Community Meal Services Challenges for Dietitians

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Community Meal ServicesChallenges for Dietitians

• Nutrition Professionals Australia

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Community Meals Services- For who?

• Frail elderly
• Poor food security
• Poor nutritional health
• Increasing demand for services
• Food safety issues
• Poor mobility
• Multiple risk factors for malnutrition

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Nutrition related issues for clients

• Energy needs decrease with age (despite this many
  are still taking insufficient)
• Low intake of protein, zinc, calcium, iron
• Fibre intake poor
• Fluid intake inadequate

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Community Meals Services-Whats required

• Funding arrangements for MonW are different in
  each state
• In SA 80 of funding comes from meal sales and
  the remaining 20 comes from Home and Community
  Care, a joint Federal and State Government
  program
• SA Govt requirement is for a nutritious meal

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Meals on Wheels Food Guide

• 1977 Commonwealth Department of Health nutrient
  guidelines for MOW
• The aim of Meals on Wheels (MOW) services is to
  improve the health of the client by providing a
  nutritious meal
• These remain the only Australia- wide guidelines

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Best Practice Guidelines??

• 1977 guidelines for MOW state that a MOW meal
  should aim to provide
• Two-thirds of the (RDA) of vitamin C,
• one half of the RDA of other vitamins, protein
  and minerals and at least one-third of the
  calories for energy
• A meal is defined as a main course of meat or
  fish with vegetables or salad. A soup or sweet
  must also be provided.

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Best Practice Guidelines??

• 1977 Commonwealth nutrient guidelines are not
  referenced
• Who decided?
• The Recommended Daily Allowances (RDAs) used were
  developed in 1954 and reviewed in 1971.
• These have been superseded by the 1991 RDIs.

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Best Practice Guidelines?

• Vitamin C containing beverages have historically
  been provided to recipients of MOW.
• The reason for this is unclear, as none of the
  studies on nutrient intake in delivered meals
  recipients in Australia show a deficiency in
  vitamin C intake.
• Despite losses of vitamin C in preparation and
  storage, intake of vitamin C in the diets of MOW
  recipients is more than adequate for the majority
  of the recipients
• Need for a supplement seems to have no evidence
  base

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Best Practice Guidelines?

• Fibre is not mentioned in 1997 Cwlth Guidelines
• Is it feasible to aim for 1/3 of 30g of fibre?

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Best Practice Guidelines?

• Since 1997 the population of older Australians
  has grown dramatically, and so has the number
  receiving home delivered meals
• There has not been a formal review of the
  guidelines for MOW service to older Australians
  since
• Achievement of the nutrient provision goal has
  not been evaluated to any significant extent.

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Do Meals on Wheels meals meet targets?

• Pargeter (1986) Nutrient intakes form delivered
  meals did not fulfil Cwlth recommendations for
  energy, protein, calcium and zinc
• Northern Sydney AHS (1993) Meal sizes differed
  significantly between 4 different food services.
  Portion sizes governed by sizes of foils and
  judgements of catering staff

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South Australia

• SA Govt requires a nutritious meal
• Meal provides a minimum of 1/3 of RDIs for a 70yo
  man or woman
• Soup
• Main meal
• Dessert
• Criteria re minimum quantities required to ensure
  RDIs are met

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Best Practice?- Other states

• WA (1992)
• To obtain the maximum subsidy, meals should
  include an approved vitamin C supplement and
  most food on the menu should be low in energy
  density (ie. low in kilojoules) and high in
  nutrient density (ie. high in nutrients per
  kilojoule).
• Menu items should be based on the Dietary
  Guidelines for Australians,
• ( these were replaced in 1999 by the Dietary
  Guidelines for Older Australians 1999 )

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Other states

• New South Wales
• The daily requirements provided by Meals in
  Wheels when one meal per day (soup, main meal and
  dessert) is supplied will be at least
• 1/3 RDI for calcium
• 1/3 for fibre
• 1/2 RDI for protein and other vitamins and
  minerals
• 1/3 RDI for energy"

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Other states

• Queensland
• 1/3 of RDI for energy and calcium
• ½ of RDI for other nutrients

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Other Countries

• United Kingdom
• Based on the Recommended Meal Standards 1995
• Minimum nutrients specified
• Main course 330-400g
• Dessert (there is a list of variations to this
  quantity) 120-200g
• Total for provision 480-600g

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Other countries

• Canada
• On average, the entrees provide 400 calories,
  desserts 200 and soups 100 calories.
• A soup, entree and dessert provide over 40 of
  the RNI for calories for women over 75 and 36
  for the RNI for calories for men over 75.
• All the entrees provide over 40 of the daily
  protein requirements for men and women over 75.

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Other countries

• United States
• On average, each meal must provide a minimum of
  one-third of the daily RDAs established by the
  Food and Nutrition Board of the National Academy
  of Sciences National Research Council. The meals
  must also comply with the Dietary Guidelines for
  Americans, published by the Secretaries of DHHS
  and USDA

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Special Diets

• No guidelines exist re which special diets should
  be provided and how to manage them
• SA Normal meal
• Diabetic (whole menu is diabetes friendly)
• Soft minced
• High energy high protein
• Light bland
• Vegetarian
• Vitamised
• Other states???

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Skills of cooks

• In SA cooks are volunteers with varying skill
  levels
• Interstate, cooks may be employees
• Which is better?
• Who provides a superior service?

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Meal utilisation?

• How much is actually eaten
• One Canadian study showed 81 of the meal is
  eaten. Soup and dessert most well utilised
• Reasons dislike of the food, poor taste,
  unpopular cooking method, disagreeable texture,
  unfamiliarity

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Meal Utilisation?

• Recipients often split the meal
• Challenge is to ensure they understand that the
  meal provides only 1/3 of requirements
• Challenge is to ensure cooks, welfare officers
  and deliverers also understand that the meal
  provides only 1/3 of requirements

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Other meals?

• If a recipient requires one meal, what about the
  others?
• Need for a package for other meals?
• Breakfast, snacks, lunch

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Feedback from recipients

• Difficult
• Recipients fear of exclusion from the service if
  they criticize it
• View that MonW is a charity and what can you
  expect?
• Pargeter and North Sydney AHS
• 86 and 84 expressed satisfaction

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Nutrition screening

• Widespread in Victoria
• Piecemeal in other states
• Conducted by metropolitan Welfare Officers in SA
  using Victorian HACC tool
• Linked with provision of a high energy and
  protein diet
• Requires strong links to other support agencies

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Multi-Cultural meals

• What are the guidelines and standards for
  culturally diverse groups?
• Standard menu structure may not suit

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Knowledge base of volunteers

• In SA, all cooks, drivers and deliverers are
  volunteers with their own beliefs about nutrition
  and special diets
• Little or no understanding of the needs of those
  that are receiving meals

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Other meal providers

• Do other providers comply with guidelines?
• Often small backyard organisations
• No standards exist

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Conclusion

• Nutritional status of Mon W recipients is at risk
• Nutrition needs of the recipient must be
  considered
• There is a lack of national guidelines
• Difficulties in obtaining reliable info on
  consumption and preferences
• Knowledge base of providers is variable

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Thankyou