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RESEARCH
urrent Research
xperts Stress Both Wellness and Amenityspects of Food and Nutrition Services inssisted Living Facilities for Older Adults
HIRLEY Y. CHAO, PhD, RD; JOHANNA T. DWYER, DSc, RD; ROBERT F. HOUSER, PhD; PAUL JACQUES, DSc;
HARON TENNSTEDT, PhD, RNmtRntaepCiaaJ
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BSTRACTbjectives There has been no consensus on best practicesn food and nutrition services in assisted living facilitiesor older adults. We documented experts’ views on opti-al food and nutrition services emphases in assisted
iving facilities, and factors affecting their views.ethods One hundred thirty-five national experts special-
zing in health, aging, nutrition and assisted living facil-ties completed a survey consisting four scenarios (ie,ome-style, restaurant/hotel, and health/medical, and aombination of these three) in six food and nutritionervices areas: dining room environment, meal services,
. Y. Chao is director of nutrition, Massachusetts Execu-ive Office of Elder Affairs, Boston; at the time of theesearch, she was a doctoral student at the Friedmanchool of Nutrition Science and Policy, Tufts University,oston, MA. J. T. Dwyer is a professor, Gerald J. andorothy R. Friedman School of Nutrition Science andolicy, Tufts University, Boston, MA, professor of medi-ine and community health, Tufts University School ofedicine, Boston, MA, director of Frances Stern Nutri-
ion Center, New England Medical Center, Boston, MA,nd a senior scientist, Nutritional Epidemiology Pro-ram, Jean Mayer USDA Human Nutrition Researchenter on Aging at Tufts University, Boston, MA. R. F.ouser is an instructor and research analyst, Gerald J.nd Dorothy R. Friedman School of Nutrition Sciencend Policy, Tufts University, Boston MA. Paul Jacquess a professor, Gerald J. and Dorothy R. Friedmanchool of Nutrition Science and Policy Tufts University,oston, MA, and director of Nutritional Epidemiologyrogram and a senior scientist, Jean Mayer USDA Hu-an Nutrition Research Center of Aging, Boston, MA.. Tennstedt is vice president and director, Institute fortudies on Aging, New England Research Institutes,atertown, MA.Address correspondence to: Shirley Y. Chao, PhD, RD,assachusetts Executive Office of Elder Affairs, Oneshburton Place, 5th Fl, Boston MA 02108. E-mail:[email protected] accepted: March 7, 2008.Copyright © 2008 by the American Dietetic
ssociation.0002-8223/08/10810-0005$34.00/0
adoi: 10.1016/j.jada.2008.07.013
654 Journal of the AMERICAN DIETETIC ASSOCIATION
eal quality, nutrition services, employees’ qualifica-ions, and therapeutic nutrition services.esults Sixty-three percent of experts favored the combi-ation scenario. Dietetics education and experts’ beliefshat assisted living facilities should be health promotionnd maintenance facilities were significant predictors ofmphases, including wellness considerations. Experts’ersonal views exerted a powerful influence.onclusions Experts chose food and nutrition service qual-ty indicators that emphasized a focus on both wellnessnd amenities as their ideal scenarios for optimal foodnd nutrition services in assisted living facilities. Am Diet Assoc. 2008;108:1654-1661.
ssisted living facilities are popular housing alterna-tives that provide a supportive environment forolder Americans who can no longer live indepen-
ently and who often have low mobility levels (1,2). Ac-ording to the National Center for Assisted Living Facil-ties, assisted living facility residents needed assistanceith 2.3 out of five activities of daily living on average,
ompared to 3.8 activities of daily living for nursing homeesidents and 1.6 activities of daily living among thoseeceiving home health services (3). Weight problems,hronic diseases, and frailty increase the prevalence ofmmobility (4). Optimal food and nutrition care can helpo maintain or improve mobility, delay the onset ofrailty, and further promote the quality of life of oldermericans (5-7).Older adults who reside in assisted living facilities are
eterogeneous, and therefore it is not surprising thatperators of these facilities differ markedly in their viewsbout optimal care relating to food and nutrition servicesn these settings (8-10). The conceptual components ofhese views can be grouped into four descriptive food andutrition service emphases: home-style, restaurant/hotel,ealth/medical, and a combination of these three (11).ach reflects a different perspective toward food and nu-
rition services in assisted living facilities. Both the hometyle with its free choice of food, informality, and inde-endence, and the restaurant/hotel style, which featuresttractively prepared foods, personalized service, and aongenial dining environment, emphasize amenities. Inontrast, the health/medical style-focused services em-hasize menus that are tailored to older adults’ preven-ive or therapeutic nutrition needs, other health issues,
nd dining safety (5,11,12-18).© 2008 by the American Dietetic Association
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Nutrition surveys of free-living older adults and those inursing homes or other acute care facilities are availableut there are none for those living in assisted living facilities19-21). The nutritional status of residents in assisted livingacilities is largely unknown. To ensure that residents inssisted living facilities are adequately nourished, manyxternal standards have been proposed and some regula-ions have been mandated (10). Although many stakehold-rs agree that assisted living facilities should promote goodutrition as well as residents’ choices, independence, auton-my, and dignity (22), it is unclear whether such conceptsre widespread and are operationalized in planning optimalood and nutrition services for older adults. This is an im-ortant matter because assisted living facility meals areften their only source of food intakes (3,9). Residents inssisted living facilities are sometimes presented with ahoice of menu offerings, but they may have no control overow the items are prepared. Some assisted living facilitiesromote autonomy by permitting residents to eat whateverhey want, but if cognitive competence and the need forherapeutic diets are not considered, nutritional status maye compromised. An assisted living facility must be able torovide appropriate food and nutrition services such asheel chair accessible dining rooms as residents’ age, theirealth and nutritional needs change, and frailty sets in
23-25). To promote optimal food and nutrition services inhese settings, key quality indicators for food and nutritionervices in assisted living facilities have been identified (26).n addition, the appropriate emphasis for these servicesust also be chosen and implemented.The objective of this study was to assess the degree of
onsensus among a panel of 135 national experts on foodnd nutrition services emphases covering six key food andutrition service areas for assisted living facilities. We alsoxamined the association between the experts’ responses touestions regarding the importance of food choice autonomyf residents, their ability to make wise dietary choices, andhe experts’ favored role for assisted living facilities. Finally,he influences of experts’ personal characteristics on appro-riate emphases in assisted living facilities’ food and nutri-ion services were examined.
ETHODShe study was approved by the Tufts-New England Med-
cal Center’s Institutional Review Board.
urvey Instrumenthe Food and Nutrition Care Indicators questionnaire wasescribed in detail elsewhere (26). Part 1 identified keyuality indicators for food and nutrition services in assistediving facilities (26). Part 2, which was used for this report,ad two sections. The characteristics of the quality indica-ors were examined from the standpoint of each servicetyle detailed in Part 1. We developed four scenarios ofervice emphases and asked respondents to choose the onef the four scenarios (home style, restaurant/hotel style,edical, or a combination of these three) that best matched
o their opinions of how assisted living facilities should beperated. A different set of four scenarios was developed forach of the six food and nutrition service areas, the dining
oom environment, meal services, meal quality, general nu- grition services, food service employee qualifications andraining, and therapeutic nutrition services. The scenariosor each service area were presented in mixed order and notabeled or defined in the questionnaire.
We also asked the experts to provide their level ofgreement (based on a seven-point scale) with threetatements. The first focused on the desirable degree ofutonomy residents should have in making food choices1�eat whatever they want to be happy, and 7�eat onlyealthful foods and meals to live longer). The secondocused on residents’ capabilities of making wise dietaryhoices (1�able to make wise dietary choices on their ownithout assistance, 4�able to make wise dietary choicesn their own, but need education and counseling, and�not able to make dietary choices on their own). Theast item queried the experts’ own favored role for as-isted living facilities (1�housing alternatives, and�health promotion and maintenance facility).
tudy Populationetails on the selection of the expert panel and the pop-lation are described elsewhere (26). Two hundred twen-y-five professionals specializing in health, aging, andutrition pertaining to assisted living facilities were se-
ected using defined criteria that focused on their educa-ion, work experience, or affiliations with national orga-izations (26). Of the 225 experts originally contacted,53 (68%) answered Part 1 of the questionnaire com-letely, 13 (5%) provided partial but insufficient data andere excluded from analysis, and 59 (27%) refused or
ailed to respond. The 135 (60%) who answered botharts 1 and 2 of the questionnaire constituted the ana-
ytical sample.
tatistical Analysishe Statistical Package for the Social Sciences (version 15.0
or Windows, 2007, SPSS Inc, Chicago, IL) and Stata (ver-ion 9.2 for Windows, StataCorp LP, College Station, TX)ere used for statistical analyses and descriptive statistics.Using the data derived from the four scenarios, each
epresenting a different emphasis, we created a singleariable that represented what we called a wellness ser-ice emphasis. The respondents who chose scenarios thatncluded health/medical or a combination of all threeervice styles were assigned to the wellness service em-hasis (which included not only health promotion andrevention, but also therapeutic and medical aspects ofare) and given a score of one for that area of concern.hose who mentioned only amenity service emphasis
restaurant/hotel or home style) with no wellness focusere coded as zero. From the sum of these scores for each
f the six food and nutrition service areas, we calculatedwellness service emphasis rating for assisted living
acility perspectives. For example, if the assisted livingacility wellness service emphasis rating was six, thexpert’s service emphases included wellness consider-tions in all six food and nutrition service areas; if theating was two it indicated that the expert’s judgment ofhe most appropriate service emphasis included wellnessonsiderations in only two of the six food and nutritionervices areas of concern. Higher ratings indicated a
reater emphasis on wellness considerations.October 2008 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1655
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1
Area of concern Operational descriptions of emphasis in service perspectives
Servicescenariosstyles
Serviceemphasistype
Dining roomenvironment
Stresses a comfortable and relaxed setting with simple decorations and a family-sizeddining room shared by residents. Safety measures are dependent on individualresident needs.
Home Aa
Emphasis is on aesthetics and social interaction among residents. The dining roomhas soft music, low noise levels, and subdued lighting. There are no more thantwo to four people at each table. Safety requirements meet basic standards forpublic restaurants.
Restaurant A
Emphasis is on the safety and medical needs of residents. This includes brightlighting, institutional furniture, and dining room tables big enough to seat allresidents at one seating. High-level safety measures are present such as railingson the wall and tile floors.
Medical Mb
Emphasis is on aesthetics, social interactions among residents, creating a home-likeenvironment, and meeting safety needs. The dining room has soft music, low noiselevels, subdued lighting, and comfortable and relaxed settings. No more than twoto four people are seated per table.
Combination ofhome/restaurant/medical styles
M
Foodservices: Mealservice
Emphasis is on personal preferences. Menu alternatives are allowed for medical,religion, and cultural and personal reasons. Meals are served preplated or familystyle from serving dishes on the table, whenever residents want to eat. Residentscan choose menu items they like—even if they only choose a single item.
Home A
Emphasis is on courteous service, attractive table settings, and plate presentation.Menu choices are extensive, and are served by wait staff. Residents can makechoices of mealtimes from the posted schedule or order room service.
Restaurant A
Emphasis is on meeting nutrition and feeding needs. Normally meals are served froma cycle menu, with no choices. Alternatives are allowed only for medical reasons.Meals are served preplated by wait staff, and served only at scheduled times.
Medical M
Emphasis is on courteous service, attractive table settings and presentation,nutritional adequacy, and meeting residents’ medical needs. Menu options arereasonable and incorporate religious and cultural concerns. Residents choose froma menu and wait staff serve the meals. Alternatives are allowed only for medicalreasons. Residents can make choices of the meal times from a set of schedules.Nutritious snacks are available at all times.
Combinationhome/restaurant/medical
M
Foodservices: Employeemanagement
Staff knowledge and training on food safety and sanitation and basic nutrition are notemphasized because management assumes residents to be knowledgeable aboutthese issues and that they can fend for themselves.
Home A
Staff experience working in restaurants or hospitality business is desirable. Employeetraining sessions focus on service styles and basic sanitation and food safetyrequirements.
Restaurant A
Staff experience working in food and nutrition services in hospitals or long-term carefacilities (eg, nursing homes) is required. Inservice training focuses on sanitationand food safety, basic nutrition, therapeutic diets, and other special needs of ahigh-risk, frail older population.
Medical M
Staff experience working either in restaurants and culinary arts or food and nutritionservices in hospitals or long-term care facilities is required. Inservice training isfocused on service styles, sanitation and food safety, general nutrition, and specialneeds for high-risk frail elder population. A minimum number of training hours arerequired before employment.
Combinationhome/restaurant/medical
M
General nutritionservices: Mealquality
Focus is on individual preference. Regular home-cooked foods are provided withvariation in portion sizes to suit each individual’s appetite. Sensory appeal andhealthfulness of the meals depend on the cook.
Home A
Focus is on taste, flavor, and appearance of individual dishes. Generous portion sizes.High-quality, expensive items (such as fresh fruits and vegetables and high grademeats) are served. Preprepared foods also are used to provide more extensivemenu choices. The healthfulness of the meals varies depending on the cook.Dishes with health or nutrition claims are provided on occasion.
Restaurant A
Focus is on meeting the total daily nutrition needs for nutrients. Meals are preparedfrom standardized recipes using lower-fat and lower-sodium ingredients, morehealthful cooking methods, and specified portion size. Food is bland and texture isoften soft or even mushy.
Medical M
Taste, flavor, appearance, and meeting total daily nutrition needs are emphasized.Meals are prepared from tested and standardized recipes specifying the quality ofthe raw ingredients, portion sizes, cooking methods, and nutrient content.
Combinationhome/restaurant/medical
M
(continued)
igure. Descriptions of food and nutrition services scenarios with different emphases in six food and nutrition services areas, on the Food andutrition Care Indicators questionnaire, which was distributed to 225 professionals specializing in health, aging, and nutrition pertaining to assisted
iving facilities. (This material was developed by Shirley Chao and Johanna Dwyer at the Gerald J. and Dorothy R. Friedman School of Nutrition
cience and Policy at Tufts University.)656 October 2008 Volume 108 Number 10
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Spearman rank order correlations were calculated toxamine the associations among the experts’ responses tohe opinion questions about the food choice autonomy ofesidents, their ability to make wise dietary choices, andhe experts’ favored role for assisted living facilities.
Logistic regression was used to determine which char-cteristics of experts, when considered individuallycrude) or together (adjusted for other characteristics andttitudes), may have influenced experts to include well-ess considerations in their judgments of the optimalervice emphases for food and nutrition services in as-isted living facilities for each service area. We used therdinary least squares linear regression analysis to de-ermine the association between the experts’ characteris-ics and attitudes and the wellness service emphasis rat-ng. The data were skewed, and to ensure that the resultsere not biased by the distribution, a binominal logistic
egression was also performed.The independent variables were experts’ character-
Area of concern Operational descriptions of emphasis in ser
General nutritionservices: Promotionand prevention
Nutrition services are assumed to be providedtheir insurance services, their caregivers, orfederal nutrition program or council on agin
Nutrition services are de-emphasized and provdemanded by residents or their families. Hobrochures and wellness-related seminars ar
Health promotion, disease prevention, and mefocus. Health professionals (eg, registered dand physical therapists) in the facility workassessment, education, and counseling to emet.
Health promotion, disease prevention, and mefocus. Health professionals (eg, RDs, nursestherapists) work together to provide assessmensure that residents’ nutrition needs are meducation are offered to residents at no ext
Therapeutic nutritionservices
Management regards the facility as a residentHowever, it provides basic heart-healthy chmeals (eg, chopped or ground)
Therapeutic diets are provided only if demandextra for them. Management regards the fahealth care facility. Legal liability is handledresponsibilities—agreements/contracts thatlook after their own therapeutic needs.
Management regards the facility as responsiblresidents in managing their health and aginindividual choices. Facility provides therapeconsumption, and informs residents’ familieare on staff /or dietitian consultant ensuresresidents are met.
Management regards the facility as responsiblelders to manage their health and to aging.monitors and documents consumption, andcaregivers when concerns arise. The staff Rresident therapeutic dietary needs are met.
aA�amenity only.bM�medical or combinations of amenities and medical.
igure. Descriptions of food and nutrition services scenarios with diffutrition Care Indicators questionnaire, which was distributed to 225 pr
iving facilities. (This material was developed by Shirley Chao and Johcience and Policy at Tufts University.) (Continued)
stics and attitudes including age (older than age 50 c
ears yes/no), sex (woman yes/no), professional back-round (registered dietitian yes/no), prior work in-olvement with assisted living facilities (worked in anssisted living facility facility yes/no), experience inorking with many assisted living facilities (10 facili-
ies or more yes/no), and the experts’ rating on the-point scales of the importance of assisted living facil-ty residents’ food choice autonomy, capabilities for
aking wise dietary choices, and the expert’s favoredole for assisted living facilities. The dependent vari-ble for the logistic regression was the assisted livingacility wellness service emphasis score (wellness con-iderations�1, amenity only�0) in each area of concernn food and nutrition services, and the dependent vari-bles for the ordinary least squares model were theellness service emphasis rating (possible score zero to
ix). Data are presented as both crude and adjusteddds ratios with P values and 95% confidence intervals.
values �0.05 were regarded as statistically signifi-
perspectives
Servicescenariosstyles
Serviceemphasistype
idents by their primary physician,mmunity services (such as a
Home A
nly when required by law or, nutrition information in flyers orred occasionally.
Restaurant A
utrition therapy are the primaryns [RDs], nurses, social workers,er as a team to provideresidents’ nutrition needs are
Medical M
utrition therapy are the primaryal workers, and physicaleducation, and counseling toutine screening, counseling, andt.
Combinationhome/restaurant/medical
M
ility, not a health care facility.and simple mechanically modified
Home A
regulations or if the resident payss a hospitality facility, not agh shared risks or shared
responsibility to individuals to
Restaurant A
romoting health, assistingcessfully, while respectingeals, monitors and documentscaregivers of any concerns. RDs
herapeutic dietary needs of
Medical M
romoting health and assistingty provides therapeutic meals,s residents’ families and
titian consultant ensures that
Combinationhome/restaurant/medical
M
emphases in six food and nutrition services areas, on the Food andionals specializing in health, aging, and nutrition pertaining to assistedDwyer at the Gerald J. and Dorothy R. Friedman School of Nutrition
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October 2008 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1657
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ESULTShe response rates from those in various disciplinesmong the 135 experts were generally similar. Of the 80erontological dietitians, 54 (68%) replied; of the 19 ex-erts in geriatric medicine and health, 13 (68%) replied;nd of the 55 experts in aging and disability, 29 (62%)esponded. The exceptions were that among the 24 ex-erts on assisted living facilities, more responded (n�21,8%), and among the 47 foodservice and restaurant op-rators, fewer did so (n�18, 38%).Most (79%) of the 135 experts were women. Most (70%)ere older than age 50 years. Fifty-three percent were
egistered dietitians, and the rest came from a variety ofther disciplines. Fifty-six percent were directly and per-onally involved with and had worked in assisted livingacilities (eg, as staff, owners, consultants, resident rep-esentatives, or investors) and the other 44% also hadome involvement with assisted living facilities (eg, asegulators, accreditors, advocates, or family members)lthough they had not worked in them. During theirareers, most (59%) of the experts had been associatedith fewer than 10 facilities, and 41% had been associ-ted with 10 or more facilities.
ervice Emphases Favored by Expertshe Figure describes the food and nutrition services sce-arios styles and types of services emphasized in eachrea on the questionnaire and how they were classified.able 1 presents the service emphases favored by thexperts in each key area of concern about assisted livingacility food and nutrition services. The majority of ex-erts favored a combined service emphasis of home style,estaurant/hotel style, and health/medical style for allreas except therapeutic nutrition for which they favoredealth/medical. “Pure” service emphases were less fre-uent than those that emphasized some features of each.ess than 1% of experts chose the home style emphasis
or the area involving foodservices employee manage-ent, and none of the experts favored the medical service
mphasis in the general meal quality area.
nclusion of Wellness Considerations in Service Perspectivesurther analysis revealed that 32% of experts (n�43) ratedellness service considerations in all six food and nutrition
ervice areas, in contrast to only 2% (n�2) who did so in norea (data not shown). The rest of the experts had a spec-rum of views about what was optimal in assisted livingacilities depending on the food and nutrition service areahat was being considered. For example, 44 experts had aellness service emphasis rating of five, but there were fiveifferent patterns of response, with the emphasis on well-ess services in different combinations of the five out of theix food and nutrition service areas. There were 11 patternsmong the 19 experts with ratings of four, nine patterns for3 experts with ratings of three, and eight patterns for 14xperts with ratings of either one or two.
xperts’ Views on Assisted Living Facility Residents andervices of the Facilitiesf the 135 experts, most (49%) viewed it more important
or residents to “eat whatever they want to be happy” A
658 October 2008 Volume 108 Number 10
ratings of one to three), 29% believed there should be aalance (rating of four), and the minority (22%) believedhe older adults should eat only healthful foods and mealsratings of five to seven).
Nearly half (46%) of experts believed older adults in as-isted living facilities were “able to make wise dietaryhoices on their own but need education or counseling”rating of four), and 42% believed they were “able to makeise dietary choices on their own without assistance” (rat-
ng of one to three). Only a minority of experts (12%) be-ieved assisted living facility residents were “not able to
ake dietary choices on their own” (rating of five to seven).Forty-five percent of experts viewed assisted living fa-
ilities as health maintenance and promotion facilitiesrating of five to seven), 31% saw assisted living facilitiess housing alternatives (rating of one to three), and 24%id not have strong opinions in either direction (rating ofour).
The correlations among the experts’ views on threepinion questions were low and positive, but significant.he importance of autonomy in food choices was posi-ively and significantly but only weakly correlated withxperts’ views on residents’ abilities to make wise dietaryhoices (r�0.24, P�0.01). The more the experts believedhat residents were capable of making wise dietaryhoices, the higher was the degree of autonomy in foodhoices they believed residents should have. Autonomy inood choices was also positively and weakly correlatedith experts’ views of assisted living facilities as housinglternatives (r�0.38, P�0.01). Views on residents’ abili-ies to make wise dietary choices were also positively butnly weakly correlated with the role of assisted livingacilities as housing alternatives (r�0.22, P�0.05).
ssociation between Experts’ Backgrounds and Personal Viewsn Wellness Service Emphases in Assisted Living Facilityood and Nutrition Servicess shown in Table 2, of all the demographic characteris-
ics of experts that were considered, only being a regis-ered dietitian was related to a wellness service emphasisn ratings of the scenarios. However, the more the expertselieved that the residents should eat healthful foods orhat assisted living facilities should be health mainte-ance and promotion facilities, the greater the wellnesservice emphasis they placed on food and nutrition ser-ices for optimal assisted living facility eldercare. Most ofhe experts’ wellness service ratings were five and six andhe distribution was skewed, so the binominal logisticegression was also performed in addition to ordinaryeast squares regression. The results were consistentith the results from ordinary least squares regression.Table 2 also presents the odds ratios for the associa-
ions between demographic characteristics and personaliews of the experts on inclusion of wellness consider-tions. The crude odds ratio, which assessed the individ-al relationships between the characteristics, experts’ersonal views and inclusion of wellness considerations,howed that many demographic characteristics (age, sex,rofessional training in dietetics, working with 10 orore assisted living facilities) and personal views were
ssociated with the likelihood of including wellness con-iderations in their views in one or more areas of concern.
djusted odds ratios, which represented the independent
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ontribution of each of the experts’ characteristics andiews to the prediction of the inclusion of wellness con-iderations, revealed that after mutual adjustment for allther characteristics and views, only a few of these re-ained significant. Dietetics education was significantly
ssociated with such views, especially in the meal qualityrea (P�0.01) and it approached statistical significancen the therapeutic nutrition area (P�0.06). Experts whoated residents’ capabilities for making wise dietaryhoices as low were more likely to include wellness con-iderations in the area of therapeutic nutrition (P�0.05).he experts’ personal views on the role of assisted living
acilities were most consistent of all and unaffected bydjustment. Those who rated assisted living facilities asealth promotion and maintenance facilities were more
ikely to favor a service emphasis that included wellnessonsiderations in areas of foodservice operation employ-es (P�0.01), meal quality (P�0.001), and therapeuticutrition (P�0.001).
ISCUSSIONhen experts were asked to evaluate food and nutrition
ervices in assisted living facilities, most included well-ess considerations in their perspectives about optimalervice emphases. The extent to which this wellness per-pective dominated varied little by the specific food andutrition service areas.The experts’ perspectives about optimal service empha-
es in assisted living facilities as well as their views aboutmportant quality indicators favored holistic views abouthe nature of food and nutrition services that should berovided in assisted living facilities (26). Virtually allespondents viewed amenities, represented by the char-cteristics of the home and restaurant/hotel service sce-arios, as being important. However, their opinions di-erged on to what extent wellness considerations shoulde included in assisted living facilities for older adults.hey seemed to view assisted living facility services asifferent from what older adults would receive at home,n restaurants, or in health/medical facilities, but inclu-ive of elements of all them.
Table 1. Emphases favored by 135 experts specializing in health, agifood and nutrition services areas in assisted living facilities for older
Service emphasis
Percent of Experts Choosing Each
Dining roomenvironment
Foodservices:Meal service
FoodsEmplomana
Amenity onlyRestaurant 5 5 16Home 25 22 �1Includes wellness
considerationsMedical 3 1 15Combination of home/
restaurant/medicalstyles 67 72 69
Optimal care in assisted living facilities is related to t
oth philosophical views and practice (11,27-29). In ourtudy, we examined the personal views and demographicackgrounds of the experts. Overall, the experts withducation as dietitians, their attitudes toward residents’utonomy with respect to food choices, and their views ofhe role of assisted living facilities were key factors inredicting their opinions that wellness considerationshould be included in food and nutrition services. Per-aps dietetics education made those experts more awaref the many nutritional and safety attributes of foodser-ices and meal quality that are difficult to identify with-ut technical expertise, whereas other characteristics,uch as taste, flavor, and appearance, are more obvious30). The experts’ views on autonomy in food choices andhe roles for assisted living facilities were also stronglyssociated with their views on residents’ abilities to makeise dietary choices. The adjusted odds ratios showed the
elatively more powerful influence of experts’ personaliews compared to other characteristics.Resnick (31) suggested that “Optimal care in ALFs
assisted living facilities] requires that nursing change itshilosophy of care in geriatrics from one that is focused onervice provision and meeting care needs to one thatptimizes health and function for each resident.” Theesults from our survey support this in food and nutritionervice areas as well and suggest that experts prefer aervice emphasis for optimal care that includes both ame-ity and health emphases for food and nutrition services
n assisted living facilities. It is noteworthy that fewerhan one third of experts rated assisted living facilities asimply a housing alternative. The implication is thatost experts view a wellness component as important in
ssisted living facilities.Our study had limitations. Some experts may have
elieved that the choices provided did not reflect theirersonal views or philosophies with respect to assistediving facilities, and other experts might have providedifferent ratings. Also, expert views reflect existing cir-umstances. The assisted living facility industry is newnd the typical residents today are relatively young andapable of making decisions on their own. However, as
d nutrition pertaining to assisted living facilities as optimal in variousts
ice Emphasis in Various Food and Nutrition Service Areas
es:
nt
General nutritionservices: Mealquality
General nutritionservices: Promotionand prevention
Therapeuticnutritionservices
11 11 6%17 10 15
0 25 34
72 54 49
ng, anadul
Serv
ervicyeegeme
he industry matures, assisted living facility residents
October 2008 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1659
Table 2. Influence of background and personal views about assisted living facilities (ALFs) of 135 experts specializing in health, aging, and nutrition pertaining to ALFs on their likelihoodof including medical considerations in their ratings of most appropriate service emphases, for six different areas of concern in the food and nutrition services provided at ALFs
Experts’ background andpersonal views
Odds ratios(ORsa)and 95%confidenceinterval (CI)
Areas of Concern in Food and Nutrition Services
Wellness considerationemphasis rating for allsix food and nutritionservices areasb
Dining roomenvironment
Foodservices:Meal service
Foodservice:Employeequalification
General nutritionservices: Mealquality
General nutritionservices:Promotion andprevention
Therapeuticnutritionaervices
DemographicsOlder than age 50 y (yes/no) Crude OR 1.77 1.8 1.38 0.9 1.1 0.75
Adjusted OR 1.82 1.96 1.39 0.9 1.07 0.65 0.0895% CI (0.78-4.26) (0.80-4.81) (0.47-4.16) (0.36-2.29) (0.34-3.41) (0.20-2.13)
Woman (yes/no) Crude OR 1.86 2.60* 2.46 2.18 0.96 0.79Adjusted OR 1.47 1.73 2.1 1.41 0.86 0.51 0.0695% CI (0.54-4.05) (0.62-4.81) (0.62-7.12) (0.50-3.94) (0.21-3.55) (0.13-2.02)
Food and nutritionprofessional (yes/no)
Crude OR 1.57 2.37* 2.83* 4.07*** 1.15 2.23Adjusted OR 1.43 2.67 2.49 4.17** 1.16 3.23 0.25**95% CI (0.53-3.84) (0.94-7.60) (0.68-9.14) (1.49-11.63) (0.33-4.12) (0.95-10.96)
Worked directly in ALFs(yes/no)
Crude OR 0.85 1.05 0.85 0.65 0.64 0.83Adjusted OR 2.07 0.6 0.86 0.49 0.85 0.85 �0.0495% CI (0.90-4.76) (0.25-1.44) (0.29-2.61) (0.20-1.19) (0.27-2.62) (0.29-2.49)
Worked with 10 or moreALFs (yes/no)
Crude OR 1.87 0.67 1.84 2.14* 1.82 2.42*Adjusted OR 0.64 0.68 1.67 1.41 2.64 2.26 0.5495% CI (0.26-1.60) (0.26-1.73) (0.53-5.22) (0.57-3.46) (0.82-8.50) (0.76-6.70)
Personal viewsc
Rated importance ofautonomy for foodselections (1�highautonomy, 7�low)
Crude OR 1.13 1.33 1.69** 1.42* 1.89*** 1.79***Adjusted OR 1.20 1.31 1.45 1.27 1.24 1.25 0.20*95% CI (0.85-1.69) (0.91-1.87) (0.92-2.27) (0.90-1.80) (0.80-1.91) (0.83-1.89)
Rated residents’ capabilities(1�very capable, 7�notcapable)
Crude OR 0.91 1.04 1.43 1.11 2.09*** 2.10***Adjusted OR 0.8 0.86 1.08 1.03 1.71 1.83* 0.0695% CI (0.54-1.18) (0.57-1.29) (0.64-1.83) (0.68-1.56) (0.98-2.97) (1.06-.3.14)
Rated role of ALFs (1�nohealth, 7�all health)
Crude OR 1.17 1.19 1.67*** 1.19 2.39*** 1.75***Adjusted OR 1.19 1.12 1.56** 1.14 2.20*** 1.67*** 0.32***95% CI (0.90-1.57) (0.85-1.49) (1.10-2.20) (0.86-1.51) (1.49-3.23) (1.18-2.37)
aThe OR is 1 when there is no relationship between the independent and dependent variables. If the OR is �1, then having the characteristic decreases the likelihood that the respondent will include wellness considerations in his selectionof the ALF’s service emphasis for dining room.bBased on ordinary least squares mean. Standardized coefficient adjusted r 2 is 0.265, f value 6.873, P�0.001.cContinuous variables.*P�0.05.**P�0.01.***P�0.001.
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ill become older, and many will develop frailty andementia, which may in turn lead experts to change theirpinions on the role of assisted living facilities and theppropriate degree of autonomy for food choices (3,9,2,33).
ONCLUSIONSxperts chose food and nutrition service quality indica-
ors that emphasized a focus on wellness and amenities.hey stressed wellness considerations as well as ameni-ies in their ideal scenarios for overall emphases on opti-al food and nutrition services in assisted living facili-
ies. Such expert perspectives may represent an emergingonsensus among opinion leaders about a unifying phi-osophy on food and nutrition services for older adults inssisted living facilities.
his work was supported in part by funds from US De-artment of Housing and Urban Development’s Doctoralissertation Research grant no. H-21512SG. The studyas also supported with resources from the US Depart-ent of Agriculture, Agricultural Research Service, un-
er agreement no. 58-1950-7-707. Any opinions, findings,onclusions, or recommendations expressed here arehose of the authors and do not necessarily reflect theiew of the US Department of Housing and Urban Devel-pment and/or the US Department of Agriculture.The authors thank Joseph Carlin, MS, RD, FADA, re-
ional nutritionist, US Administration on Aging, forending support letters to all experts and for his moralupport. The authors also thank Nancy Wellman, PhD,D, and Victoria Castellanos, PhD, RD, National Re-ource Center on Nutrition, Physical Activity, and Aging,lorida International University; Michael Banville, MS,assachusetts Assisted Living Facilities Association;
nd Karen Love and Jackie Pinkowitz, Consumer Con-ortium on Assisted Living, for their efforts in reviewingnd commenting on the questionnaires. In addition, theuthors thank Marcia Doyle, MS, RD, manger, Clinicalutrition Service, Tufts-New England Medical Centerrances Stern Nutrition Center; the nutritionists of theassachusetts Meals on Wheels Association; and theassachusetts Executive Office of Elder Affairs Assistediving Ombudsman unit for their help in testing theurvey instrument, as well as the executive committee ofhe Gerontological Nutritionists Dietetic Practice Groupf The American Dietetic Association Executive Commit-ee for reviewing the survey instrument.
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