Anna Ipsen, BS, DI College of Russell Sage

In 2009, persons over the age of 60 represented 11% of the total population.1 By 2025, the percentage is anticipated to increase to 15%, and double by 2050, at 22%.1 Larger elderly populations creates heightened health care costs and socio-economic burden.1

Process of aging changes that lead to unintended weight loss and ultimately malnutrition1,2,3:
Decreased metabolic rate and appetite Reduced taste acuity and smell Chewing and swallowing difficulties Increased medication use Depression Constipation or altered gastrointestinal function Side effects of chronic disease symptoms Declined cognitive and physical capabilities

Elderly choose to come to nursing homes to receive necessary care. Within residential care, the risk for unintended weight loss and malnutrition still exists, from 30-70%.2 Providing adequate nutrition and recognizing role in the geriatric health and quality of life is becoming increasingly important.2

Treatment of residents who exhibit unintentional weight loss or are malnourished and consistently consume 75% or less of meals and snacks:
Encouragement from CNAs to consume as many calories at meals and snacks as possible.3 Small nutrient dense snacks in-between meals (yogurt, cottage cheese, cookies, crackers, puddings, magic cups, etc.) Oral liquid supplementation (fruit juices, Boost, Ensure, Glucerna, Mighty Shakes, etc.)

Use of supplementation in the elderly is a combined effort between dietary staff, dining services, and Certified Nursing Assistants.
Dietary staff: evaluate intake and prescribe diet orders
Find appropriate supplement for resident Be aware of acceptance and refusal Monitor weight changes

Dining services: order and stock necessary supplements

Certified Nursing Assistants: encouragement and support

increases likelihood residents will take supplement

Cost to purchase and stock adequate oral liquid supplementation to meet the residents' needs is an added expense to the kitchen and dining services. Any waste of oral liquid supplementation that does not get consumed and thus does not fulfill the nutritional goal of residents can potentially create a burden on overall food costs and budgeting

This study examined the amount of nutrition supplementation being produced, distributed, and wasted from a dining service perspective at a 120-bed Nursing and Rehabilitation Center, the impact it has on overall food costs, and a means to potentially reduce excess waste/food costs.

Interview with head clinical nutrition manager

Types of supplements offered at the facility and which is most popular. Background on Fortified Shakes; replacement of Mighty Shakes supplement.
Reasoning behind switch
Difficulty regulating Mighty Shakes with expired labels Our Food Rules policy Comparable in nutritional content Comparable in cost

Number of residents using Fortified Shakes Current and future goals

16 residents; total of 45 servings per day

Three flavors: Vanilla, Chocolate, and Strawberry 48 serving recipe yield to 36 serving recipe yield due to excessive waste Continue to monitor and control waste Create new flavors?

Four question survey of 16 residents using Fortified Shakes.

Do you like the taste of Fortified Shakes? Do you like chocolate, vanilla, or strawberry the best? 3) How often do you refuse your Fortified Shake? 4) How often are you not offered your Fortified shake?

Production and waste in fluid ounces over five consecutive days; Monday through Friday recorded.
Saturday and Sunday intentionally excluded Averages determined for daily, weekly, monthly, and yearly waste based on information collected

Cost analysis to determine the waste over same five days.

Averages calculated for daily, weekly, monthly, and yearly costs

Evaluation of diet orders of the residents on Fortified Shakes.

Each individual was reviewed using PointClick Care Health System
Daily energy and fluid intake percentages
No refusal of supplementations found

Weight changes Progress Notes

Feedback from the individual's resident survey

All 16 residents interviewed liked the taste of the their Fortified Shake.

Elimination of vanilla flavored shake Chocolate and Strawberry flavored shakes kept at 36 serving recipe yields.
Greatest amount of waste Highest cost of waste Least preferred flavor

New amount of daily production and waste in fluid ounces recorded over following five consecutive days post intervention Cost analysis per those five days calculated
Average fluid ounce waste per day, month, week, and year Average cost of waste per day, month, week, and year

Comparison to determine benefit between pre and post interventions using average fluid ounces and average costs per day, week, month, and year

Total of 16 residents are prescribed Fortified Shakes; some receive supplementation more than one time per day. Total of 45 servings (270) fluid ounces per day needed. Shakes offered during meal or snack time by Certified Nursing Assistants in six ounce servings. Shakes prepared by the Cold Prep Food Service Worker daily due to a one day shelf life. A 48 serving recipe yield was first used to produce a total of 288 fluid ounces and divided into 96 fluid ounces of each chocolate, vanilla, and strawberry flavors. Excessive waste change the recipe yield to 36 servings, a total of 216 fluid ounces, which was to be divided into 72 fluid ounces of each flavor. Each shake per six ounce fluid serving contained 230-280 calories depending on flavor and six grams of protein. The cost to per six ounce serving is $0.26.

100% of resident liked the Fortified Shakes Favorite flavor

Strawberry (nine residents; 56%) Chocolate (six residents; 38% Vanilla last (one resident; 6%)

Shake refusal

Shake offerings

Never (twelve residents; 75%) Sometimes (four residents; 19%) Always (one resident; 6%)
Never (fourteen residents; 88%) Sometimes (one resident; 6%) sometimes Always (one resident; 6%)

Records of the total production of Fortified Shake = 216 fluid ounces (72 ounces of vanilla, chocolate, and strawberry each) per day, a total of 1,080 fluid ounces over five days (360 fluid ounces per flavor). Vanilla had the greatest waste with a total of 264 fluid ounces (72, 36, 56, 48, 52) over five days. Chocolate followed with a total of 188 fluid ounces (30, 26, 60, 64, 8) over five days. Strawberry had the least waste with 69 fluid ounces (23, 0, 13, 25, 8) over five days. Total waste after combining all three flavors = 521 fluid ounces over the five days. Average waste per day was 104.2 ounces daily, 729.4 ounces per week, 3,126 ounces per month, and 38,033 ounces per year.

A total of $9.36 per day is spent to make the three flavors ($3.12 each), a total of $46.80 over five days. Vanilla waste cost was highest at $11.54 ($3.12, $1.56, $2.43, $2.08, $2.35) over five days. Chocolate waste cost followed at $8.16 ($1.30, $1.13, $2.60, $2.78, $0.35) over five days. Strawberry waste cost the least at $2.99 ($1.00, $0.00, $0.56, $1.08, $0.35) over five days Total waste cost combined of all three flavors = $22.69. Averages were calculated as $4.54 per day, $31.79 per week, $136.20 per month, and $1,657.10 per year.

Total waste of 144 fluid ounces (72 ounces chocolate and strawberry each) per day, a total of 720 fluid ounces (360 each) over five days. Chocolate had the greatest waste with a total of 235 fluid ounces (48, 52, 48, 48, 39) over five days. Strawberry had less waste with 169 fluid ounces (18, 24, 36, 48, 43) over five days. Total waste combined = 404 fluid ounces over five days. Average waste per day was 80.8 ounces daily, 565.6 ounces per week, 2,424 ounces per month, and 29,492 ounces per year.

A total of $6.24 per day is spent to make the two flavors ($3.12 each), a total of $31.20 over five days. Chocolate waste cost was highest at $10.35 ($2.08, $2.25, $2.08, $2.08, $1.86) over five days Strawberry followed, at $7.15 ($0.78, $1.04, $1.56, $2.08, $1.69) over five days Total cost after combination = $17.50. Averages were calculated as $3.50 per day, $24.50 per week, $105.00 per month, and $1,277.50 per year.

Averages in fluid ounces were compared pre and post intervention per day, per week, per month, and per year.

The number of average fluid ounces were translated into dollar amounts per day, per week, per month, and per year to analyze for cost benefits of the intervention.

Per day difference was 24.2 fluid ounces, per week 163.8 fluid ounces, per month 702 fluid ounces, and per year 8, 604 fluid ounces.

Per day cost benefit was $1.04, per week $7.29, per month $31.20, and per year $379.60.

This study demonstrates reducing total daily production of Fortified Shakes can cause significant cost benefits per day, week, month, and year. Excessive waste still exists

Oral liquid supplementation receptiveness by residents is a combined effort between dietary, dining services, and Certified Nursing Assistants. Participation from three departments necessary in the care of residents receiving shakes, otherwise it may not be consumed. If not consumed, resident will be at continued risk for unintended weight loss or malnutrition. Waste is costly to dining services, who is preparing Fortified Shakes daily.

Investigation of barriers to nursing staff providing the Fortified Shakes to residents each day. WHY?

Production of only the chocolate and strawberry at 36 servings, or 216 fluid ounces per day is not enough supplementation to cover the 45 servings, or 270 fluid ounces prescribed to residents. Studies have shown that residents who receive encouragement and support from Certified Nursing Assistance at meals and snacks show increased consumption of oral liquid supplementation by 50%.4 Providing assistance can be time consuming and is often shortened and glossed over. Incorrect documentation on the percentage of liquid oral supplementation taken can send false information to dietary staff. If weight loss and malnutrition are still occurring, as well as excessive waste being discarded daily, it would appear that the issue may lay within the nursing department.

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