eligible to participate in this study was lower than
the (18%) predicted by our feasibility study (Leslie et al.,
2006). However, these undernourished residents had not
been identified before the study and no nutritional intervention/care had been implemented. Thus, the lower than
expected incidence of undernutrition is likely to be a
result of chance and is unlikely to reflect the nutritional
awareness of care staff.
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
Recruitment for the present study was limited by our
strict choice of BMI cut-off (<18.5 kg m–2) in line with
the WHO criteria to identify undernutrition (World
Health Organization, 1998). Other surveys used BMI
<20 kg m–2 (Finch et al., 1998), thus identifying higher
numbers of undernourished people. Debate continues
about appropriate BMI cut-offs for older people, with a
loss of muscle mass favouring the lower cut-off. Our
choice was in line with the NICE Clinical Guideline 32
(NICE, 2006), which states that a BMI of ≤20 kg m–2
should be used only with evidence of unintentional
weight loss of 10% over the previous 3–6 months.
Because recent weight changes could not be determined
in the present study, the BMI cut-off of <18.5 kg m–2
was appropriate.
The fragility of the study population and the effect of
undernutrition on health were confirmed by an attrition
rate of 25%, including seven deaths. A further seven participants experienced acute illness with undernutrition a
likely contributor. It was impossible to exclude those with
undiagnosed illness as a cause of undernutrition but, in
both groups, illness encouraged weight loss. However, in
intervention participants, mean weight loss was less than
in controls. This clinically relevant finding suggests the
intervention conferred some benefit by stalling the often
chronic weight loss.
391
W. S. Leslie et al.
Diet enrichment for under nourished older people
Table 4 Difference between intervention and control subjects in the
changes in anthropometric and dietary measures between baseline
and week 12 (n = 16)
Measurement
Energy intake (kcal)
Energy (kJ)
Body weight (kg)
MUAC (mm)
BMI (kg m–2)
Fat (g)
Protein (g)
Carbohydrate (g)
Nonstarch
polysaccharide (g)
Thiamin (units)
Riboflavin (units)
Niacin (units)
Folate (units)
Iron (mg)
Calcium (mg)
Zinc (units)
Potassium (units)
Vitamin A (units)
Vitamin C (mg)
Vitamin D (ug)
95% CI
P
Difference
(SEM)
174
707
1.5
0.5
0.7
18.9
0.1
6.5
0.2
(127)
(531)
(0.8)
(0.3)
(0.4)
(8.7)
(4.9)
(18.4)
(0.8)
82 to 418
343 to 1749
0.2 to 2.9
1.3 to 1.2
0.1 to 1.3
2.7 to 33.3
10.2 to 10.2
31.1 to 44.1
1.8 to 1.3
0.20
0.20
0.08
0.11
0.10
0.05
1.00
0.72
0.78
0.1
0.1
2.8
19.7
0.6
38.4
0.3
623
26.5
4.1
0.7
(0.1)
(0.2)
(2.9)
(19.7)
(0.9)
(68.5)
(0.8)
(380)
(468)
(8.7)
(0.7)
0.3 to 0.2
0.3 to 0.3
3.2 to 8.8
61.9 to 10.2
1.3 to 2.5
101 to 178
1.2 to 1.7
155–1402
984–981
10.9–20.8
0.55–1.29
0.87
0.82
0.35
0.33
0.53
0.58
0.72
0.11
0.96
0.65
0.33
BMI, body mass index; CI, confidence interval; MUAC, mid upper arm
circumference; NA, not applicable.
Food provision and baseline dietary intakes
That food provision in all homes was adequate, with the
exception of vitamin D, was reassuring because shortfalls
in a wide range of nutrients can be found with institutional catering. Attempts to improve food provision and
remedy nutritional shortfalls often fail (Caroline Walker
Trust, 1995; Mikkelsen et al., 2007). The shortfall in dietary vitamin D intakes those not exposed to sunlight regularly is well recognised. Recently, one-third of resident’s
in care homes in the UK were estimated to be vitamin D
deficient (Hirani & Primatesta, 2005). Solutions to
address poor status include regular sunlight exposure or
supplementation with vitamin D and calcium (Hirani &
Primatesta, 2005).
The shortfalls in energy intake, and other macronutrients observed in all those identified as undernourished,
were similar to those reported previously (Leslie et al.,
2006). That these occurred despite adequate provision
highlights the need for encouragement with eating for all
residents. A family style approach has been advocated to
maximise intakes (Nijs et al., 2006) and this was already
in use. However, assisting residents experiencing eating
difficulties was not a specific staff task, and may have
increased energy intake further. Setting aside time at meal
times for staff to assist those experiencing eating
392
difficulties at all meals has been valued in other settings
(Food in Hospitals, 2008). Protected mealtimes is one of
the 10 key characteristics of good nutritional care, and an
integral part of protected mealtimes is the provision of
assistance with meals (National Patient Safety Agency,
2009).
Change in energy intake
The present food enrichment intervention was simple and
required minimal extra work for staff. The focus was on
increasing energy density, without increasing portion size.
Acceptability varied but no resident refused the intervention completely. Accommodating individual tastes and
food preferences was impossible within this fixed intervention. A wider range of food enrichment may have improved
acceptance and further increased energy intake, although it
would have made the intervention more complex. A previous acute study (Gall et al., 1998), which utilised a variety
of different supplementations, achieved a significant
improvement in energy but the increase was only a quarter
of that aimed for, suggesting a wasteful approach, which
would be unjustifiable over the long-term.
Although the cost of the intervention was low, the cost
of providing it lay with the care home itself, which, in
the private sector, would potentially reduce profit. The
provision of commercially prepared, nutritionally complete food supplements, although far more costly (British
National Formulary, http://www.bnf.org/bnf/index.htm;
accessed on 24 January 2012) and less well accepted over
the long-term, would be paid for by the National Health
Service and may make the use of commercially prepared
supplements more attractive to many units.
Weight change
Although the increase in energy intake in the present
study fell short of the daily target 1673 kJ, it was sufficient to favour significant weight gain in intervention residents. Weight gain has not always been measured in
previous similar studies (Gall et al., 1998), whereas, in
others, weight gain was observed (Lauque et al., 2000;
Odlund Olin et al., 2003). Similarly, commercially prepared supplements are sometimes successful in achieving
weight gain, (Payette et al., 2002; Lauque et al., 2004)
and sometimes not (Edington et al., 2004).
Although between-group differences in weight change
were not significant (P = 0.08), the within-group changes
in body weight in the intervention group do suggest a
positive effect from food enrichment. It is possible that,
had this study continued for longer, significant between
group differences in energy intake and body weight may
have emerged.
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
W. S. Leslie et al.
The success of the present intervention depended on
cooperation of, and awareness of undernutrition among
care home staff, the majority of whom were unqualified.
The greatest improvements in energy intake and weight
were seen in homes with co-operative and interested staff.
This is a worrying and pervasive problem. If a simple
supplementation programme were to be considered for
volunteer use, consideration must be given to educating
and training staff.
Limitations
Undernutrition is stated to affect wellbeing/quality of life
(Larsson et al., 1995; Beattie et al., 2000; McMurdo & Witham, 2007), although the relationship between the two is
reported as being unclear. Quality of life may be of greater
importance to older people than prolonging life (Hickson
& Frost, 2004). Well being/quality of life was included as
an outcome measure in the present study. Attempts were
made to assess this using the EuroQol 5D (EQ5D) pre
and post-intervention, because this tool has been used in
similar studies (Smoliner et al., 2008). However, the frailty
of participants in the present study meant they found it
impossible to comprehend fully the questions included in
the EQ5D and respond appropriately, as also reported by
others (Hickson & Frost, 2004). A measure of well being/
quality of life would have been of value to indicate
whether any effects from increased energy intake and a
stalling of weight loss were translated into improvements
in well being or functional capacity.
Conclusions
The finding that no undernourished residents were identified before the present study suggested that nutrition was
not a priority in caring for older people, with nutritional
management representing a poorly-defined part of their
routine care. Regular weight checks and/or the use of
screening tools could avoid undernutrition being overlooked.
The present study has highlighted the difficulties of
carrying out a clinical trial in such a frail dependent
group. The present intervention did not achieve statistically significant between-group differences in energy
intake or weight change; however, increased energy
intake in intervention subjects did lead to significant
weight gain. This suggests that food enrichment, which
is advocated by NICE (2006), holds promise with
respect to addressing undernutrition in care homes at
least. Future interventions of a longer duration, a larger
sample size and tailored to individual tastes are needed
to confirm or exclude the value of food enrichment to
address undernutrition. Additional data collection on
ª 2012 The Authors
Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.
Diet enrichment for under nourished older people
recent weight change and functional capacity may also
be of value in the evaluation of food fortification.
Acknowledgments
We thank GSK for financial support, Dr Fiona Wallace
for advice and guidance, and Crossreach for access to the
care homes.
Conflict of interests, source of funding and
authorship
This study was funded by GlaxoSmithKline (GSK). HT is
employed by GSK. The remaining authors declare no
conflict of interest. All authors critically reviewed the
manuscript and approved the final version submitted for
publication.
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ª 2012 The Authors
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