Making the most of snacks: increase the energy and protein intake

Study carried out in 2006 within 42 geriatric homes in France and 21 in Germany.

The care teams from the care centers for dependant elderly people have strong awareness of the importance of nutrition for the health and well being of the patients. However, the prevalence of malnutrition amongst the seniors in health institutions is between 15 and 65% in Western countries.

The objective of this study was to compare the nutritional care provided to the elderly in health institutions in France and Germany, by replying to the following questions:

• Is there sufficient staff that was provided training about dietetics ?
  
  
• Do the elderly people receive at least two snacks per day at 10am and 4pm, as recommended by the French Nutrition and Health National Programme ?
  
  
• How are the patients' requests expressed?

We have carried out in 2006 a survey by phone targeting the persons in charge of nutrition in the geriatric homes. We have contacted 110 medical care establishments in France and 67 in Germany.

There is a relatively small number of dieticians in rest-homes,  but in every establishment there is a person in charge of nutrition. In France, the person in charge of nutrition is in most cases the head nurse or the director of the establishment, who is often a geriatrics doctor. In Germany, it is in most cases the cook of the establishment.

In total, the people in charge of nutrition in 63 establishments accepted to take part in our survey and to fill in our questionnaire:  42 establishments in France and 21 in Germany, which represented respectively 38% and 31% of the medical care establishments we had contacted.

The medical care establishments that accepted to take part in our study had an average of 184 patients in France and 99 patients in Germany. But in Germany, the establishments look after more incapacitated patients, who require assistance for their daily actions.

Presence of dieticians or nutritionists in care centers for dependant elderly people

In France, 95 of the contacted care centers responded to the question. 42 care centers (44%) had a dietician working with the health care team. 
These dieticians visit regularly the patients in their rooms. They control the nutritional state of the patients, motivate them, and inform the staff about specific nutritional requirements.
They often work at several medical care establishments, up to five establishments, with a very important work load.
The hospital medical care establishments have more dieticians than the private establishments, who sometimes call in the nutritionist from the closest hospital center when needed.

In Germany, 24 establishments responded to the question : only one benefited from the support of a dietician. Any decision concerning nutrition is taken during the care team meetings (geriatrics doctor, head nurse, head chef): each of them comments about each patient.

The head cooks are trained to prepare meals adapted to the specific needs of the elderly, in particular recipes with high caloric intake.

Kitchens

in France, most of the care centers work with external catering companies, with the kitchen of the centre being used as a second kitchen only. Menus are chosen for the week according to the supplier's proposals.

In Germany, most of the contacted care centres have a self sufficient kitchen, with meals being prepared on site.

Snacks

In France, the meals and snacks are generally distributed as follows:

• 7 h : breakfast
• 10 h : snack
• 12 h : lunch
• 16 h : snack
• 19 h : dinner

In Germany, Mahlzeiten are generally distributed every 3 hours:

• 6 h 30 : Früstuck
• 9 h 30 : Zwischenmahlzeit
• 12 h 30 : Mahlzeit ou Mittagessen
• 15 h 30 : Zwischenmahlzeit
• 18 h 30 : Abendessen
• 21 h 30 : Spästück.

The morning snack is given at 10am in France and in Germany, but not systematically in France.
The afternoon snack is given between 3.30 and 4pm in France, and between 2pm and 3pm in Germany.
An additional snack can be given in the evening, on prescription, more often in Germany than in France.

In France as in Germany, the reasons given for a non systematical distribution of snacks, are: lack of staff, including the snack on the breakfast tray, snack being covered by the patient or by his family, snack on demand, snack on self service.

In most cases, the food that is distributed are rusks and biscuits with tea or coffee, bread and cheese (especially in Germany), natural or flavoured yoghurts, very often fruit compotes and more rarely nutritional complements, on prescription.

Nutritional complements are prescribed by the care center gerontologist doctor, by the town GP, or by the care center nutritionist.

Listening to the patients' requests

In France and in Germany, patients generally seem satisfied with their diets, but the swallowing problems are often mentioned.

In France, requests are written down by the carers during the interview carried out when the patients enter the care center. This interview covers tastes, dislikes, and food compulsory requirements. The carers assist the patients for them to fill in satisfaction surveys as well.
Catering committees are also organised, once per month in most cases. They are an opportunity for each individual to express their wishes for the menus, and highlight what they have liked and disliked.
Activities like baking a cake or pastries once a week and for birthdays are often included in the activity calendar of the care center, and they are well appreciated by the patients.

In Germany, the management of the requests (Beschwerde Management) is part of a complex process that involves the patient, his relatives, the administration and the "requests manager", who will look for ways to improve the management of the quality (Qualitätmanagement).

Conclusions

1. There is a difference between France and Germany concerning the stakeholders of the prevention of malnutrition for the elderly people in care centers, with more dieticians in France and a direct involvement of the head chef in Germany.
2. The German care centers are more organised and more systematic for the distribution of snacks as recommended in the French Nutrition and Health National Programme.
3. In France and in Germany, the patients' requests are taken into account. However, due to a lack of staff, it is not always possible to provide the assistance that is expected by the dependant persons and their families, in particular as far as snacks are concerned.

Reference

Bihr Julia. Place de la nutrition dans la pratique de l'odontologie : enquête auprès de 63 établissements gériatriques en France (42) et en Allemagne (21). LOM URE 01, Nice 2006.