Journals of Gerontology Series A: Biological Sciences and Medical Sciences Large Type Edition
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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60:125-128 (2005)
© 2005 The Gerontological Society of America

Using the FoodEx-LTC to Assess Institutional Food Service Practices Through Nursing Home Residents' Perspectives on Nutrition Care

Bronwynne C. Evans1, and Neva L. Crogan2

1 Arizona State University College of Nursing and Healthcare Leadership, Tempe.
2 University of Arizona College of Nursing, Tucson.

Address correspondence to Bronwynne C. Evans, PhD, RN, Arizona State University College of Nursing, POB 872602, Tempe, AZ 85287-2602. E-mail: bronwynne.evans{at}asu.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Undernutrition occurs in approximately 2 of every 5 nursing home residents, negatively influencing their health and quality of life. The purposes of this study were to collect data about institutional meal preparation and food service practices that promote or retard adequate nutritional intake and to evaluate residents' food and food service satisfaction.

Methods. The FoodEx-LTC, a simple, 44-item, 5-subscale questionnaire that measures food and food service satisfaction, was administered to 61 residents. Serum albumin and body mass index gauged the nutritional status of each resident. SPSS for Windows, version 10, was used for analyses.

Results. Overall, 89% of residents were satisfied or somewhat satisfied with the food service. Of those who ate in the dining room, 44% had to wait to go back to their rooms, presenting a quality of life issue. Fifty-two percent received food they hated, 56% often received the same food, and 59% received food always cooked the same way. Most residents (75%) felt comfortable refusing food they did not like, but 65% did not complain. Most (79%) wanted to choose what to eat, but only 54% believed that choosing when to eat was important.

Conclusions. The FoodEx-LTC, used to monitor nutrition care in nursing homes, incorporates residents' views into service delivery and responds to the Health Care Finance Administration's Nutritional and Hydration Awareness Campaign, part of the federal Nursing Home Initiative. Using the FoodEx-LTC to identify residents' perspectives may promote resident satisfaction and dietary intake through adaptation of nursing home food and food service practices.

UNDERNUTRITION is a common, multidimensional, frequently undetected problem for approximately 2 of every 5 nursing home residents, negatively influencing their health and quality of life (1–3). Undernutrition can be defined as any insufficient dietary intake of essential nutrients and may result from risk factors such as chronic illness; polypharmacy; dietary restrictions; mechanical problems resulting from ill-fitting dentures or loss of teeth; normal changes of aging in taste, smell, and satiation; lack of choice and control in relation to food; loss; dependency; loneliness; and depression (4–8). In long-term care facilities, undernutrition results in diminished efficacy of treatment, increased complications and costs, and decreased resident satisfaction (9).

Plate waste studies and estimation of nutritional intake by nursing home staff may help determine actual amounts of food consumed by residents (10–12). However, evaluation of institutional practices that control the food that arrives on the resident's table, and the resident's satisfaction with this food, are important factors to identify the influence of these practices on individual consumption (13). The purposes of this study were (a) to collect preliminary data about institutional meal preparation and food service practices that promote or discourage adequate nutritional intake and (b) to examine residents' food and food service satisfaction.


   METHODS
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 Abstract
 Methods
Results
 Discussion
 References
 
Sampling
Participants were recruited from 4 nursing homes in the southwestern region of the United States. To be included in the study, residents had to be 65 years or older, have lived at 1 of 4 nursing homes for at least 1 month, be able to make themselves understood, and have adequate cognitive skills for daily decision-making, as determined by a Mini-Mental Status Examination score of at least 18.

FoodEx-LTC
Qualitative and quantitative data complement each other as we try to understand nutritional problems in nursing homes (1). We conducted 20 in-depth interviews with nursing home residents regarding positive memories associated with food, and the strengths and weaknesses of the food and food service in the facility. Qualitative analysis of these interviews served as the basis for the development of the FoodEx-LTC, a simple, 44-item, 5-subscale questionnaire that measures resident food and food service satisfaction. The FoodEx-LTC may be self-administered or interviewer administered and can be used across long-term care settings. Forty-one items may be answered as "true," "somewhat true," "somewhat false," and "false." The remaining three items (the subscale entitled "Exercising Choice") require responses to the question "How important to you is ...?" with answers ranging from "important" to "not important." Content validity and internal reliability of the FoodEx-LTC are reported in another publication (14).

Procedure
A master's degree–prepared nurse met with each resident, obtained informed consent, and administered the FoodEx-LTC. The nurse read each item to the resident and scored it based on the resident's response. We used SPSS for Windows, version 10 (SPSS, Chicago, IL), to generate descriptive statistics for the analyses. We used biological parameters of serum albumin and body mass index to gauge the nutritional status of each resident at the time of the interview. We found no significant correlations between body mass index and the subscale scores. The Pearson's r values and the significance (noted in parentheses) were as follows: subscale 1, –.054 (.362); subscale 2,.219 (.072); subscale 3,.203 (.091); subscale 4, –.132 (.194); and subscale 5,.196 (.096).


   RESULTS
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 Abstract
 Methods
 Results
Discussion
 References
 
Sample
Sixty-one older adults participated in the study. Of the 61 residents, 11 (23.9%) had a body mass index less than 22, suggestive of undernutrition, and 16 (28.6%) had albumin levels less than 3.5 g/dl. <--?1-->Albumin levels are often used as a biochemical index of undernutrition in older adults, although albumin has a long half-life (5). Table 1 lists the age and sex of the participants.


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  		Table 1. Demographic Characteristics.

 
Subscale 1: Enjoying Food and Food Service
Subscale 1 measured resident enjoyment of food and food service. Table 2 lists individual item means and medians. Most responses indicated that residents generally enjoyed the food served in the nursing home. However, of those who ate in the dining room, 44% reported that they had to wait to go back to their rooms, which may be construed as a quality of life issue. Furthermore, when asked about the food served during the past week, most residents (52%) reported receiving food they hated. In addition, 56% of residents reported that they often received the same food and 59% reported that the food was always cooked in the same way.


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  		Table 2. Results for FoodEx Subscales One Through Five.

 
Subscale 2: Exercising Choice
Subscale 2 measured the residents' ability to exercise choice (Table 2). Most residents (75%) reported that they felt comfortable refusing food that they did not like. In contrast, 65% of residents reported that they did not complain about the food to enhance their satisfaction with meals. Most (79%) wanted to choose what to eat, but only 54% believed that choosing when to eat was important.

Subscale 3: Cooking Good Food
Items in subscale 3 focused on cooking good food (Table 2). Most residents described facility staff in a positive light. For example, 78% believed that staff knew how to prepare a meal. Seventy-two percent believed that the staff had experience in food service, and 75% believed that staff knew how to make food look presentable. However, only 57% of residents believed that staff thought of clever ideas regarding food and food service, indicating a need for improvement. Overall, 88% of residents reported that they were satisfied or somewhat satisfied with the food served at their nursing home.

Subscale 4: Providing Good Food Service (the Negative View)
Subscale 4 addressed food service issues affecting meal times (Table 2). For example, 85% of residents agreed that staff ordered or fixed sufficient food for meals. Seventy percent agreed that staff did not have trouble cooking for large groups. However, 41% of residents reported that staff sometimes had trouble getting the meal ready on time, and 23% of residents agreed that food was poorly prepared or served because of equipment problems.

Subscale 5: Providing Good Food Service (the Positive View)
In subscale 5, residents expressed their overall satisfaction with the food service within their nursing home. Most responses (Table 2) were recorded as true or mostly true, indicating that most residents believed that they received freshly cooked foods, fresh fruits and vegetables, and the right amount of food, all served at the right time. Residents reported that kitchen staff worked hard to serve food everyone liked, cared about the food they served, and were friendly and courteous. Overall, 89% of residents were satisfied or somewhat satisfied with the food service.


   DISCUSSION
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 Methods
 Results
 Discussion
References
 
Elders require adequate caloric intake, but if nursing home residents do not enjoy their meals, they may eat sparingly (6). However, little is known about why residents fail to eat. It has been suggested that the quality of care, including staffing and provision of foods that residents enjoy, may affect their consumption (3,6). The FoodEx-LTC can help differentiate those residents at risk for undernutrition because of poor food quality or lack of attention to their food preferences, and it can facilitate prompt alteration of dietary services.

Residents expect familiar, good-tasting foods that are presented well, and residents are more satisfied with their care when these expectations are met (15). However, in this study, more than one half of the residents regularly received food they disliked and a lack of variety of foods. This finding is especially troubling because repeated consumption of flavorful meals is needed to increase daily feelings of hunger, dietary intake, and body weight (16).

A liberalized geriatric diet fits most prescriptions for long-term care residents (17,18). In this study, most residents wanted to choose what to eat. Offering a variety of delicious, well-prepared foods that satisfy residents, rather than simply serving a larger amount of unappealing foods, results in increased intake. In fact, the mere provision of larger food amounts for nursing home residents with decreased body mass index may actually result in decreased food consumption (19).

Although food quality is the best predictor of satisfaction with meals (20), residents also should be asked about satisfaction with the interpersonal aspects of food service. In this study, residents did not believe that staff took the trouble to cook creatively, although they did view staff as caring about the food they served. Residents also were not confident that they would be returned to their rooms promptly after meals. It is possible that toileting issues arising during this prolonged interval in the dining room might reduce residents' willingness to consume adequate amounts of food and fluids.

The quality of interactions between nursing home residents and nursing assistants, the personnel most often directly involved in meal service, also affects the amount of food that residents consume (21). However, hesitancy in expressing negative feelings about food or food service in the dining room can occur because of feared retribution from staff, or because complaining in public is perceived as socially unacceptable. This hesitancy can even extend to remaining silent about disgusting food (13,22) but can be overcome when the FoodEx-LTC is administered privately, away from the dining room and the food service staff.

Conclusions
This study shows that although many residents enjoy food in the nursing home, they may not complain when they are unhappy. Consequently, staff must actively solicit this information through instruments such as the FoodEx-LTC. In addition, residents' prolonged wait in the dining room after meals may make them reluctant to consume adequate amounts of food for fear that they will not have access to the toilet.

Meal service and food quality affect quality of life (23). Some of these residents received food they hated, and they were served the same food time after time, always prepared in the same way. One of the greatest advantages of the FoodEx-LTC is that it addresses residents' perspectives, positively affecting its practical utility and validity (24,25). Using the FoodEx-LTC to identify perspectives such as these and incorporate residents' views into service delivery may promote resident satisfaction and dietary intake (26). The challenge is to acknowledge residents' wishes through patient-oriented, rather than task-oriented, meal procedures and link physical status to food and food service (13).

The FoodEx-LTC responds to the Health Care Financing Administration's Nutritional and Hydration Awareness Campaign, an integral part of the federal Nursing Home Initiative (2). Using this instrument to monitor nutrition care in nursing homes is an objective approach to documenting the need for changes in service delivery and intervening in residents' food and food service before undernutrition occurs.


   Acknowledgments
 
Supported in part by a grant from the Lawrence Emmons Research grant program, University of Arizona, College of Nursing, Tucson, Arizona.


   Footnotes
 
Decision Editor: John E. Morley, MB, BCh

Received July 21, 2003

Accepted September 15, 2003


   References
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 Abstract
 Methods
 Results
 Discussion
 References
 

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