Improving food services for elderly, long-stay patients in Australian hospitals: Adding food fortification, assistance with packaging and feeding assistance

ORIGINAL RESEARCH

Improving food services for elderly, long-staypatients in Australian hospitals: Adding foodfortification, assistance with packaging andfeeding assistancendi_1587 137..144

Karen WALTON, Peter WILLIAMS and Linda TAPSELLSmart Foods Centre, School of Health Sciences, University of Wollongong, Wollongong, New South Wales, Australia

AbstractAim: The study aims to highlight barriers and feasible opportunities to enhance nutrition support of elderly,long-stay patients in Australian hospitals.Methods: A total of 218 dietitians, nurse unit managers and food service managers from medical and rehabilitationwards of 184 hospitals completed a web-based survey about current practices, perceived barriers and priorityopportunities to enhance nutrition support in their context.Results: Cook-fresh food was the most commonly reported food-service system (50%). Eighty-eight percent stillused paper menus and one- or two-week cycles were the most common menu cycle lengths. Lack of choice due tospecial diet, boredom arising from the length of stay, a lack of feeding assistance, limited variety and inadequateflexibility of food service were the key barriers identified. Food fortification, assistance with packaging, additionalfeeding assistance by nurses, non-nursing feeding assistance and further nutrition assessment were key prioritiesfor improvement.Conclusion: A ‘toolbox’ of strategies is needed as no one intervention will improve nutrition support of all patients.Further practice-based outcomes and cost-benefit studies are needed to enhance support and advocacy for feasiblefood service interventions in the future.

Key words: feeding assistance, food fortification, food service, hospital, menu, packaging.

Introduction

The prevalence of malnutrition in Australian hospitals hasbeen reported to be up to 49%.1–7 There are many possiblecauses and long-stay and elderly patients are particularlyvulnerable.7–11

Malnutrition in the hospitalised elderly is preventableand treatable.12–14 Providing nourishing snack options,food fortification15–17 and nutritional supplements can help

improve dietary intakes.18–22 While factors that influenceintakes and some interventions have been investigated inother countries, an Australian survey of key stakeholdersabout barriers and feasible interventions is lacking.

This study builds on an earlier focus group study withpatients, nurses, food service managers, food service assis-tants, dietitians and nutrition assistants in NSW hospitals,which asked their views about all aspects of food servicefor long-stay patients.23 This revealed five key themes ofconcern: the food service system; menu variety; preparationto eat/feeding assistance; packaging; and serve size. Thosefindings were used to plan a comprehensive national surveyof key stakeholder views, the results of which are presentedin this paper.

The aims of this study were to:Explore current practices of food service provision inAustralian hospitals.Determine the key barriers to adequate dietary intakes.Prioritise the most practical interventions for ongoingimprovements to food service provision.

K. Walton, PhD, APD, Senior Lecturer, Bachelor of Nutrition andDietetics CoordinatorP. Williams, PhD, FDAA, Advanced Dietetics Practice CoordinatorL. Tapsell, PhD, FDAA, Director of Smart Foods Centre and Nutritionand Health Strategic Research InitiativeCorrespondence: K. Walton, Smart Foods Centre, School of HealthSciences, University of Wollongong, Wollongong, NSW 2522,Australia. Email: [email protected]

Accepted September 2011

Nutrition & Dietetics 2012; 69: 137–144 DOI: 10.1111/j.1747-0080.2012.01587.x

© 2012 The AuthorsNutrition & Dietetics © 2012 Dietitians Association of Australia

137

Methods

The 2005 Australian Hospitals Directory listed 748 publicand 549 private hospitals, of which 670 were initiallydeemed eligible to participate in the survey. As longer-stay,elderly patients were the focus of this research, we excludedday only; maternity, paediatrics, psychiatric, palliative care,dental, eye and endoscopy hospitals; those with fewer than20 beds; and those with no medical ward.

A letter of invitation was mailed to the food servicemanager (FSM) and chief dietitian at each hospital duringAugust 2005. Information for nurse unit managers (NUMs)was sent to the director of nursing, along with a letter out-lining the study and asking that the information be for-warded to the most appropriate NUM. The NUM is definedas a senior registered nurse who manages a hospital ward.

Three versions of a web-based questionnaire were devel-oped. Each had the same 35 core questions, plus othersspecific to each professional; for example, food servicesystem (food service managers), nutrition assessment (dieti-tians) and foods brought in from outside (nurses). Initialversions of each questionnaire were pilot tested with fourdietitians, two food service managers and two NUMs, whichresulted in some changes to the order of questions andresponse options.

The key questions related to barriers to dietary intakesand priority interventions.23 Participants were asked tochoose and rank their top 10 barriers from a possible list of20, where number one was the most important barrier and10 was the least important. Participants then chose theirtop 10 intervention priorities (in no particular order) from alist of 20, and provided a feasibility rating for each (where1 = very easy, 2 = somewhat easy, 3 = possible, 4 = somewhatdifficult and 5 = very difficult).

Fifty-five of the original 670 hospitals were unable to takepart in the survey as they had either amalgamated, closedor advised that they did not routinely see long-stay,elderly patients, leaving us with 615 eligible hospitals.Survey responses were received from 92 dietitians, 58 FSMsand 68 NUMs from 184 hospitals (Table 1). Public hospitalsrepresented 68% of the invited sample and were the work-place of 77% of the participants. Responses represented 42%of hospital beds across Australia.

Stakeholder responses to each question were determinedand a combined mean feasibility rating was calculated foreach priority intervention. The number of responses for eachoption was recorded and a factor applied to account forthe importance of order. For example, the number of timesthat an option such as ‘limited variety’ was rated as ‘1’ (mostimportant) was multiplied by 10; the number of times it wasrated as ‘10’ (least important) was multiplied by one. Simpleaddition allowed a cumulative total for each barrier for eachstakeholder group to be determined, which was the resultantraw, unweighted data.

To calculate a combined summary of the 10 most impor-tant barriers and priority interventions identified by allthe three stakeholder groups, the number of responses fromeach stakeholder (92 dietitians, 58 FSMs and 68 NUMs) wasmultiplied by an appropriate weighting factor: 615/92 fordietitians, 615/58 for FSMs and 615/68 for NUMs. Theseweighted results are reported in Tables 3 and 4.

Statistical analyses were performed using the StatisticalPackage for the Social Sciences (SPSS Version 15 forWindows, 2006, SPSS Inc., Chicago, IL, USA). Chi-squareanalyses or Fisher’s exact test were used to determine anystatistically significant differences between categorical data.The P-value was set at <0.05 and all tests were two tailed.

Ethics approval was obtained from the University of Wol-longong Human Research Ethics Committee. Informationsheets were sent to each participant, and completion of thesurvey was viewed as consent given.

Results

Table 2 shows that FSMs reported cook-fresh as the mostcommon food service system. Fifty percent of respondentswere in hospitals with a cook-fresh system; 31% had cook-chill, 17% used a combination of systems and 2% used acook freeze system. Findings from a 2001 NSW food servicesurvey are included for comparison.24 Approximately 93% ofall hospitals plated meals centrally, while 7% used decentra-lised plating and there was no difference based on hospitalsize. Patient meals were mostly delivered by a food serviceassistant (88%), followed by ward assistants (5%) and nurses(2%), with no significant association between the staffmember who distributed meals and the hospital size.

Table 1 Hospital size (bed numbers) and stakeholder categories (number, %)

Bed numbers DietitianFood service

managerNurse unitmanager Total

�100 beds 36 30 28 9439% 52% 41% 38% Diet

32% FSM30% NUM

>100 beds 56 28 40 12461% 48% 59% 45% Diet

23% FSM32% NUM

Total 92 58 68 218

Diet, dietitians; FSM, food service manager; NUM, nurse unit manager.

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138

Paper menus were used in 88% of hospitals. A combina-tion of paper menus and palm pilots were used in 10.7% ofhospitals with >100 beds, while only 3.3% of hospitals with<100 beds used a palm pilot. There was no significant asso-ciation with hospital size (P = 0.402). One- and two-weekmenu cycles were used in 53.7% of responding hospitals andwere more common in the larger hospitals (65% of those>100 beds), while a four-week cycle was more common forthe hospitals with �100 beds (40%), although overall therewas no significant association with hospital size (P = 0.094).

Ninety percent of FSMs felt that special dietary, religiousand cultural needs were adequately met in their hospitals,significantly higher than the proportions of NUMs (58%),and dietitians (48%) who were satisfied with the adequacy ofchoices available for patients on special diets (P = 0.001).

There was no significant difference between the stake-holder views that adequate serving sizes were offered:87.6% of dietitians, 96% of FSMs and 92.5% of NUMsagreed. There was also agreement that small serves wereavailable when required: 94% of dietitians, 88% of NUMsand 95% of FSMs.

Seventy-six percent of dietitians, 67% of NUMs and 78%of FSMs agreed that additional main meal options tothose on the standard menu could be offered to long-staypatients. Patients on high-protein, high-energy (HPHE) dietsappeared to have regular options of HP milk, HP commercialsupplements, yoghurt, dairy dessert, or cheese and biscuits.Most nurses (86.5%) reported that additional items werealso available on the ward for patients when required.Approximately 73% reported that long-stay patients oftenhad food and beverage items brought in for them by friendsor relatives, the most popular items being chocolates andlollies, fruit, soft drinks, main meals and desserts.

There was agreement that the setting up of patients toaccess their meals and assisting those unable to feedthemselves is primarily the responsibility of nurses. Approxi-mately 42% of patients in the current study were observed torequire some form of assistance with food and/or beveragepackaging.

The mean reported time available for each main meal was40 minutes. Almost all nurses (98.5%) felt that they hadadequate time to assist and feed patients who required it,

although they did report the need to divide their timebetween several patients when there were numerous patientson the ward requiring assistance. Fifty-five percent of dieti-tians and 59.5% of FSMs reported that some non-nursingfeeding assistance was provided, most often by food serviceassistants and visitors. Few dietitians (14.5%) or FSMs(21.5%) indicated that trained, non-nursing staff wasavailable to assist with feeding at meals and only one sitementioned a volunteer feeding assistance programme.

Only 60% of dietitians thought patients’ nutritional needswere adequately assessed, while a significantly greater pro-portion (87.5%) of NUMs agreed (P = 0.001). Dietitians(94.5%) reported that nurses used food records to recorddietary intakes, but the usefulness of these records varied:26.7% rated them very useful and 46.7% rated them useful.The reasons for limitations were that they were not alwaysfilled in at the time of the meal so they were not alwaysaccurate, or up to date.

More than 80% of hospitals offered nutritionally fortifiedversions of some foods and beverages, particularly soup,mashed potato, milk and juice. The most common fortifi-cants were protein powder, skim milk powder, glucose poly-mers and cream, with no difference between availability insmall or larger hospitals (P = 0.726).

Table 3 summarises the top 10 barriers to dietary intakesidentified by each stakeholder group and the combinedtotals using the raw and the weighted data. The combinedlist included the same top 10 barriers, whether the data wereunweighted or weighted, with only the order of barriers 3–4being changed by the weighting. Several other barriers wereidentified by two stakeholder groups only. Dietitians andFSMs both noted limited nutritional assessment and com-munication between staff as barriers, while dietitians andNUMs identified lack of flexibility of food service and tasteof food.

Table 4 summarises the top 10 priority interventions.The combined list included the same top 10 interventions,with only the order of priorities 4–5 and 9–10 changed by theweighting. Interestingly, both dietitians and FSMs identifiedadditional feeding assistance by nurses, non-nursing feedingassistants available at meals and additional assistance to setup for meals as priorities, while dietitians and NUMs both

Table 2 Food service systems surveyed in 2001 (NSW) and 2005 (Australia)

Food servicesystem

2005 200124

Hospitals with�100 beds(n = 29, %)

Hospitals with>100 beds

(n = 29, %)Total

(n = 58, %)NSW total

(n = 21, %)

Hospitals with<100 beds

(n = 47, %)

Hospitals with�100 beds(n = 46, %)

Total(n = 93, %)

Cook-fresh 65.5 34.5 50.0* 38.0 76.6 28.8 53.8Cook-chill 17.3 44.9 31.0 47.7 19.1 62.3 41.7Frozen 0 3.4 1.7 0 N/A N/A N/ACombination 17.2 17.2 17.2 14.3 4.3 8.9 4.5Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0

*P < 0.05.A chi-square analysis between hospital size (�100 or >100 beds) and cook-fresh versus all other systems (cook-chill, frozen and combination)for 2005 was statistically significant, with a P-value of 0.018.

Hospital survey of barriers and priorities


139

Tab

le3

Mai

nba

rrie

rsto

adeq

uate

hosp

ital

nutr

itio

nde

scri

bed

byst

akeh

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rs

Barr

ier

num

ber

Die

titia

nsR

aw No.

Wt.

No.

Food

serv

ice

man

ager

sR

aw No.

Wt.

No.

Nur

seun

itm

anag

ers

Raw No.

Wt.

No.

Com

bine

dst

akeh

olde

rto

tals

Raw No.

Wt.

No.

1La

ckof

feed

ing

assi

stan

ce83

766

0.4

Bore

dom

due

tole

ngth

ofst

ay35

944

8.8

Lim

ited

vari

ety

585

624.

2La

ckof

choi

cedu

eto

spec

ial

diet

1482

1434

.6

2La

ckof

flexi

bilit

yof

food

serv

ice

758

598.

1La

ckof

feed

ing

assi

stan

ce35

043

7.5

Lack

ofch

oice

due

tosp

ecia

ldi

et54

858

4.7

Bore

dom

due

tole

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ay14

5614

31

3La

ckof

choi

cedu

eto

spec

ial

diet

689

543.

6La

ckof

mea

lse

tup

assi

stan

ce33

041

2.5

Pack

agin

gdi

fficu

ltto

open

543

579.

4La

ckof

feed

ing

assi

stan

ce14

5613

84.9

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redo

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leng

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stay

677

534.

2C

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unic

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aff

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tien

ts

291

363.

8La

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flexi

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serv

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498

531.

4Li

mit

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riet

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5113

95.5

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mit

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553

2.6

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ited

nutr

itio

nal

asse

ssm

ent

255

318.

8Bo

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mdu

eto

leng

thof

stay

420

448.

1La

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flexi

bilit

yof

food

serv

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1408

1319

.4

6La

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mea

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tup

assi

stan

ce61

348

3.7

Lack

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530

6.3

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415

442.

8Pa

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diffi

cult

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en12

7112

50.1

7Pa

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ing

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cult

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940

9.5

Lim

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mon

itor

ing

ofin

take

s22

728

3.8

Lack

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ally

appr

opri

ate

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317

338.

2La

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lse

tup

assi

stan

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2211

93.9

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las

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men

t50

139

5.3

Com

mun

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ion

betw

een

staf

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5La

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assi

stan

ce27

929

7.7

Lim

ited

nutr

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nal

asse

ssm

ent

994

968

9Ta

ste

offo

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037

0.8

Pack

agin

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ltto

open

209

261.

3La

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feed

ing

assi

stan

ce26

928

7Ta

ste

offo

od96

591

3.6

10C

omm

unic

atio

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twee

nst

aff

387

305.

3Li

mit

edva

riet

y19

123

8.8

Tem

pera

ture

offo

od25

627

3.2

Com

mun

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ion

betw

een

staf

fan

dpa

tien

ts

881

887.

1

Raw

No.

refe

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unw

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rea

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No.

refe

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valu

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ter

the

wei

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are

appl

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Aco

mpl

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desc

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ofth

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Met

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.

K. Walton et al.


140

Tab

le4

Mai

npr

iori

ties

for

adeq

uate

hosp

ital

nutr

itio

nby

stak

ehol

ders

Prio

rity

Num

ber

Die

titia

nsR

aw No.

Wt.

No.

Food

serv

ice

man

ager

sR

aw No.

Wt.

No.

Nur

seun

itm

anag

ers

Raw No.

Wt.

No.

Com

bine

dR

aw No.

Wt.

No.

1Fo

odfo

rtifi

cati

on11

993

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ddit

iona

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edin

gas

sist

ance

bynu

rses

5366

.3A

ssis

tanc

ew

ith

pack

agin

g47

50.1

Food

fort

ifica

tion

202

190.

9

2A

ddit

iona

lfe

edin

gas

sist

ance

bynu

rses

112

88.4

Ade

quat

em

onit

orin

gin

take

s53

66.3

Impr

oved

vari

ety

ofm

enu

opti

ons

4548

Ass

ista

nce

wit

hpa

ckag

ing

188

180.

3

3N

onnu

rsin

gfe

edin

gas

sist

ant

avai

labl

eat

mea

ls

106

83.6

Nut

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onas

sess

men

tof

all

pati

ents

5265

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quat

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xibi

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4042

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188

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4961

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on37

39.5

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nurs

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assi

stan

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ble

atm

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179

170.

5

5N

utri

tion

asse

ssm

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57.5

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3739

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617

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66.3

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4151

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157

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prov

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n.



141

identified more nourishing between mid-meal snacks, andimproved variety of menu options as priorities for change.

Table 5 provides the mean feasibility ratings of the inter-ventions. The top 10 priorities (from Table 4) are indicatedin bold. Food fortification, the highest-rated intervention,was also rated favourably regarding ease of implementation,closely followed by packaging assistance and provision ofmore nourishing between-meal snacks. However, interven-tions such as additional feeding assistance, improved menuvariety, nutrition assessment and greater menu flexibilitywere perceived as harder to implement, although on averagenone were rated as ‘very difficult’.

Discussion

A number of the trends in food service practices identified inthis survey may be barriers to the provision of adequatepatient nutrition. Firstly, while cook-fresh was the mostcommon food service system, it seems that the overall usagehas decreased (from 53.8% in 2001 to 38% in 2005 inNSW), while cook-chill and combination approacheshave increased. Cook-chill may limit the range of foodsthat can be provided on the menu and affect patient mealacceptance.25

Secondly, meal plating was still predominantly centra-lised, although some sites used bulk delivery carts in at leastsome wards. Kelly reported the benefits of decentralisedplating on the intakes of patients in medical wards,26 andseveral other recent studies have also supported this deliveryoption with various patient populations.27–29

Thirdly, more hospitals are offering menus with cyclelengths of one week or less (particularly the larger hospitals).This may be a result of changes to streamline production,and limit human resources and consumables in a bid to savecosts.4,6 This is likely to increase the problems of discontentwith menu variety.

Lastly, while almost all nurses felt they had sufficienttime to assist the feeding of patients, the other two stake-holders saw inadequate assistance as a barrier and feltfurther feeding support was required. The reported averagetime available (40 minutes) should be adequate for patientsto eat in an unhurried manner. However, it is acknowl-edged that some patients will need assistance and encour-agement from nursing staff and the number of patients andstaff will influence the time required. Seventy percent ofpatients in a Sydney hospital were reported as needingsome form of assistance with meals, and designated staffroles were not consistently assigned responsibility for thisimportant task.30

All stakeholders agreed on six key barriers: lack of choicedue to a special diet, boredom due to length of stay, limitedmenu variety, lack of feeding assistance, packaging difficultto open and lack of meal set up assistance. The first threeissues relate to a lack of customisation in hospital foodservices while the last three barriers relate to a lack of time byfood service and nursing staff.

All three stakeholders agreed on five feasible priorityinterventions: food fortification, assistance with packaging,nutrition assessment, adequate monitoring of intakes andflexibility of menu choices. Of note were the additional

Table 5 Feasibility rating for each priority intervention and stakeholder group

Priority interventionMean feasibility

ratingDietitian

ratingFSMrating

NUMrating

Serve size options (small offered) 1.7 2.0 1.7 1.3Food fortification 2.3 2.4 2.0 2.4More information on menu choices 2.3 2.3 2.4 2.3Packaging assistance 2.5 2.4 3.0 2.7Adequate time allowed 2.5 2.5 2.1 2.8Improved communication staff & patients 2.7 2.7 2.5 3.0More nourishing between meal snacks 2.7 2.6 3.0 2.5Additional foods brought from home 2.8 2.6 3.3 2.9Improved communication between staff 2.8 2.7 3 2.7Improved layout and appearance of meal tray 2.9 3 3.3 2.7Adequate monitoring of intakes 3.0 3.2 3.0 2.6Additional assistance to set up for meals 3.0 2.7 3.2 3.3Additional feeding assistance by nurses 3.2 3.6 3.2 3.3Improved taste 3.2 3.3 3.1 3.2Additional culturally appropriate dishes 3.2 3.6 2.4 3.1Dining room 3.3 3.2 3.4 3.3Adequate flexibility of menu choices 3.3 3.5 3.1 2.9Improved variety of menu options 3.3 3.4 3.2 3.3Nutrition assessment of all patients 3.5 3.8 3.5 3.2Non nursing assistant available at meals 3.6 3.7 3.3 3.5

1 = very easy, 2 = somewhat easy, 3 = possible, 4 = somewhat difficult, 5 = very difficult.The bold text indicates the top 10 cumulative priorities for the three stakeholders (Table 4).FSM, food service manager; NUM, nurse unit manager.

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priorities identified by the dietitians and the FSMs (addi-tional feeding assistance by nurses, non-nursing feedingassistant available at meals and assistance to set up for meals)and by both the dietitians and the NUMs (more nourishingbetween meal snacks and an improved menu variety). Thefirst three items concern the ward environment, while thelast two concern the food service system. This indicates thatstakeholders tended to focus on solutions outside of theirown areas of control.

Food fortification was ranked as the most feasible inter-vention (mean 2.3), and more than 83% of hospitals werealready using this in some form. This intervention has beenevaluated favourably in the literature15,16,31 and is valuablebecause it can increase the intakes of small eaters. However,it is reliant on other strategies such as assistance with feedingand opening packaging to be successful.

Improved packaging had a feasibility of 2.5, suggesting itmight be relatively easy to address. Forty-nine percent ofpatients surveyed in two Queensland teaching hospitals haddifficulty opening packaging7 and this problem was identi-fied also in our previous study.23 The use of packaged itemsappears to be increasing, which can adversely affect thevisual appeal of the meal, the environment and negativelyimpact food consumption. Further research is required toinvestigate what types of packaging patients find easiestto open.

The priority of more nourishing snacks (feasibility rating2.7) reflects literature that indicates that many patients findmeals too large and less appealing.7,32 Items such as choco-late, cheese and biscuits, high-energy cakes, and sandwichescould be incorporated as mid-meal snack offerings, and arerecommended in the new nutrition standards for NSW hos-pitals.33 Trials are needed to examine the cost-effectivenessof this strategy compared with the use of more traditionalcommercial supplements.

Nutrition assessment of all patients (mean feasibility 3.5)and monitoring of intakes (3.0) were rated harder to imple-ment, although regarded as high priorities by dietitians.However, the systematic implementation of nutrition screen-ing and monitoring for all inpatients would be a more prac-tical priority in the first instance.34

Three of the identified barriers (lack of choice due to aspecial diet, boredom due to length of stay and limitedvariety) could be addressed by improved menu variety(mean feasibility 3.3). Other research suggests that customi-sation is an important determinant of overall patient satis-faction with hospital food services.35

Additional feeding assistance by nurses or trained volun-teers and additional meal set up assistance were ranked morehighly as priorities by the dietitians and FSMs, than theNUMs. Nurses in the survey reported that they could assisttheir patients when required in most instances. This is incontrast to the findings of many others researchers whosuggest that busy nurses have little time to encourage andassist those who need it.36–38

These three potential strategies (nutritional assessment,improved menu variety and feeding assistance) were alsoviewed as more difficult to implement. Implementation of a

‘protected meal times’ could help in addressing these threeissues because meal times would be prioritised and nursingstaff would be available to assist with setting up, feeding andmonitoring.39 The possible role for trained volunteers inassisting with feeding assistance, opening of packages andmonitoring also requires further consideration. Trained vol-unteers have assumed this role in one aged care ward of aSydney hospital, with apparent improvements in patients’intakes.40

Although the survey response rate was low, it includedresponses from hospitals with almost half the hospital bedsin Australia. There were more responses from dietitians thanfrom FSMs or NUMs, but the weighted results take accountof the differing numbers of responses from each stakeholdergroup. Hospitals smaller than 20 beds were not included;however, the responses from 20 hospitals with less than 100beds provided information on issues likely to affect thesmallest sites.

There was significant agreement between stakeholdersregarding many key barriers and priority interventions toimprove dietary intakes of long-stay patients. Limited menuvariety, boredom due to length of stay, food packaging, anda lack of feeding and set up assistance are particular barriersthat warrant further consideration. Priority interventionsinclude the application of food fortification, additionalassistance with packaging, meal set up and feeding whenrequired, improved menu variety, more nourishing betweenmeal snacks and an increased use of nutritional assessment.Clearly, there are numerous barriers to adequate intakes byhospital patients, and a ‘toolbox’ of interventions is requiredas no one approach will fix all the problems. Further, cost-benefit and outcome studies will enhance support and advo-cacy for feasible food service interventions in the future.

Acknowledgements

Funding was provided by the Smart Foods Centre, Univer-sity of Wollongong. Our thanks to Greg Abernethy (webdesigner), Prof David Steel (statistical advice) and threedietetics research students (Christine Wirtz, NatashaAinsworth and Lauren Lynch) who assisted with the dataanalyses.

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Improving food services for elderly, long-stay patients in Australian hospitals: Adding food fortification, assistance with packaging and feeding assistance