Foreword 7
Summary and recommendations 9
Chapter 1 Why nutritional guidelines are needed 14
Chapter 2 Food prepared for older people: who provides it, and who eats it? 17
Food prepared for older people in residential and nursing homes
Community meals
Chapter 3 How a good diet can contribute to the health of older people 21
How the body changes with ageing
Malnutrition
Common health problems that can be improved by diet
Chapter 4 Nutritional requirements of older people 29
Chapter 5 Nutritional guidelines for food prepared for older people 40
Food prepared for people in residential and nursing homes
Community meals
Chapter 6 Examples of menus which meet the nutritional guidelines 46
Example menus for older people living in residential or nursing homes
Example menus for community meals
Chapter 7 Nutritional assessments 51
How to identify older people who might be at risk of malnutrition
Assessing food provision
Chapter 8 Exciting the appetite 60
Providing variety and choice
Timing and frequency of meals
Food presentation
Social occasions
Physical activity
Appendix 1 Recommendations of the COMA report on The Nutrition of Elderly People 63
Appendix 2 Care Homes for Older People: National Minimum Standards 64
Appendix 3 Good sources of nutrients 65
Appendix 4 Portion guide 69
Appendix 5 Sample nutritional assessment methods for use in the community 70
Appendix 6 Useful addresses and further reading 74
6
List of Tables and Figures
Table 1 Nutritional requirements of older people 30
Table 2 Nutritional guidelines for food prepared for older people in residential or
nursing homes 41
Table 3 Nutritional guidelines for community meals for older people 44
Table 4 Example menus for older people living in residential or nursing homes 47
Table 5 Example menus for community meals for older people 49
Table 6 Examples of community meals suitable for older people from Asian
and Afro-Caribbean backgrounds 50
Table 7 Weight loss score 56
Figure 1 Estimating height from ulna length 52
Figure 2 Measuring from mid upper arm circumference 53
Figure 3 The Malnutrition Universal Screening Tool (MUST) 54
Figure 4 BMI score (and BMI) 55
7
Foreword
T
he Caroline Walker Trust is
dedicated to the improvement
of public health by means of
good food. Established in 1988 to
continue the work of Caroline Walker,
and in particular to protect the quality
of food, it is a charitable trust whose
work is wholly dependent on grants
and donations.
The Trust has produced a number of
publications, training materials and
computer packages which provide
practical guidance on eating well for
those who care for vulnerable people
in our society. The Trust’s first Expert
Report
Nutritional Guidelines for
School Meals,
1
published in 1992, has
been widely used as the basis for
quantitative standards for school meals
and is provided as guidance by the
Department for Education and Skills in
its nutritional guidelines for school
lunches.
2
Practical and nutritional
guidelines have also been produced for
under-5s in child care
3
in 1998, and for
looked after children and young
people
4
in 2001. More information
about these documents and their
accompanying training packs and
software can be found on the Caroline
Walker Trust website: www.cwt.org.uk.
In 1995 the Trust produced the first
edition of this publication –
Eating
Well for Older People
.
5
Members of the
working group responsible for that
report were also involved in the
VOICES report
Eating Well for Older
People with Dementia,
6
produced in
1998. A computer program called the
CORA Menu Planner,
7
produced in
response to the publication of the first
edition of Eating Well for Older People,
has provided a practical tool for those
planning menus for older people and is
now extensively used across the UK.
Since this report was first published, it
has been widely used in residential and
nursing homes, and in the community,
both to raise the profile of eating well
for older people and to provide
practical guidance for those who work
in this sector and for those who advise
and support them.
When the first edition of the report was
published in 1995, the last national
survey of the nutrition of older people
available to the Expert Working Group
was over 20 years old. The Committee
on Medical Aspects of Food and
Nutrition Policy (COMA) had
recognised this lack of information in
their reports on Dietary Reference
Values
8
and on the Nutrition of Elderly
People.
9
The Government responded
to COMA’s recommendations, and
commissioned a nutrition survey of
people aged 65 years and over in
Great Britain as part of the National
Diet and Nutrition Survey (NDNS)
programme. The results were
published in 1998,
10, 11
after the first
edition of this report had been
published. More recently, the
Government has also published a
National Service Framework for older
people.
12
This report on Eating Well for Older
People remains in high demand. It is
now five years since the NDNS survey
of people aged 65 years and over was
published. The Trust recognised that it
would be appropriate to ensure that
the report took account of this more
recent information and of the National
Service Framework for older people,
and therefore decided to produce a
new edition.
The Trust is delighted that many of its
recommendations have been
incorporated into the new National
Minimum Standards for Care Homes
for Older People
13
and this new report
will hopefully be a good starting point
from which nutritional standards can
be further improved.
The Trustees would like to thank the
original Expert Working Group, and
particularly Anne Dillon Roberts the
Chair, for their work in compiling the
first edition of this report. They would
also like to thank Dr Helen Crawley
and Rosie Leyden for updating this
report and June Copeman and Anita
Berkley for their useful comments on
the text for this edition.
We hope that this second edition of
this report will be as well used as its
predecessor and provide practical
advice to all those who have an
important role to play in the care of
older people.
Professor Martin Wiseman
Chair, Caroline Walker Trust
Foreword
8
References
1 Sharp I. 1992. Nutritional Guidelines
for School Meals. Report of an Expert
Working Group. London: The Caroline
Walker Trust.
2 Available from: www.dfes.gov.uk
3 The Caroline Walker Trust. 1998. Eating
Well for Under-5s in Child Care.
London: The Caroline Walker Trust.
4 The Caroline Walker Trust. 2001. Eating
Well for Looked After Children and
Young People. London: The Caroline
Walker Trust.
5 The Caroline Walker Trust. 1995. Eating
Well for Older People. 1st edition.
London: The Caroline Walker Trust.
6 VOICES. 1998. Eating Well for Older
People with Dementia. London:
VOICES.
7 The Caroline Walker Trust. CORA Menu
Planner. London: DGAA Homelife.
Available from The Caroline Walker
Trust (www.cwt.org.uk).
8 Department of Health. 1991. Dietary
Reference Values for Food Energy and
Nutrients for the United Kingdom.
Report on Health and Social Subjects
No. 41. Report of the Panel on Dietary
Reference Values of the Committee on
Medical Aspects of Food Policy.
London: HMSO.
9 Department of Health. 1992. The
Nutrition of Elderly People. Report on
Health and Social Subjects No. 43.
Report of the Working Group on the
Nutrition of Elderly People of the
Committee on Medical Aspects of
Food Policy. London: HMSO.
10 Finch S, Doyle W, Lowe C, Bates CJ et
al. 1998. National Diet and Nutrition
Survey: People Aged 65 Years and
Over. Volume 1: Report of the Diet and
Nutrition Survey. London: The
Stationery Office.
11 Steele JG, Sheiham A, Marcenes W,
Walls AWG. 1998. National Diet and
Nutrition Survey: People Aged 65
Years and Over. Volume 2: Report of
the Oral Health Survey. London: The
Stationery Office.
12 Department of Health. 2001. National
Service Framework for Older People.
London: The Stationery Office.
Available from: www.dh.gov.uk
13 Department of Health. 2002. Care
Homes for Older People: National
Minimum Standards. London: The
Stationery Office. Available from:
www.dh.gov.uk
9
Summary and recommendations
Chapter 1 Why nutritional guidelines are needed
The Caroline Walker Trust Expert Working Group regards the provision of
community meals – including meals delivered to the home and meals served at
a lunch club or day centre – as a vital component of community care.
Adequate nutritional standards of food in residential care accommodation –
including both residential and nursing homes – are crucial to the well-being of
residents and patients.
The Working Group makes the following recommendations:
• The nutritional guidelines in this report (see Tables 2 and 3 on
pages 41 and 44) should become minimum standards for food
prepared for older people in residential care accommodation and
for community meals. Cost considerations should not override
the need for adequate nutritional content in the planning and
preparation of food for older people.
• Local authorities should adopt these nutritional guidelines and
insist on them being maintained in residential and nursing homes
with which they contract for long-term care, and in the provision
of community meals.
Chapter 2 Food prepared for older people: who provides
it, and who eats it?
In 2001, 341,200 older people lived in residential care accommodation and a
further 186,000 people in nursing homes. About a quarter of people over 85
years of age live in long-stay care. The percentage of the population in long-
term care has remained steady but the actual number has been rising because
of the increase in population in these age groups. That growth is set to continue
because of the particularly rapid increase in the number of over-85s.
Many older people in residential care accommodation are undernourished,
either through previous poverty, social isolation, or personal or psychological
problems, or due to the effects on appetite of illness or medication.
Since this report was originally published there have been a number of
recommendations made relating to food service to older people in residential
and nursing care. These recommendations are welcomed but there is still a
need to provide practical information to managers of residential or nursing
homes on how they can achieve appropriate nutritional content in the food
they serve.
Community meals, whether delivered to people’s own homes or eaten in lunch
clubs or day centres, are a very important source of nutritious food for older
people living in their own homes and unable to cook adequately for
themselves.
The Working Group makes the following recommendations:
• Residential and nursing homes applying for registration should be
required to meet the nutritional guidelines for food prepared for
older people as part of the registration process. Monitoring of the
nutritional standard of meals should be carried out regularly, and
Summary and recommendations
10
homes which do not meet the guidelines should receive
appropriate advice and help to meet the standards, or forfeit
registration.
• In residential care accommodation, at least £18 per resident per
week (2004 prices) should be spent on food ingredients to ensure
that food of sufficient nutritional content can be made available.
• Individuals, their relatives or advocates should enquire about a
prospective home’s commitment to nutritional standards and
should ask how much money per resident per week is spent on
food ingredients.
• Those providing community meals need to take into account the
needs and wishes of older people from black and ethnic
minorities who do not have access to an appropriate lunch club.
• Lunch clubs should be developed for older people in any setting
where it is already the custom for older people to gather.
Chapter 3 How a good diet can contribute to the health
of older people
The ageing process affects people at different rates. A good diet and physical
activity help to minimise potential health problems and accelerate recovery
from episodes of illness.
As activity lessens, calorie requirements fall. However, if insufficient food is
eaten, the level of nutrients in the diet can become dangerously low, leading to
a vicious circle of muscle loss, even less activity, and even lower appetite.
Mouth problems and swallowing difficulties may also lead to low food intake.
The importance of regular care of the teeth and mouth is stressed.
There are more underweight than overweight older people and, in old age,
being underweight poses far greater risks to health than being overweight.
Poor nutrition can contribute to a number of health problems including:
constipation and other digestive disorders; anaemia; diabetes mellitus; muscle
and bone disorders including osteoporosis, osteomalacia and osteoarthritis;
overweight; and coronary heart disease and stroke. Poor diet may also
contribute to other health problems such as declining mental health, changes to
the nervous system and the immune system, cataract and some cancers.
In addition to the nutritional guidelines given in Chapter 5, the Working Group
makes the following recommendations:
• Older people should be encouraged to undertake regular physical
activity, such as walking, as this strengthens and builds up
muscle and bone, and increases calorie requirements, which
increases appetite. Even chair-bound people should be
encouraged to do regular leg and arm movements.
• Facilities should be provided for regular dental check-ups. This
means taking people to the dental surgery, either from their own
homes or from residential homes, or having community dentists
visit the home.
• Architects designing accommodation for older people should be
encouraged to take account of the need for residents to have
regular exposure to sunlight, which is a source of vitamin D.
Features could include windows that allow UV light to pass
through the glass, sheltered alcoves on the south side of
Summary and recommendations
11
Chapter 5 Nutritional guidelines for food prepared for
older people
The Dietary Reference Values are translated into nutritional guidelines for food
prepared for older people in residential care accommodation and for
community meals.
The Working Group recommends that:
• The average day’s food, over a one-week period, for people living
in residential care accommodation, should meet the COMA
report’s Estimated Average Requirement for energy and the
Reference Nutrient Intakes for selected nutrients. Quantified
nutritional guidelines for food prepared for older people in
residential or nursing homes are given in Table 2 on page 41.
In relation to community meals, the Working Group recommends that:
• The average community meal should provide a minimum of 33%
of the Dietary Reference Values prepared by COMA in 1991,
except for energy and certain key nutrients, which should be
provided at higher levels.
• In view of the common occurrence of undernutrition in
housebound older people living in their own homes, providers
should increase the energy, calcium, iron and zinc content of
community meals to 40% of the Dietary Reference Values, and the
folate and vitamin C content to 50%. Quantified nutritional
guidelines for community meals are given in Table 3 on page 44.
• Research is needed to find out how much of the meal is eaten by
those who receive community meals, and how the service can
best meet the needs of its users. Alternative methods of providing
food – such as smaller meals and snacks which together comprise
the nutrients more usually associated with a conventional meal –
also need to be evaluated.
Chapter 4 Nutritional requirements of older people
This chapter discusses the intake levels for food energy and nutrients and
concludes that:
• The Dietary Reference Values prepared by COMA (the Committee
on the Medical Aspects of Food Policy) in 1991 should be used as
the basis for the nutritional guidelines for food prepared for older
people.
buildings, and well-paved paths with hand rails and no steps.
• Older people living in residential and nursing homes who rarely
go outside are likely to need vitamin D supplements and should
consume a diet which provides sufficient calcium. Advice on
supplements should be taken from a GP.
Summary and recommendations
12
Chapter 6 Examples of menus which meet the
nutritional guidelines
This chapter gives examples of menus both for meals prepared for older people
in residential care accommodation and for community meals, to demonstrate
that it is possible to meet the nutritional guidelines proposed in Chapter 5,
easily and cost-effectively.
Chapter 7 Nutritional assessments
The importance of nutritional assessment is discussed.
The Working Group makes the following recommendations:
• Vulnerable older people living in the community should have a
nutritional assessment, and the results should help inform the
design of the person’s care package. The assessment could be
carried out by a member of the care management team or the
primary health care team.
• All older people entering residential care accommodation should
have their food and fluid needs assessed in the first week after
admission, and should be monitored regularly thereafter.
• All residential and nursing homes should have weighing scales,
preferably sitting scales, for monthly weight checks. The scales
should be checked regularly.
• The weight of each resident or patient should be recorded in the
person’s care plan at least once a month.
• Care managers and service providers need to ensure that routine
reassessments are made. All people found to be at risk in the
initial screening should be reassessed at frequent intervals.
Thereafter, reassessments will be necessary with changing
circumstances.
Chapter 8 Exciting the appetite
The importance of appetite should be given a high profile. It is no good
producing nutritious meals unless they are eaten.
The Working Group makes the following recommendations:
• Older people living in residential care accommodation or
receiving community meals should be offered a variety and some
choice of food.
• Records of the food preferences of each person should be kept.
• Every effort should be made to make the eating environment as
attractive and as culturally appropriate as possible.
• In residential care accommodation, residents should be
encouraged to invite guests in either for a simple meal, or for tea
or coffee.
• Residents should be encouraged to go on trips and outings
outside the residential care home. This may stimulate appetite by
providing exercise, fresh air and a change of food choice.
Summary and recommendations
13
• Snacks should be provided in between more formal mealtimes or,
in the case of community meals, be delivered with the main meal,
thereby ensuring that, if they wish, older people can eat a little at
a time, but more frequently.
• Advice should be sought from an occupational therapist or
speech and language therapist, for those who may need special
aids or help with eating or drinking.
• Physical activity routines, even of a very modest nature, should
be established for all older people living in residential care
accommodation.
• Staff or volunteers at lunch clubs should encourage physical
activity among older people, either by providing information or
by organising simple activities at the club.
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