How can we help patients in long-term care mindlessly eat more?

The cause of malnutrition is multi-factorial and patients in long term care (LTC) are at increased risk due to swallowing disorders, disabilities and health issues (2). The Canadian Malnutrition Task Force (CMTF) reports that 45% of elderly patients in LTC are malnourished (1). The traditional food first model of nourishment can provide patients with adequate energy through meals and snacks, but what do we do if the patients aren’t eating what they are given? Before rushing to recommend nutritional supplements, let’s consider what other options we have.

Mindless Eating is a concept that has been studied over the past decade by food psychologists and focuses on how eating behaviours are influenced by environmental factors causing individuals to “increase consumption norms and decrease consumption monitoring” (8). In other words, environmental cues can affect our eating behaviours, causing us to stop paying attention to what we’re eating which results in overeating. The numerous studies in this area have identified several ways that we can change our environment to prevent us from overeating. In LTC, overeating is something that may be beneficial for a large proportion of the population, so why not try manipulating the environment to promote increased intake

The complete dining experience can be seen as a combination of the eating environment and the food environment. The eating environment consists of factors that are associated with food but independent of food. This includes atmospherics, food accessibility, social interactions, and distractions. The food environment consists of factors that are directly related to the way food is provided or presented (7). Let’s examine each of these a bit more closely to see what principles can be manipulated in LTC foodservice settings.

The Eating Environment

The atmosphere or physical environment encompasses the light, temperature, colours, smells and sounds, all of which can be varied. Bright lights have been found to activate humans, causing them to eat faster, whereas warm light is considered to be relaxing and slows down movements. Dim lights promote disinhibited eating leading to longer duration of meals and increased intake (6). Warm environments seem to decrease intake, while the cold encourages increased intake (6). Colours and other visual cues from the walls, carpet, paintings window or furniture placement cause an environment to be perceived as either stimulating or relaxing (5,6). Smells play an important role in stimulating appetite and unpleasant odours may decrease the desire to eat. We seem to be more sensitive to smells before and during meals and good smells will actually make our food taste better (6). Background noise in general increases intake and appropriate music selection can decrease feelings of depression and anxiety, leading to a more pleasant dining experience (6,7). Overall, these findings suggest that a relaxing environment is conducive to increased intake (5,6,7).

Food accessibility refers to the effort required to get food. When food is more readily available to us, we have the tendency to eat more (5,7). Social interactions, such as who and how many people are present for a meal, have a significant impact on intake. Family and friends produce relaxation which increases the length of mealtimes (6,7). It is suggested the number of people at a meal is positively correlated with the amount of food consumed (6).

Distractions are anything that will divert attention away from eating. These include watching television, listening to the radio or books on tape, or reading (6,7). There is often increased intake when distractions are present because people stop paying attention to how much they are eating. Additionally, some distracting behaviours can become associated with eating such as the need to eat while watching television (5,6).

The Food Environment

The overall presentation of a meal will determine how appetizing it appears and therefore how much will be consumed. Factors that have an influence here include the colours, shapes, portions, packaging, and temperatures.

The colour of food tells us how good it will taste. Food is more appealing and tastes better if it brighter in colour (6). The colour of food can be intensified or muted depending on the colour of the dish in which it is served. If food is served in a dish that contrasts the colour of the food, the colours will be intensified and food will be more appetizing (4). We may also have emotional responses to some colours, which will affect our mood and how we perceive the flavor of a food or beverage (3).

Shapes and sizes of plates, bowls, glasses and utensils have a strong influence on our intake. The sizes of these items serve as indicators of what is an appropriate amount to serve and consume (7). The size of a dish can change our perception of how much food is actually on it. The same amount of food will look like much less when on a 12” plate compared to an 8” plate. Additionally, the shape in which food is presented impacts our perception of quantity. For example a round scoop of mashed potatoes will appear smaller than the same amount spread out (5). The shapes and sizes of our tableware are directly related to portion sizes. The portions that are served suggest an appropriate amount of food to consume. Increasing portion sizes will increase intake even for unfavourable foods which may be related to the “clean your plate” mentality that many of us have (5, 7).

Food temperature is an important factor which can influence the acceptability of a food. Food is most acceptable when it is served at what is considered a usual temperature for the person receiving it. This usual temperature is based on past experience and exposure with that item. It is also suggested that hot foods are preferred in cold weather and cold foods preferred in hot weather (6).

Packaging is another factor within the food environment. Packaging can impact intake in two ways. The physical shape or size of a package will influence our perception of portion size and intake rate. For example, bottles or cups with a wider openings produce faster drinking. Additionally packing can affect our perceived accessibility to food. When packaging is clear we are able to see the food which promotes intake, whereas opaque packaging may cause us to forget that a food item is present (6,7).

Mindless Eating in LTC

It is easy to identify several of the ways that the eating environment can be altered in a LTC setting to encourage increased intake, many of which will require little or no additional costs. It can be made more relaxing through changing the lighting, colours, smells and sounds to make it feel more home-like. Changes such as dimming the lights, adjusting the temperature and playing enjoyable music are simple changes that require very little additional effort from staff.  Making food more accessible is also something that can be done with minimal effort. This would involve doing things such as making sure food items are within reach, unwrapped or uncovered. Using clear lids and packaging would make foods visible and more likely to be consumed.

Central dining rooms are already used in most LTC facilities (2), but encouraging family and friends to stay during mealtime could make the social experience even more pleasurable. Additionally, lengthening mealtimes within reason could positively influence intake. Patients in LTC often require some assistance at meal times. When feeders are responsible for several patients, they may feel rushed and stressed to get all patients fed within the designated time frame, which may be transferred to patients – this burden could be remedied through an extension of meal times. The company of family or friends can have a calming effect on patients, so having them present could help to reduce the feelings of anxiety that may come with meals for some patients. Central dining rooms also offer a good venue for providing distractions such as showing a television show or movie, playing talk radio or a book on tape.

Changing the food environment is also possible within the LTC setting, though will require more effort and cooperation from food service and in some cases a financial investment. Reassessing the menu while keeping in mind the tableware that is available can help identify meals that may be bland in appearance. For example, white fish or mashed potatoes served on a white plate would be seen as less appetizing than the same items served on a coloured plate.  Without making major changes to the menu a few of the things that can be done are finding new ways to plate foods and adding of garnishes that create visual interest and appeal.

Think about the different ways that the environment might be influencing intake in your patient population and what changes are feasible at your facility. Encouraging mindless eating is one way we could try to produce a reduction in the incidence of malnutrition and improved patient outcomes in LTC.

References

1. The Canadian Malnutrition Task Force. Toronto: Abbott; [cited 2013, Dec 16]. Malnutrition is a Big Problem in Hospitals; [about 3 screens]. Available from: http://nutritioncareincanada.ca/files/CMTF-Brochure-Eng.pdf
2. Dietitians of Canada: Ontario Long Term Care Action Group. Best Practices for Nutrition, Food Service and Dining in Long Term Care Homes. Dietitians of Canada. April 2013. Available at: http://www.dietitians.ca/Downloadable-Content/Public/2013-Best-Practices-for-Nutrition,-Food-Service-an.aspx
3. Harrar V, Spence C. The taste of cutlery: how the taste of food is affected by the weight, size, shape, and colour of the cutlery used to eat it. Flavour. 2013. 2(1):21.
4. Piqueras-Fiszman B, Aldaide J, Roura E, Spence C. Is it the plate or is it the food? Assessing the influence of the color (black or white) and shape of the plate on the perception of the food placed on it. Food Quality and Preference. 2012. 24: 205-208.
5. Sobal J, Wansink B. Kitchecapes, Tablescapes, Platescapes, and Foodscapes: Influences of Microscale Built Environments on Food Intake. Environment and Behaviour. 2007. 39(1): 124-142.
6. Stroebele N, De Castro JM. Effect of Ambience on Food Intake and Food Choice. Nutrition. 2004. 20: 821-838.
7. Wansink B. Environmental Factors That Increase the Food Intake and Consumption Volume of Unknowing Consumers. Annu. Rev. Nutr. 2004. 24: 455-479.
8. Wansink B. From mindless eating to mindlessly eating better. Physiology and Behaviour. 2010. 100: 454-463.