Provision of meals on wheels to the elderly : case studies in the era of local government reform

Australia’s ageing population is on the increase. It is predicted that by 2021 one quarter of Victoria’s elderly population will be aged 60 and over. Not only are people living longer, but they also wish to remain living in the community. The Home and Community Care (HACC) Program was established in 1985 to facilitate and assist the elderly and disabled to remain in their home. In Victoria around 51% of HACC funds are managed by local governments, a level of government that has recently undergone major reforms, which ultimately impacted on the manner in which services were provided. The HACC program funds Meals on Wheels, a service that provides meals for those elderly who no longer can prepare their own meals. The aim of this study was to assess the Meals on Wheels service provided by two Melbourne councils with different service philosophies. The study has four main components: (1) Menu analysis by food and variety; (2) Analysis of actual meals; (3) Clients assessment of Food Services; and (4) Client assessment of the organoleptic qualities of Meals on Wheels. Two Melbourne councils were chosen for their different approaches to service delivery. The City of South tendered out both meal production and delivery, while the City of North maintained its MOW service in-house. The case study method of research allowed for each council’s service to be assessed objectively and without comparison. Several methodologies were used for collecting data in this study. Menu analysis was carried out by comparing the MOW menus with the HACC menu planning guidelines together with general menu planning principles. Analysis of actual meals was in two stages. The weights of the meals were recorded and compared with the HACC recommended food serving portions and meal combinations over a five-day period were analysed for their nutrient contents. Face to face interviews were conducted with clients for their assessment of MOW and the assessment of the organoleptic qualities of the meals was carried out over a five-day period. The results concluded that both councils menus were based on sound menu planning principles, but did not conform with Home and Community Care menu planning guidelines fully and did not include a serve of bread, fruit and milk. The weight analysis of the meal combinations revealed some discrepancies between actual meals and Home and Community Care guidelines by not meeting the recommended serving sizes. Meal combinations generally met Home and Community Care standard for kilojoule and protein, but other nutrients, such as thiamin, riboflavin, magnesium, calcium and zinc were generally below the recommended levels for Meals On Wheels. The majority of study group lived alone and received four to five meals per week. Delivery times of meals, selective menus and food quality were issues raised by clients. Whilst the quality and variety of vegetables was raised by clients they generally rated the organoleptic qualities of the meals as satisfactory. This study examined the four components of the service. A simple method of evaluation the service was developed, which highlight discrepancies with HACC standards and encouraged the councils to set a customer satisfaction standard. A number of recommendations are made to ensure that meals are aesthetically pleasing, including a list of different methods for preparing vegetables. The provision of additional foods, such as a “snack pack” is recommended to improve the supply of essential nutrients that were below the Home and Community Care standards. Meals on Wheels is a vital support service for the elderly living in the community and as such should aim to provide a high quality service that meets the needs of its clients.

Effects of dietary constituents on coronary heart disease risk factors

Coronary Heart Disease (CHD) is a major cause of death in Western countries. Mediterranean and Asian populations have a lower risk of death from CHD compared to Westernised population, as do vegetarian versus omnivorous populations. Dietary constituents of traditional diets consumed by these populations are thought to influence both the classical risk factors for CHD, and the more recently identified risk factors, such as oxidative modification of low density lipoprotein (LDL), LDL particle size, arterial compliance and haemostatic factors. The aim of this thesis was to examine the effects of several food components, particularly soybean and monounsaturated fat (MUFA), on CHD risk factors through 3 carefully controlled dietary interventions, and a cross-sectional study. A randomised crossover dietary intervention study was conducted in 42 healthy males to investigate the effect on CHD risk factors of replacing lean meat with tofu, a soybean product regularly consumed by Asian populations, while controlling all other dietary factors. The tofu diet resulted in significantly lower total cholesterol and triacylglycerol levels compared to the lean meat diet, and LDL particles that were more resistant to in vitro oxidative modification. However, insulin, fibrinogen, factor VII, and lipoprotein (a) were not significantly different on the 2 diets. A postprandial study was subsequently conducted to investigate any acute effects of a tofu test meal on the oxidative modification of LDL in 16 male subjects. There was no significant difference between the susceptibility of LDL to oxidative modification before and after the tofu meal. Twenty eight healthy subjects completed a separate randomised crossover dietary intervention comparing a high MUFA fat diet, using an Australian high oleic sunflower oil, with a low fat, high carbohydrate diet on CHD risk factors. The high MUFA oil diet significantly increased high density lipoprotein cholesterol compared to the low fat diet as well as producing LDL that were more resistant to oxidative modification. Neither the size of the LDL particle nor arterial compliance were significantly different on the 2 diets. Twelve matched pairs of vegetations and omnivores were also studies to compare the habitual diet of a low and higher risk population group, to compare their risk factors and identify dietary constituents that may explain the differences. The vegetarians consumed less saturated fat (SFA) and dietary cholesterol while consuming more polyunsaturated fat, dietary fibre and vitamin E compared to omnivores. The vegetarians had lower total cholesterol, LDL cholesterol and triacylglycerol levels compared to the omnivores and had LDL particles that were more resistant to in vitro oxidation. These findings contribute to our knowledge about the dietary constituents that can alter some CHD risk factors in healthy subjects, and which could reduce the risk of developing CHD. Investigations in high risk groups might reveal even more benefits.

A healthy diet consistent with Australian health recommendations is too expensive for welfare-dependant families

Objective: Examine the cost of healthy food habits for welfare-dependent families in Australia.

Method:  A seven-day meal plan was developed, based on Australian public health recommendations, for two typical welfare-dependent families: a couple-family (two adults, two children) and a one-parent family (one adult, two children). The cost of the meal plan was calculated using market brand and generic brand grocery items, and total cost compared to income.

Results: In Australia, the cost of healthy food habits uses about 40% of the disposable income of welfare-dependent families. Families earning an average income would spend only 20% of their disposable income to buy the same healthy food. Substituting generic brands for market brands reduced the weekly food cost by about 13%. This is one of few economic models to include generic brands.

Conclusion: Compared with average-income Australian families, healthy food habits are a fiscal challenge to welfare-dependent families.

Implications: These results provide a benchmark for economic and social policy analysis, and the influence disposable income has on prioritising healthy food habits.

Community nutrition : providing for older citizens

Diet quality is a contributing factor to the health of the increasing number of aged. A fortnightly small group meal program focusing on social interaction was trialled. It was concluded that the program had strong support from participants and that there is scope for expansions of existing food service programs to include alternative styles of presentations; and that the principle of the Community Meals Program should be continued and endorsed.

Using omeprazole to link the components of the post-prandial alkaline tide in the spiny dogfish, Squalus acanthias

After a meal, dogfish exhibit a metabolic alkalosis in the bloodstream and a marked excretion of basic equivalents across the gills to the external seawater. We used the H⁺, K⁺-ATPase pump inhibitor omeprazole to determine whether these post-prandial alkaline tide events were linked to secretion of H⁺ (accompanied by Cl^–) in the stomach. Sharks were fitted with indwelling stomach tubes for pretreatment with omeprazole (five doses of 5mg omeprazole per kilogram over 48 h) or comparable volumes of vehicle (saline containing 2% DMSO) and for sampling of gastric chyme. Fish were then fed an involuntary meal by means of the stomach tube consisting of minced flatfish muscle (2% of body mass) suspended in saline (4% of body mass total volume). Omeprazole pretreatment delayed the post-prandial acidification of the gastric chyme, slowed the rise in Cl^– concentration of the chyme and altered the patterns of other ions, indicating inhibition of H⁺ and accompanying Cl^– secretion. Omeprazole also greatly attenuated the rise in arterial pH and bicarbonate concentrations and reduced the net excretion of basic equivalents to the water by 56% over 48h. Arterial blood CO₂ pressure and plasma ions were not substantially altered. These results indicate that elevated gastric H⁺ secretion (as HCl) in the digestive process is the major cause of the systemic metabolic alkalosis and the accompanying rise in base excretion across the gills that constitute the alkaline tide in the dogfish.

Depression, nutritional risk and eating behaviour in older caregivers

Objective
This study investigated the relationship between depression, nutritional risk and dietary intake in a population of older caregivers.

Design
Mailed questionnaire with sub group participating in a home-based interview.

Participants and setting
Seventy-six community dwelling caregivers aged 50 y or over from Victoria, Australia.

Measurements
Questionnaires provided information on weight, height, hours of care, depressive symptoms, nutritional risk and appetite. The home-based interview assessed dietary intake and shopping, cooking and meal consumption habits.

Results
The sample had a mean±SD age of 70.3±12.8 y, BMI of 27.2±4.8 kg/m2 and the time spent caring was 101.8±68.1 h/wk. Overall, 32% of caregivers had depressive symptoms, 21% were at risk of malnutrition and 21% reported their appetite was fair/bad/very bad. Caregivers with depressive symptoms (32%) compared to those with no depressive symptoms (53%) had a poorer appetite (p<0.05). Of the 20 caregivers who participated in the home interview, 25% reported they ate their meals alone.

Conclusion
A significant proportion of community dwelling older caregivers had depressive symptoms, were at risk of malnutrition and had poor appetites, although the majority were overweight or obese.

Post-prandial remnant lipids impair arterial compliance

OBJECTIVES
We sought to examine the effects of plasma lipids, especially in remnants after a fat meal, on systemic arterial compliance (SAC), a newly recognized cardiovascular risk factor.
BACKGROUND
Post-prandial remnants correlate with coronary heart disease events through mechanisms that may include vascular dysfunction, although the effect on SAC has not been studied.
METHODS
Systemic arterial compliance was measured non-invasively over 6 h after a fat meal in 16 subjects with varying plasma triglyceride levels. Changes were related to rises in plasma lipids and remnant lipids. Systemic arterial compliance was measured in 20 subjects after a control low-fat meal.
RESULTS
The fat meal induced increments in plasma triglyceride and remnant cholesterol and triglyceride (respectively +54%, 50% and 290% at 3 h, analysis of variance <0.001). Systemic arterial compliance fell at 3 h and 6 h by 25% and 27% (analysis of variance <0.001). Baseline SAC correlated significantly with all lipid concentrations at 0, 3 h and 6 h, but only with triglyceride on stepwise regression analysis. The SAC response to the low-fat meal was very small and not significant.
CONCLUSIONS
This is the first demonstration of SAC becoming impaired after a fat meal. Remnant lipids and plasma total triglyceride appeared to contribute to the fall in SAC.

Who is eating where? Findings from the SESAW study

Objective: Foods prepared outside of the home have been linked to less-than-ideal nutrient profiles for health. We examine whether the locations where meals are prepared and consumed are associated with socio-economic predictors among women.
Design: A cross-sectional study using self-reported data. We examined multiple locations where meals are prepared and consumed: (i) at home; (ii) fast food eaten at home; (iii) fast food eaten at the restaurant; (iv) total fast food; (v) non-fast-food restaurant meals eaten at home; (vi) non-fast-food restaurant meals eaten at the restaurant; and (vii) all non-fast-food restaurant meals. Multilevel logistic regression was used to determine whether frequent consumption of meals from these sources varied by level of education, occupation, household income and area-level disadvantage.
Setting: Metropolitan Melbourne, Australia.
Subjects: A total of 1328 women from forty-five neighbourhoods randomly sampled for the SocioEconomic Status and Activity in Women study.
Results: Those with higher educational qualifications or who were not in the workforce (compared with those in professional employment) were more likely to report frequent consumption of meals prepared and consumed at home. High individual and area-level socio-economic characteristics were associated with a lower likelihood of frequent consumption of fast food and a higher likelihood of frequent consumption of meals from non-fast-food sources. The strength and significance of relationships varied by place of consumption.
Conclusions: The source of meal preparation and consumption varied by socioeconomic predictors. This has implications for policy makers who need to continue to campaign to make healthy alternatives available in out-of-home food sources.

Fish oil in aquaculture : in retrospect

The use of fish oils by aquaculture is the key impediment on the future growth and sustainability of the industry. Fish oil, the key provider of health-beneficial omega-3 long-chain polyunsaturated fatty acids, fluctuates drastically in supply and cost, and is extracted unsustainably from world oceans. Resultantly, its persistent use has fueled a heated global debate and sparked a generation of research focus into possible means of reducing the aquaculture industry's dependence on this resource. This chapter introduces the subject of fish oil usage in aquaculture on a global basis, and briefly traces the history of related issues. Accordingly, the major fish species utilized for fish meal and fish oil production are traced and the chemical and nutritional characteristics of fish oils of different origins are provided. The future expected availability of fish oil for aquaculture and the sustainability of the reduction industry are subsequently discussed.

n-3 Polyunsaturated fatty acid-rich vegetable oils and blends

α-Linseed, camelina. perilla, and echium oils are n-3 C₁₈ polyunsaturated fatty acid (PUFA)-rich vegetable oil sources viewed as favorable replacements to fish oil in aquaculture feed (aquafeed) production in consideration of their high (α-linolenic acid (ALA, 18:3n-3) and/or stearidonic acid (SDA, 18:4n-3) contents and potential for subsequent bioconversion to n-3 long-chain polyunsaturated fatty acids (LC-PUFA) in farmed aquatic species. While the total production of these oils is currently low in comparison with that of other terrestrial oil sources, their distinct fatty acid composition and high n-3 to n-6 ratio deliver a unique substitute to fish oil in aquafeeds, presently unparalleled in other alternative terrestrial oil sources. The dietary inclusion of these oil sources has therefore attracted significant research attention, resulting in a multitude of investigations across a broad range of aquatic species (finfish and crustaceans). Generally, providing that the essential fatty acid (EFA) requirements of the species under investigation were met and an adequate level of fish meal was present in the diet, it was found possible to replace 100% and 60-70% of the dietary fish oil component for freshwater and marine species, respectively, with minimal impact on growth performance indices. However, the substitution of fish oil with n-3-rich vegetable oils and/or vegetable oil blends resulted in substantially reduced concentrations of health-promoting eicosapentaenoic acid (EPA, 20:5n-3) and docosahexaenoic acid (DHA, 22:6n-3) in the edible portion of the farmed species. This chapter provides an overview of the use of n-3 PUFA-rich vegetable oils and/or vegetable oil blends for use in aquafeeds. In particular, key aspects of oil production, processing, and refinement will be presented, and individual differences pertaining to the physical, chemical, and nutritional characteristics of the oil types will be highlighted. Following on from this, a summary of the key findings relevant to n-3 PUFA-rich vegetable oil inclusion in aquafeeds will be discussed, with particular emphasis placed on growth performance and nutritional modification.

Skipping breakfast : longitudinal associations with cardiometabolic risk factors in the childhood determinants of adult health study

Background: The long-term effects of skipping breakfast on cardiometabolic health are not well understood.

Objective: The objective was to examine longitudinal associations of breakfast skipping in childhood and adulthood with cardiometabolic risk factors in adulthood.

Design: In 1985, a national sample of 9–15-y-old Australian children reported whether they usually ate breakfast before school. During follow-up in 2004–2006, 2184 participants (26–36 y of age) completed a meal-frequency chart for the previous day. Skipping breakfast was defined as not eating between 0600 and 0900. Participants were classified into 4 groups: skipped breakfast in neither childhood nor adulthood (n = 1359), skipped breakfast only in childhood (n = 224), skipped breakfast only in adulthood (n = 515), and skipped breakfast in both childhood and adulthood (n = 86). Diet quality was assessed, waist circumference was measured, and blood samples were taken after a 12-h fast (n = 1730). Differences in mean waist circumference and blood glucose, insulin, and lipid concentrations were calculated by linear regression.

Results: After adjustment for age, sex, and sociodemographic and lifestyle factors, participants who skipped breakfast in both childhood and adulthood had a larger waist circumference (mean difference: 4.63 cm; 95% CI: 1.72, 7.53 cm) and higher fasting insulin (mean difference: 2.02 mU/L; 95% CI: 0.75, 3.29 mU/L), total cholesterol (mean difference: 0.40 mmol/L; 95% CI: 0.13, 0.68 mmol/L), and LDL cholesterol (mean difference: 0.40 mmol/L; 95% CI: 0.16, 0.64 mmol/L) concentrations than did those who ate breakfast at both time points. Additional adjustments for diet quality and waist circumference attenuated the associations with cardiometabolic variables, but the differences remained significant.

Conclusions: Skipping breakfast over a long period may have detrimental effects on cardiometabolic health. Promoting the benefits of eating breakfast could be a simple and important public health message.

Socio-economic and demographic variations in school lunch participation of French children aged 3-17 years

Objective: To assess school canteen attendance in a French nationally representative sample of children and to analyse its association with the socioeconomic and demographic characteristics of the children and their families.
Design: Data from the second French national cross-sectional food consumption survey (INCA2), performed in 2006–2007, were used. Information on usual weekly school canteen attendance was collected through a self-reported questionnaire, and demographic and socio-economic variables through a face-to-face questionnaire. The associations between school canteen attendance and the socio-economic and demographic variables were investigated by multivariate logistic regression analyses.
Setting: The INCA2 sample was representative of the children aged 3–17 years in France.
Subject: Analysis was performed on 1413 schoolchildren who completed the school canteen attendance questions.
Results: Some 65?6% of schoolchildren aged 3–17 years had school lunch at least once weekly. This rate of attendance was positively correlated with age. Whatever the school level, school canteen attendance was positively associated with the educational level of the caregiver/parent. In pre- and elementary-school children, enrolment at the school canteen was also higher when the caregiver/parent worked, or in single-parent families. In secondary-school children, school lunch participation decreased with children living in more densely populated areas and increased with the level of the household’s living standards.
Conclusions: School canteen attendance was positively associated with children’s socio-economic background. This could reduce the effectiveness of the forthcoming school meal composition regulations designed to improve the diet of children from deprived backgrounds, who are more likely to have unhealthy food habits.

Sources of Sodium in Australian children's diets and the effect of the application of sodium targets to food products to reduce sodium intake

The average reported dietary Na intake of children in Australia is high: 2694 mg/d (9–13 years). No data exist describing food sources of Na in Australian children's diets and potential impact of Na reduction targets for processed foods. The aim of the present study was to determine sources of dietary Na in a nationally representative sample of Australian children aged 2–16 years and to assess the impact of application of the UK Food Standards Agency (FSA) Na reduction targets on Na intake. Na intake and use of discretionary salt (note: conversion of salt to Na, 1 g of NaCl (salt) = 390 mg Na) were assessed from 24-h dietary recall in 4487 children participating in the Australian 2007 Children's Nutrition and Physical Activity Survey. Greatest contributors to Na intake across all ages were cereals and cereal-based products/dishes (43 %), including bread (13 %) and breakfast cereals (4 %). Other moderate sources were meat, poultry products (16 %), including processed meats (8 %) and sausages (3 %); milk products/dishes (11 %) and savoury sauces and condiments (7 %). Between 37 and 42 % reported that the person who prepares their meal adds salt when cooking and between 11 and 39 % added salt at the table. Those over the age of 9 years were more likely to report adding salt at the table (χ2 199·5, df 6, P < 0·001). Attainment of the UK FSA Na reduction targets, within the present food supply, would result in a 20 % reduction in daily Na intake in children aged 2–16 years. Incremental reductions of this magnitude over a period of years could significantly reduce the Na intake of this group and further reductions could be achieved by reducing discretionary salt use.

Obesity prevention in the family day care setting : impact of the romp & chomp intervention on opportunities for children's physical activity and healthy eating

Background The Romp & Chomp intervention reduced the prevalence of overweight/obesity in pre-school children in Geelong, Victoria, Australia through an intervention promoting healthy eating and active play in early childhood settings. This study aims to determine if the intervention successfully created more health promoting family day care (FDC) environments.
Methods The evaluation had a cross-sectional, quasi-experimental design with the intervention FDC service in Geelong and a comparison sample from 17 FDC services across Victoria. A 45-item questionnaire capturing nutrition- and physical activity-related aspects of the policy, socio-cultural and physical environments of the FDC service was completed by FDC care providers (in 2008) in the intervention (n = 28) and comparison (n = 223) samples.
Results Select results showed intervention children spent less time in screen-based activities (P = 0.03), organized active play (P < 0.001) and free inside play (P = 0.03) than comparison children. There were more rules related to healthy eating (P < 0.001), more care provider practices that supported children’s positive meal experiences (P < 0.001), fewer unhealthy food items allowed (P = 0.05), higher odds of staff being trained in nutrition (P = 0.04) and physical activity (P < 0.001), lower odds of having set minimum times for outside (P < 0.001) and organized (P = 0.01) active play, and of rewarding children with food (P < 0.001).
Conclusions Romp & Chomp improved the FDC service to one that discourages sedentary behaviours and promotes opportunities for children to eat nutritious foods. Ongoing investment to increase children’s physical activity within the setting and improving the capacity and health literacy of care providers is required to extend and sustain the improvements.

Pre-exercise carbohydrate ingestion : effect of the glycemic index on endurance exercise performance

Purpose: This study aimed to examine the effect of glycemic index of pre-exercise carbohydrate (CHO) ingestion on exercise metabolism and performance.

Methods: Eight endurance trained men ingested a high glycemic index (HGI), low glycemic index (LGI), or a placebo (CON) meal 45 min before exercise and then cycled for 50 min at 67% V·O_2max. Subjects subsequently performed a 15-min self-paced performance ride in which total work (kJ) was recorded.

Results: Plasma glucose concentrations were higher (P < 0.01) after ingestion in HGI compared with LGI and CON (7.53 ± 0.64 vs 5.55 ± 0.21 and 4.65 ± 0.14 mmol·L^-1 for HGI, LGI, and CON, respectively, 30 min postprandial; mean ± SE) but declined at the onset of exercise and were lower (P < 0.01) compared with LGI and CON (4.03 ± 0.31 vs 4.64 ± 0.24 and 5.09 ± 0.16 mmol·L^-1 for HGI, LGI, and CON respectively; mean ± SE) at 10 min of exercise. Plasma glucose remained depressed (P < 0.01) until 30 min into exercise in HGI compared with other trials. Plasma insulin concentrations were higher (P < 0.01) following ingestion during rest and exercise in HGI compared with LGI and CON. Plasma FFA concentrations were lower (P < 0.05) following ingestion in HGI and LGI compared with CON and higher (P < 0.05) in LGI compared with HGI at the start and end of exercise. RER and CHO oxidation was higher (P < 0.01) in HGI compared with LGI and CON during submaximal exercise. There were no differences in work output during the performance cycle.


Conclusions: These data indicate that pre-exercise CHO feedings with varying glycemic indexes do not affect exercise performance following short term submaximal exercise despite alterations in metabolism.