Seven main themes related to the research questions could be identified from the interviews, which could be grouped into three topics: barriers for treating undernutrition in older adults (3 themes), current dietetic treatment (2 themes), and new strategies to complement current treatment (2 themes). The results are presented in this order.
Barriers for treating undernutrition in older adults
Theme 1: Loss of appetite and physical limitations in older adults
Decreased appetite and physical limitations of older adults were mentioned as barriers to comply with dietetic counselling. Both the dietitians and the older adults reported a decreased appetite within older adults leading to a decreased intake. Some of the older adults mentioned that they eat because they know they have to, or because their partner or children want them to eat.
“I used to eat when I was hungry, and that was okay. Nowadays I have no appetite and as a result everything is less tasty.” [man, 92 years, home]
“I don’t feel hungry, but I have to eat five slices of bread a day. That’s just a law, or a law.. well, you just really need to eat, right?” [man, 68 years, hospital]
Physical limitations were also an important barrier for complying with nutritional recommendations. Dietitians mentioned that it is too exhausting for many older adults to buy groceries and to cook a hot meal like they used to do. Switching to ready to eat meals that are delivered at home were mentioned as possible solutions. However, these meals are not always very well appreciated or the older adults use one meal for two days, which is not the intention.
“We always said that when people start with Meals on Wheels that they become undernourished within half a year.[…] older people do not order seven meals a week, but only three or four meals a week, and eat two days from one portion.” [D7]
Theme 2: Low awareness and knowledge among older adults on undernutrition
Dietitians mentioned that their older clients do not think of themselves as being undernourished. They have to educate older adults about undernutrition and its health consequences. The dietitians said that some of their older clients think that weight loss is positive and nothing to worry about at their age. Moreover, according to dietitians, older adults think eating less and losing weight is a normal consequence of ageing and their lower physical activity pattern.
“What I often hear is that they feel like they eat enough and they don’t need that much, because they don’t do that much anymore.” [D6]
Many of the older adults did not refer to themselves when they spoke about undernutrition, even though they were under treatment by a dietitian because of their poor nutritional status. They did not associate themselves with undernutrition but related it to hunger in developing countries or in times of war.
Interviewer: “When we mention ‘undernutrition among older adults’, what comes to mind?” Respondent: “No, nothing comes to mind.” [man, 74 years, hospital]
Interviewer: “If I talk about undernutrition, what comes to mind?” Respondent: “That you don’t get enough, actually by far not enough, food. I just think of for example the war, I lived through it, from’40 to’45. But for myself, I never have experienced real hunger, with all the farmers in this area, there was plenty of food. But in the cities, they did not get enough.” [male, 84 years, hospital]
Only after dietitians explained to the older adults that undernutrition can cause fatigue, muscle weakness or delayed wound healing, did the older adults start relating it to their own situation. When the older adults were asked what they thought would be healthy or adequate nutrition for their age, they mentioned bread, which contains fibre, and sufficient fruit and vegetables. Furthermore, they mentioned it is important to eat moderately; not too much sugar or fat and not too much in general.
“And then they tell me ‘well, older people need to eat a bit more.’ Well, that’s not true!” [woman, 87 years, hospital]
Theme 3: Late referral to a dietitian
Another issue that the dietitians raised is that physicians refer older adults to them too late. Dietitians in primary care mentioned that nutritional screening is not done routinely by the general practitioners (GPs) and they feel that they should be consulted much earlier to provide proper nutritional care.
“One GP refers more often to me than others. The other GP, if we look at primary care, does not refer patients. And often [when dietitians get consulted] I see that they are consulted too late and that the situation has been like this for a longer time.” [D12]
Dietitians working in a hospital did not mention late referral by a physician as being a barrier. Primary care and nursing home dietitians mentioned that not all physicians are aware that undernutrition is a health concern and they don’t feel valued enough by all doctors.
“For example, when we get someone who is being transferred from another nursing home or hospital. This person lost 5 kg in a short time, so he gets protein- and energy enriched snacks, but I wasn’t asked for a consultation after admission. So you ask the hospital nurses ‘how come?’ [response of nurses]: ‘Well, the doctor said, just wait a bit and see what happens, but we also did not really agree.’ So, will they also wait a bit with consulting a physical therapist and see if someone starts walking by themselves? Or maybe they will just swallow properly by themselves, or would they consult the speech therapist?” [D7]
In summary, the interviews in both groups indicated that physical limitations and loss of appetite were found to be major barriers to comply with dietetic recommendations. Furthermore, older adults are often not aware that they are undernourished and they lack knowledge regarding undernutrition and its health consequences. Lastly, according to dietitians, some physicians seem to be unaware of undernutrition among older adults, and consequently refer them too late to a dietitian.
Current dietetic treatment
The next two themes reflect on current dietetic treatment as provided by dietitians. The dietitians mentioned how they try to tailor their recommendations to the needs and habits of their patients and gave their opinion on the role of nutritional supplements in dietetic treatment.
Theme 4: Dietetic treatment and recommendations
Dietitians said to focus mostly on protein and energy undernutrition, not on micronutrients when we asked about their recommendations. The dietitians said that they try to educate older adults about the consequences of undernutrition and the accompanying complaints. Furthermore, they explained that their recommendations are based on a patient’s first interview: they listen carefully what foods their older clients like and dislike, and which eating patterns they have. According to the dietitians, their recommendations should fit into the needs and habits of the patient. Practical advice that most of the dietitians said to give is to take energy and/or protein rich snacks in-between three main meals. Another common recommendation was the use of full fat dairy products and double sandwich fillings. However, the dietitians also mentioned that older adults needed to be motivated and experience for themselves that eating more often could improve their condition.
“I always try to get six eating and drinking occasions in a day. To make sure that the three main meals are not too small but also not too big, and that they use three in-between meals.”
Interviewer: “And does this usually work?”
Respondent: “Yes, but they have to be motivated. Because they don’t enjoy eating and drinking so much anymore when they are sick. And now they have to think about food and drinks all day. If they notice that it helps, then they are willing to do it. But they have difficulties with it.” [D4]
The older adults themselves reacted diversely to the questions about the advice of eating snacks. Some of them liked that they can eat smaller meals divided throughout the day, because three big meals were difficult to finish completely due to rapid satiety. Others, however, mentioned that they found it hard to get used to eating that often during a day.
Theme 5: Regular products versus oral nutritional supplements
Dietitians mentioned that they preferred to increase intake with regular food products first because these are familiar to the older adults and better fit in with their eating habits. If that did not work, ONS were advised but dietitians mentioned these had a stigmatizing image and the taste is not well appreciated. Dietitians often mentioned that they told older adults to see ONS as medicine.
“Sometimes I say to people ‘Yes, that drink [ONS] is a small sip, and you maybe have to force yourself to drink it, but it is important that you take it and think of it as a medicine.’” [D3]
Some of the dietitians mentioned that not everyone likes the taste of ONS but this is different for every patient. This was confirmed by the older adults: they gave mixed reactions on the questions of what their experiences were with ONS. Some of them liked it because it was easy to use, but they did not like the taste. Others found the taste acceptable. Dietitians thought that the opinion of doctors, nurses, and dietitians about ONS matters. Care givers should not present it as a negative thing, although they might not like it themselves.
”What I notice, is that the way you talk about it to the patient makes a big difference. ONS have a bit of a negative image: ‘it is sweet and it is hard on the stomach for a long time.’ If you sell it like that, then nobody wants to use it. But if you say: ‘there is lots of protein in it, and it has a fresh tangy taste to it.’ That’s how you can sell it! So the way you talk about it, makes a big difference.” [D3]
In summary, the focus of dietetic counselling was mostly on protein and energy, not on micronutrients. Dietitians preferred using regular food products first to increase intake, before prescribing ONS. Although dietitians tried to adapt their dietary advice to the likes and dislikes of older clients, older clients often experienced difficulties applying dietary advice, such as eating more frequently, because this involved changing their eating habits. Drawbacks of ONS were a stigmatizing image and low palatability. Some of the older adults mentioned that they did not like the taste of ONS, while others found it acceptable.
New strategies to complement current treatment
The last two themes discuss a new strategy to complement current undernutrition treatment options, in the form of enriched foods and drinks.
Theme 6: Enriched regular products
We asked the dietitians about their ideas on enriched regular products as an alternative to ONS. Dietitians see a potential use for enriched products, if they taste better than ONS. Several positive and negative points were mentioned, but no specific dosages of nutrients per portion. Dietitians would find it positive if enriched products would fit better in the eating habits of older adults than ONS do. This may improve compliance in the long term. They think it may fill a gap between using regular products and ONS:
“As an option between regular nutrition and ONS, I would like it to have more protein and calories than regular nutrition. This would be more preferable than, for instance full fat dairy. If it is protein enriched! That would be a better option than immediately starting with ONS, or a more attractive option […] because it would be tastier and more normal [than ONS]. And it is not yet medical nutrition.” [D9]
The idea that it would be less “medical” has an upside and a downside according to the dietitians: on the one hand dietitians said they often use the association with a medicine as a means to show the importance of being compliant with using ONS, while on the other hand the dietitians said ONS can be stigmatizing and would not feel as eating real food.
“An advantage is that enriched foods are like normal foods, or are actually normal. People will feel less that they are using a medical related drink. I think that for some people that will help, but for some others it helps when it feels like a medicine.” [D5]
Theme 7: Product properties essential for usage of enriched products
We asked the older adults about their eating patterns and what features influence these to gain more insights into their behaviour. The older adults mentioned during our interviews that they have certain traditional eating habits:
“Well, just very normal, I would say plain Dutch meals: potatoes, vegetables and meat, and with some variety in it, then I feel fine.” [man, 91 years, home]
The older adults told us, furthermore, that they stick to their usual food choices, even during hospitalization they ordered from the meal service what they would eat at home.
Both the older adults and dietitians mentioned that older people usually have less appetite and therefore the portion sizes should become smaller than regular but it should provide the same amount of protein. It was also mentioned that enriched products should replace foods and drinks that are regularly consumed, not as an extra consumption or added volume.
When we asked about the packaging of products and their user friendliness, we got mixed answers from the dietitians. Some gave particular examples of difficult to open packages, including the milk and yoghurt cartons with a cap on it. They said, however, that they do not think about these practical issues when advising older adults. Furthermore, one-portion packages were said to be useful because the product will not expire so quickly, but on the other hand these are usually more difficult to open than larger packages. The older adults gave very clear comments on packages: the font used on labels is usually too small to read or packages are difficult to open. They mentioned that their fine motor control had decreased. Most of them have found ways to open things, using scissors and other tools:
“We sometimes struggle with it, but we have tools for it.” [man, 91 years, home]
When it comes to product characteristics, dietitians stressed that new enriched products should come in a variety in flavours, taste and textures. This was based on their experience with ONS: most ONS are in liquid form and most have a sweet taste, while taste and texture preferences differ among older adults.
To summarize the opinions about this new strategy, dietitians stated that enriched products should fit the eating habits of older adults to improve long-term compliance: small portion sizes, easy to open and prepare, good palatability and a variety of tastes and textures. ONS fit the eating habits for some, but not for all older adults. The medical image of ONS might convince some older adults to use it, while it evokes resistance in others.