To avoid malnutrition in seniors, ‘tiny little interventions’ can go a long way

Aug 24, 2023

Chef Joshna Maharaj prepares a batch of mango shortbread sandwich cookies. She works with institutions to redesign their food services, including hospitals, where she learned a lot about making meals more accessible to elderly people.Fred Lum/The Globe and Mail

There's a story that Joshna Maharaj tells about her time designing meals for elderly patients in hospitals.

It starts with a conversation the chef-activist had with a hospital administrator. The kitchen staff at the hospital had found a way to inject an extra shot of carbon dioxide into the sandwich packages they served to patients.

"They were boasting to me about it," recounts Ms. Maharaj. "It meant the sandwiches could sit in the fridge for an extra seven days."

From the administrator's perspective, this was a boon for the hospital: It meant higher efficiency, and lower costs.

But the CO2 also meant that the triangle sandwich packages had to be reinforced with extra adhesive. And that made them more difficult to peel open.

Among older populations, dexterity challenges are a common problem, and a well-known symptom of dementia, Alzheimer's and Parkinson's disease. So the thick, finicky plastic was frustrating – sometimes impossible – for patients to manoeuvre.

"The patients can't open the packages. And there aren't enough staff to help," said Ms. Maharaj. "So they don't eat."

That alone, she says, would have been a tragedy.

But further compounding matters is that, in those same institutions, the nutritionist in charge doesn't always talk directly to the patient about why they aren't eating.

"And then, the worst-case scenario happens," said Ms. Maharaj. "A bottle of Boost or Ensure ends up on the tray next time." Instead of proper meals, the patient is left with a meal supplement.

Hand-held food can make it easier for seniors to get their nutrition, but complex packaging or cutlery can be barriers, Ms. Maharaj says.Fred Lum/The Globe and Mail

It's a story that illustrates a much bigger problem: In Canada, over one-third of adults over the age of 65 are at risk of malnutrition. This, in turn, puts them at higher risk of a long list of other diseases, as well as frailty, falls, and hospitalization. The problem has a disproportionate effect on certain segments: Those living alone or experiencing depression, for example, are at a higher risk. But malnutrition is prevalent in institutional settings too, including hospitals and long-term care centres. And it's a problem that cuts across income level, class and gender.

Ms. Maharaj is a former restaurant chef who, about a decade ago, turned her focus to food at large institutions. What she's learned is that, yes, many of the problems are deeply entrenched and systemic. Many retirement and long-term care homes are run by large corporations, with accountants making decisions based on cost. Other institutions, such as hospitals, rely on government funding – on the whims of elected officials serving four-year terms, and doling out scarce, short-term grants.

But the point of the sandwich story is that small changes can make a difference too. Sometimes it's about thoughtful design. In some cases, small adaptations – a specialized piece of cutlery, for instance, or a different dining-room layout – can result in older adults having more autonomy over their experience. And that can make all the difference to their health, pleasure and dignity.

For Ms. Maharaj, an intervention might be as simple as a muffin pan.

When she was hired by Trillium Health in Mississauga two years ago to create a new menu for the hospital's geriatric unit, she focused on hand-held, nutritious foods: dishes that elderly patients could enjoy without struggling with forks and knives. She used the muffin pan to create little "pucks" of food. Shepherd's pie "muffins." Spaghetti baked into a puck with melted cheese – noodles the patients could hold in the palm of their hand, instead of fiddling with a fork.

"Tiny little interventions," she said, "that can really open up an experience for someone."

Consider the problem: One-third of adults in Canada are at risk of poor nutrition, which can include malnutrition.

This means that they say they skip meals "almost once a day," have lost significant amounts of weight (10 pounds or more in the past six months), or follow a poor diet with fewer than two servings of fruits and vegetables a day.

Poor nutrition would be a problem for any age group. Already, diet-related diseases (such as diabetes or cardiovascular disease) are among the leading causes of death in Canada: a well-documented problem that costs our health-care system some $26-billion each year.

But older populations are especially vulnerable, given that they need higher amounts of specific nutrients, including calcium, protein and vitamin D.

Inadequate intake of these can lead to quicker loss of muscle mass and subsequent weakness, which can lead to falls and other serious health risks.

And given the size of this demographic, the problem is an urgent one. Already, almost one-fifth of Canadians are aged 65 and older. By 2035, that number is expected to be one in four.

A retirement-home resident gets an order of pureed salmon. Pureed foods can be a boon for elderly people who have trouble swallowing.Tuan Minh Nguyen/The Globe and Mail

Still, it's a problem that's often overlooked.

In institutional settings dedicated staff members might be able to help those with extreme challenges, said Heather Keller, the Schlegel Research Chair in nutrition and aging at the University of Waterloo. This might include problems with swallowing, which results from reduced strength in the throat. Diseases like dementia and Parkinson's, too, can lead to difficulties with chewing or swallowing. Loss of appetite and dental problems are also common among older populations.

But even in institutional settings, said Prof. Keller, older adults might find their challenges go unrecognized. Busy or overworked staff may not notice someone who is just beginning to experience trouble with dining – for instance, someone in the beginning stages of dementia who simply loses interest in the middle of a meal.

"They might just eat a little bit on their plate, and the staff will go, ‘Oh, they’re just eating less,’" she said. "So they don't intervene."

Outside of long-term care settings, said Prof. Keller, the problem becomes even more difficult to monitor. Older people living at home or with families may not understand or know to seek help.

For these groups, said Prof. Keller, there might be additional challenges in accessing food – there may be no grocery store nearby, for instance, or a shopping cart may be too heavy to push around the supermarket. On top of dexterity problems, muscle weakness might leave them unable to use a knife, or can opener.

Connie Price, 61, says the physical effort of preparing fruits and vegetables has become daunting due to her health.Tuan Minh Nguyen/The Globe and Mail

Connie Price, for instance, is 61, but because of a number of injuries and health conditions (some of which are exacerbated with age), she found herself having more and more trouble cooking.

"I like a lot of fruits and vegetables, and that takes a lot of preparation," she said. "And either I couldn't stand long enough to wash it, or have the strength to chop it," she said.

"It was getting harder and harder to do things in a safe way."

Beyond cooking, common dining implements, such as utensils and dishes, can create barriers that might be addressed by simple design tweaks. Prof. Keller, for example, has experimented with using coloured dishware that contrasts with the colour of the meal. Up to a quarter of older adults with vision loss found the coloured plates made it easier to distinguish between food and plate.

Dutch product designer Louise Knoppert was inspired to create a line of dining tools for people who use feeding tubes, or have other conditions that cause difficulties in ingesting food. One of them, called "Sponge," sucks liquid up and squeezes it directly into a diner's mouth. Another is called "Dip," and brushes food directly onto the tongue. The tools let users experience flavour even if they have trouble with manual dexterity or with swallowing.

Ranee Lee holds the senior-friendly plates she made with industrial designer Amanda Huynh.Fred Lum/The Globe and Mail

Ranee Lee, who teaches industrial design at OCAD in Toronto, was motivated to create an accessible plate after watching her mother, Anna, who has late-stage Alzheimer's, struggling to feed herself at her nursing home.

At one meal, Anna tried, repeatedly, to get a piece of braised beef onto her fork. She pushed the meat from one edge of the plate across to the other, watching it fall over the side and onto the table.

"I thought, ‘There must be other ways of doing it without making them have to fight and struggle,’" said Ms. Lee.

So Ms. Lee enlisted the help of her friend Amanda Huynh, a fellow industrial designer, and together they developed a ceramic plate with raised ridges in the centre, in the shape of concentric circles. The ridges act as a kind of barrier to prevent food from falling off the plate, and make it easier to lift food up with a fork or spoon.

The goal was to create something functional, but also beautiful. Something that looked and felt grown-up – not infantile, like the trays and tableware used by some nursing homes. They also wanted something that was culturally appropriate for Ms. Lee's mother, who is ethnically Chinese. The circles are a common theme in Chinese plateware, and they also help facilitate Chinese meals, which are usually served with just chopsticks and a spoon.

It's a design they’re hoping might be adopted by nursing homes, but that would blend into the tableware of most private homes, too.

"It's this opportunity for a really dignifying experience," said Ms. Huynh. "Food is at the core of who we are. We want to be validated through what we eat."

The Rudermans have lunch together with Sophie Krausz at Baycrest Terraces. The retirement home's dining room was redesigned a few years ago to give residents more choice in where (and with whom) they sit, and whether they need assistance or not.Tuan Minh Nguyen/The Globe and Mail

It's lunchtime at Baycrest Terraces in north Toronto.

Some 180 residents live at the retirement community, in a mix of independent, assisted-living, and fully-assisted apartments. At about quarter to one, a group of five residents sit around a dining table, enjoying the sun filtering in through floor-to-ceiling windows.

This is where Ms. Price, the woman who had been having difficulty chopping fruits and vegetables, now lives. Her challenges had progressed to the point where she had to use a wheelchair to get around, and could no longer live on her own.

Ms. Price describes how, just a few years ago – after she had moved into Baycrest – she was hospitalized for extreme anemia. Once she returned to her Baycrest apartment, the kitchen staff took it upon themselves to prepare for her a long list of meals designed to address her iron deficiency.

"And look at your rosy cheeks now," says Marlene Ruderman, 91, a friend and fellow resident.

"143. Up from 53," says Ms. Price, reeling off her hemoglobin levels.

"Wow." Ms. Ruderman is impressed.

Ms. Price lists off the dishes the staff made especially for her. "Liver, beef tongue –"

"How was it?" asks Ms. Ruderman.

"Um." She pauses. "Yeah," she says finally. "They did well with it."

Ms. Price credits the kitchen staff with preparing foods to help get her iron levels up.Tuan Minh Nguyen/The Globe and Mail

The dining room at Baycrest was redone just a few years ago, painted dusty blue and sage, and decorated with white tablecloths and fresh carnations at every table. It looks like a restaurant you might find at a Marriott.

It's not just the aesthetic. Prof. Keller's research has shown that a social dining room – one where residents feel involved, and connected – are ones where they’re more likely to eat. Over the years, she's created training for long-term care centres on how to better design these spaces.

As much as possible, the program encourages institutions to give residents choice. This includes choice over where they sit, who they sit with, what they eat, and whether or not they want assistance.

At Baycrest, the space functions, more or less, like a restaurant. The dining room is open from 11:30 to 1:30 for lunch, and 4:30 to 6:30 p.m. for supper. Residents sit wherever they want, and order off of a menu. The facility serves a predominantly Jewish population, so everything is kosher. On Fridays there's Shabbat dinner, and the room is lit with candles.

And though the program at Baycrest was not designed specifically to adhere to Prof. Keller's guidelines, it follows many of the same principles.

"What I wanted to be looking at was, ‘What is the experience they’re getting?’" said Melissa Turzanski, program director at Baycrest. "Is it an experience that offers connections, autonomy and choice?" The experience comes at a cost: About $5,700 per month on average for an independent living apartment. (The average income of adults over 65 in Ontario in 2020, meanwhile, was just over $3,800 per month.)

Condiments are arranged beside a menu at the Baycrest dining room.Tuan Minh Nguyen/The Globe and Mail

Today's lunch at Baycrest is a choice between vegetable pad thai with crispy spring rolls, or salmon and spinach strudel topped with a creamy cheese sauce. Each option comes with pureed vegetable soup and a fresh salad. Dessert is strawberries with whipped cream.

When the food arrives, it's served on proper blue and white ceramic plates. There's real silverware, and salt and pepper on each table.

Ms. Price, who is gluten intolerant, orders off of the à la carte menu instead. She tucks into her plate of salmon, tuna and egg salad.

"There are trade-offs when you live in community," she says.

"You’ll hear one person say the soup is too bland, and another person say the soup is too salty. Because it's not like home," she said. "But for a community, this is so good."

Ms. Krausz, 81, enjoys her lunch.Tuan Minh Nguyen/The Globe and Mail

Another resident at the table, Sophie Krausz, 81, murmurs in agreement. Ms. Krausz follows a pureed diet, and today has ordered a pair of soft boiled eggs, a dish of pickled herring and pureed cantaloupe for dessert.

She tries, then pushes away, her ice cream. "I have everything that I want," she says.

The group seated around the table add up to almost 425 years of living. They represent a wide range of life experiences – travelling the world, acquiring PhDs, working as surgeons, entrepreneurs, and parents, grandparents, great-grandparents – and an equally wide range of views that they can spend many mealtimes disagreeing over. Except today, they all agree on this: At least the food here is good.

"Respect, I think, is the key thing," said Ms. Price.

"No matter where someone is, they should be treated with dignity."

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