A plum by any other name might taste sweeter!

I've finally had a chance to catch my breath and do some reading on the information I encountered at the Dietitians conference in Sydney last week. The first interesting finding was the use of prunes as a prevention for osteoporosis.

Prunes are essentially plums that have been dried to reduce their water content, this naturally concentrates the sugar content and makes them very sweet. The Australian Prune Industry was promoting a study conducted by Hooshmand et al. 2016 [1] that suggested that eating 50g of prunes (5-6 prunes) daily for 6 months prevented the loss of bone mineral density in older women suffering from osteopenia. Osteopenia is the precursor to osteoporosis, the bones are weaker than normal but not yet brittle enough to break.

Women over 50 are at higher risk because they have lower bone mass than men, they live longer (which means the bones age more) and post-menopausal women are more prone because estrogen has a protective effect. Our bones are the largest calcium repository in our body. As calcium is essential for normal cell function, if we don't consume enough in our diet then our body will withdraw calcium from our bones and this is what leads to weak and brittle bones.

The study involved 48 women who were divided into three groups; (1) 16 ate 50g prunes/day; (2) 16 ate 100g prunes day and (3) 16 ate no prunes for six months. At the beginning of the trial, the women had DEXA scans to measure their bone density and had blood samples taken to measure biological markers that are associated with loss of bone density. The measures were repeated again at the end of the trial.

Both 50g and 100g/day had the same bone protective effects... this means that these participants had no change in their total bone mineral density between baseline and six months. The group that did not consume prunes had a loss of total bone density. It is important to note that although there was an overall total protective effect when they looked at specific areas (e.g. hip, which is the area most likely to fracture), there was no difference. This means that we can't make specific claims along the lines of prunes preventing hip fractures but the results of this study suggest that they have an overall protective effect.

According to a systematic review conducted by Wallace 2017 [2], there have only been five human trials to look at the effect of prunes on bone density and it appears all were conducted among women. Three showed positive results but these three were conducted by the same research team (1,3,4). Unfortunately this drastically increases the chance of bias, if the results are truly present then other research teams should be able to replicate the trial and produce the same results. Two other studies show limited or no benefit (5,6). This means that overall there is limited evidence to suggest prunes may have a protective effect in preventing the loss of bone mineral density in women.

Despite the lack of conclusive evidence in this area, prunes have multiple benefits that warrant their inclusion and promotion in the diet of older adults. As dietitians, we commonly prescribe prunes for hospitalized elderly to assist in bowel regulation. They are also low GI (30), high in vitamin A and potassium. One 40g serve of prunes (approx 5 prunes) contains 6.5g protein and 3.1g fibre (6). If served with fortified custard they would make an excellent high protein, energy, fibre and calcium option at breakfast or dessert.

[1] Hooshmand, S.; Kern, M.; Metti, D.; Shamloufard, P.; Chai, S.C.; Johnson, S.A.; Payton, M.E.; Arjmandi, B.H. The effect of two doses of dried plum on bone density and bone biomarkers in osteopenic postmenopausal women: A randomized, controlled trial. Osteoporos. Int. 2016, 27, 2271–2279.

[2] Wallace, T. NutrientsDried Plums, Prunes and Bone Health: A Comprehensive Review. Nutrients 2017, 9(4), 401.

[3] Hooshmand, S.; Chai, S.C.; Saadat, R.L.; Payton, M.E.; Brummel-Smith, K.; Arjmandi, B.H. Comparative effects of dried plum and dried apple on bone in postmenopausal women. Br. J. Nutr. 2011, 106, 923–930.

[4] Hooshmand, S.; Brisco, J.R.Y.; Arjmandi, B.H. The effect of dried plum on serum levels of receptor activator of NF-kappaB ligand, osteoprotegerin and sclerostin in osteopenic postmenopausal women: A randomised controlled trial. Br. J. Nutr. 2014, 112, 55–60.


[5] Arjmandi, B.H.; Khalil, D.A.; Lucas, E.A.; Georgis, A.; Stoecker, B.J.; Hardin, C.; Payton, M.E.; Wild, R.A. Dried plums improve indices of bone formation in postmenopausal women. J. Womens Health Gend Based Med. 2002, 11, 61–68.


[6] Simonavice, E.; Liu, P.-Y.; Ilich, J.Z.; Kim, J.-S.; Arjmandi, B.; Panton, L.B. The effects of a 6-month resistance training and dried plum consumption intervention on strength, body composition, blood markers of bone turnover, and inflammation in breast cancer survivors. Appl. Physiol. Nutr. Metab. 2014, 39, 730–739.

Millennials, the first generation to voluntarily puree their food?

Currently, one of the big food sensations is smoothie bowls. The basic concept is to make a thicker-than-usual smoothie, place it in a bowl and eat it with a spoon (vs drinking through a straw).

Smoothie bowls are taking over the internet as the next insta-wellness, ultra-cool trend. There are even eateries that specialise in smoothie bowls and they are not cheap, prices range from $10 - $16. For a SMOOTHIE! In a BOWL!

I have to admit, I don’t get it. Is it a chilled fruit soup? Is it a franken-porridge? Is it a smoothie gone horribly wrong?

If you have lived under a rock the past few years and don’t know what a smoothie bowl is, here is a fairly standard iteration…






As a dietitian, I can’t help but wonder... if you have a perfectly functional set of teeth, your swallowing apparatus is working as intended and you are older than one, why on earth would you want to puree your food?

Dysphagia is a condition that describes difficulties in swallowing, it is diagnosed by speech pathologists who typically prescribe a texture modified diet. One study estimates that up to 68% of residents in nursing homes are affected by dysphagia.

An individual with dysphagia might be restricted to one of three textures.

1. Soft diet – food must be moist, cut into pieces no larger than 1.5cm x 1.5cm and easily break apart when pressed with a fork, we’re talking cooked in the slow cooker all day soft.

2. Minced diet – as above but food must be cut into pieces no larger than 0.5cm x 0.5cm and there should be no hard or sharp lumps.

3. Pureed diet – as above but food must be pureed, smooth and free of lumps.

Being prescribed a pureed diet is one of the biggest determinants of malnutrition in elderly because it isn't considered to be palatable. They call it baby food! Nobody wants to eat baby food, well nobody but babies (and Millenials)!

Another common reason that our aged care residents are prescribed texture modified diets is poor dentition. In a recent Australian study 82% of residents required a dental referral due to decayed or broken teeth. Naturally, this led to them being prescribed a texture modified diet. Do you know who else doesn't have teeth and can't chew their food? Babies!

There are thousands of elders who would love to chomp into something solid! They can’t experience the juicy crunch of biting into a crisp apple, instead, they can only have applesauce.

I don't get it... are Millenials the first generation of adults to voluntarily puree their food?

Acquiescence Bias (yea-sayers and nay-sayers) and why it matters

Acquiescence bias is something we are all guilty of. When researchers discuss this term we do so in the context of participants’ responses to survey questions, but it has some real-world implications.

So what is it, why does it matter and how often do you agree when you maybe shouldn’t?

Acquiescence bias is also called “yea-saying” or “nay-saying”. In questionnaires, this is identified by people always agreeing (or disagreeing) to whatever is being asked. For example, a personality questionnaire might ask “Do you enjoy going out to parties and hanging out with others” and you might agree and tick yes. A little further down another question asks “Would you rather stay at home and read a book/watch Netflix than attend a party?”.

Because these questions are considered to be in opposition, if you answered yes to both then researchers would consider that acquiescence bias had occurred. The assumption would be the respondent hadn’t truly read through the question, or fully understood the question, and had simply answered yes consistently throughout.

Another theory here is that the questions prompt individuals to consider specific situations and dig up memories that endorse the question. When you read the first question you might think back to the Christmas office party where your manager photocopied their butt and think to yourself “Why yes, I do enjoy parties” and tick the yes box. When you read the second question you might recall the last TV series you binge-watched on Netflix and, if asked to compare that how much you enjoyed the party, you might also tick yes. Therefore, they may not be contradictory. You can still prefer to stay at home and watch Netflix and enjoy going to parties.

As I have just hinted, the issue is with the wording of the questions and the type of scale used for the response. Life is rarely black and white and a simple yes or no response usually doesn’t cut it when trying to measure human experiences.

Closed-ended questions are those that require a simple yes or no response and these are more likely to bring out more acquiescence bias because most of us want to be seen to fit in and be agreeable. Closed-ended questions can also be leading and it is for this reason that they are not allowed in court. If you are asked “Was the thief wearing a green shirt?” many people will say yes because they don’t want to appear stupid, or as if they have a failing memory.

Also, if all of the questions in a survey are positively framed, this can increase the likelihood of getting a bunch of yes ticks. For this reason, questionnaires usually contain both positively and negatively framed questions to prevent you from just zoning out and mindlessly ticking yes.

To confuse matters further, if the person interviewing you is very friendly towards you, this increases the likelihood that you will tell them what you think they want to hear.

So why does any of this matter in the real world that doesn’t involve my PhD? Yea-saying isn’t limited to questionnaire responses. My partner and I were out for dinner and he had put a lot of time into researching the ideal spot for a romantic rendezvous. The website displayed photos of tables elegantly candle-lit tables draped in white. We were therefore in for quite a rude shock when we discovered it was the back end of a bistro, there wasn’t a tablecloth to be found and the candles were battery operated. Furthermore, the food was no better than you could have obtained from the pub across the road and it was considerably more expensive. Neither of us was happy.

At the end of the meal when the waiter, who had been very friendly throughout the meal, asked “Was everything to your satisfaction” my partner replied “yes”.

The researcher in me bristled. “You just gave him incorrect information”, I pointed out to my partner. “I didn’t want to hurt his feelings”, my partner replied. Interesting.

We spent our hard earned and somewhat scarce earnings on a meal that was rather ordinary in a setting that was not-as-advertised and neither of us was happy. Yet when asked if he was happy, he indicated that he was because he felt his discomfort was more important than our displeasure.

As a researcher and a proponent of the quality improvement cycle, I encourage you to leave honest feedback whenever you are asked. If the meal was a disappointment, be honest in communicating that. This doesn’t give you license to be rude or aggressive, but either I or my partner could have said “Actually, we were disappointed because….” This would have given valuable feedback to the owners.

In any industry where you are providing a service to others, acquiescence bias doesn’t help us to improve. We need to know if you got the service you were expecting and if not, how we could have done better.

I can't get no.... Satisfaction

Despite the title, I'm not about to launch into a Rolling Stones sing-a-long. I often get asked the question, ‘what exactly is food service satisfaction’ and this is one of the best ways I have found to explain it.

Think about the last time you went out to dinner, what was the first thing you noticed when you walked into the restaurant? What was the ambience like? Was it too loud and difficult to have a conversation with your friends? What was the lighting like? Was it too bright or too dim? What was the attitude of the person who seated you? Where they polite or indifferent?

You’ve been seated at your table and been provided with a menu. Do you have any special dietary requirements? Was there enough choices on the menu for you? Were the foods familiar or were there a lot of dishes with complicated names that weren’t really helpful? How long did you have to wait before someone took your order? Did you ask any questions regarding the menu? Were the staff helpful?

So you successfully ordered and the staff place your food in front of you. The first thing you notice is the plating, did it look appealing or was it slopped on a plate? What was the portion like? Was it too large or too small? Were there delicious aromas wafting up to greet you enticing you to eat? Was it the right temperature or was it cold by the time it reached you? What was the texture like? Were the salads crisp or sad and limp? Was the meat tender or tough and dry? Did you have a choice of condiments? Last, but not least, how did it taste?

The really interesting thing about satisfaction is that it can mean different things to different people. I’m quite sensitive to loud, clanging noises so being seated near the kitchen will reduce my overall satisfaction even if the food is good. Similarly I am a vegetarian, if the only option on the menu is hot chips, it really doesn’t matter how good those chips are, I’m going to be less satisfied because it was a default choice.

What happens when you aren’t satisfied with the food? We have a few options. We can walk out, complain, but most commonly we choose not to go back again.

What if you had to eat at the same restaurant for breakfast, lunch and dinner, day after day after day and you weren’t happy with the food service? For some residents, this is their reality.

They may be required to eat in dining rooms that are loud, or they may not like where they are seated (or who they are seated with). There could be nurses trying to dispense medications while they are eating. They may not have had any choice and provided with a default meal. It may be too cold by the time they get to eat it. Or they may get served all three courses at once so the ice cream is a puddle by the time they get to it.

Understanding and measuring satisfaction is an essential component to improving the food service in aged care.

Bring on the baby boomers

The Aged Care Quality Standards are being rejigged and, at first glance, they appear pretty sexy -  but are they really? To understand these changes first let me first talk about the existing Quality of Care Principles (2014) and the current accreditation standards.

The existing Quality of Care Principles (2014) can be divided into two parts, the stuff relevant to aged care homes and the stuff relevant to community care. We’re going to discuss the stuff relevant to aged care homes which are (1) Care and services for residential care services (the stuff that aged care homes should provide to their residents); (2) Accreditation Standards (the stuff that aged care homes need to do if they want to stay in business.

In this entire document, meals are mentioned six times and food is mentioned twice. Colour me underwhelmed.

Schedule 1.10 states:

• that recipients must be offered meals of adequate variety, quality and quantity served each day at times generally acceptable to both recipients and management and generally consisting of three meals and three snacks
• that cultural, religious or special dietary requirements should be respected
• food, including fruit of adequate variety, quality and quantity and non alcoholic beverages be provided.

These sound lovely, but they are quality standards and not necessarily accreditation standards. There are currently four standards that Residental Aged Care homes must meet in order to stay in business and only one of these mentions meals:

2.10 Nutrition and hydration states:

• that care recipients (people living in aged care homes) receive adequate nourishment and hydration, this includes assistance with special diets (for health, religious or cultural reasons) and assistance to eat meals if necessary.

There are also a bunch of food safety requirements that have to be taken into consideration. Older people are more vulnerable to food borne pathogens and so extra care must be taken when preparing their food…. (but that’s a post for another time).

So, there’s what you should do (Quality of Care Principles) and what you have to do (Accreditation Standards).

The new and shiny draft Aged Care Standards Guidance Material mentions meals 41 times and food 25 times. Clearly, there has been a much greater focus in this iteration of the Standards. But what do they actually say?

Meals have their own section now, and requirement 4.5 states that ‘Where meals are provided, they are varied and of adequate quality and quantity’. The standard goes on to acknowledge that if meals are tasty, residents are given choice and the overall dining experience is positive that consumers (residents) are more likely to eat. So far, so good.

There follows a list of supporting strategies; actionable things that homes can do to help achieve the standard. There’s also a bunch of reflective questions that aged care providers can ask themselves to self-evaluation whether or not they are doing a good job. This is where I flipped an eyebrow.

If aged care facilities were capable of self-reflecting we wouldn’t have a Facebook group dedicated to 'The unacceptable food served in aged care' where photographs like the one below are shared.

Last year I was asked to give study tips to third-year dietetics students; I started with “Those of you with good study tips probably won’t learn anything new and those of you who need good study tips probably won’t listen to me anyway”. Self-reflection is a little like that. But I digress…

The supporting strategies are excellent. They include things like ensuring residents have access to food 24/7, engaging residents in meal preparation and cooking and consulting with dietitians. But these are just suggestions, not mandates.

The current generation of aged care residents is very polite and compliant, they don't like to complain. Despite paying 85% of their aged care pension for the 'privilege' of staying in an aged care home, many residents will suffer in silence. Indeed they have been dubbed the 'silent generation', discouraged against political activism and encouraged to conform with social norms.

I think aged care CEO's have a rude awakening coming. The baby boomers are coming! I think it's very exciting because it will mean an increase in the quality of care being demanded and therefore being offered.

God's Waiting Room

The world elderly is typically used to describe a person aged 65 years or more. It’s not a great word because it conjures images of frailty and the need for constant care. More recently the terms ‘robust aging’ and 'active aging' have been coined because they better reflect the vitality (e.g. mental, physical and social health) of many older adults.

People aged 60-79 are now referred to as ‘young-old’ and choose to remain employed or otherwise continue their normal daily activities well beyond the ‘accepted’ age of retirement (1). Indeed, the age for eligibility for the Aged Pension in Australia was 65 years but increased to 65.5 years in 2017 and is intended to increase by six months every two years to 67 years (2). This suggests that our government believes that we should continue actively contributing to the workforce.

The term ‘old-old’ is now used to describe people aged 80+ as often the final years of life are accompanied by the illness, disability and frailty we typically associate with the term ‘elderly’. Personally, I prefer the term elder. It can refer to any older person, regardless of age, and it confers wisdom and experience. It also demands respect.

In Australia, there are over 2,700 aged care homes providing 185,482 beds. During the 2015-2016 financial year 234,931 elders lived in this setting. As the population of Australia ages and the age profile changes, this number is projected to rise.

The average length of stay is 2.8 years and for the vast majority (91%) of older adults living in an age care home, it will be the last home they reside in. I read one article recently that referred to aged care homes as ‘God’s waiting room’, a place where we store old people while they are waiting to die (3).

Paints a pretty grim picture, doesn’t it? Imagine being stuck in your doctor’s waiting room for the last few years of your life. Or worse, the waiting room of any government agency *shudder* such as Centrelink. I think our elders deserve better.

What if, rather than a dull, drab waiting room, our elders' days were filled with activities they wanted to participate in and served food they actually enjoyed eating? What if life in an aged care home was designed to make the last few years an enjoyable transition? A fantastic 'So long and thanks for all the fish' celebration of life (4).

Sadly, there are aspects about institutionalised care that I can’t change. Luckily, the one thing I can address (the food) is something that can have a huge impact on resident enjoyment and quality of life. Have I mentioned that food service dietitians are superheroes in disguise?  

(1) Ansah, John P. et al. “Projection of Young-Old and Old-Old with Functional Disability: Does Accounting for the Changing Educational Composition of the Elderly Population Make a Difference?” Ed. Giuseppe Sergi. PLoS ONE 10.5 (2015): e0126471. PMC. Web. 27 Apr. 2018.

(2) https://www.humanservices.gov.au/individuals/services/centrelink/age-pension

(3) https://theconversation.com/gods-waiting-room-life-needs-to-be-valued-in-nursing-homes-59980

(4) https://en.wikipedia.org/wiki/So_Long,_and_Thanks_for_All_the_Fish

Hey now, you're a rockstar! (The importance of industry engagement during your PhD)

Clinical dietetics is perceived to be the most glamorous area for dietitians to work in and no doubt it is fun. There is a sense of urgency and adrenaline that you only find in a hospital setting that can be invigorating.

Community dietetics involves dealing with groups of people to empower them to make important changes to their health and wellbeing. That's pretty cool and important.

Foodservice dietitians are the least visible and perceived as the least glamorous, a rare few want to spend their days dealing with food safety plans. In fact just recently, at an industry event, someone asked me why, after going to University for four years, would I go into *that* side of things.

But that's kind of my bag. I like problem-solving.

When people have nutritional problems it's complex and multifactorial. Often the solution is to address something out of their control and that just makes me feel powerless. Conversely, foodservice systems are like a puzzle wherein problems often have a practical, and actionable, solution.

Research dietitians land in among that hierarchy depending on their field of expertise. I'm researching foodservice so I'm right at the bottom. Most people find my project to be terribly dull. Even other researchers glaze over and appear disinterested (you mean you're not solving the obesity epidemic)? *sigh* No. No, I'm not.

Recently I had the pleasure of attending an industry event hosted by the Maggie Beer Foundation. I was shocked and amazed at the reaction I received from the twenty cooks and chefs that were present at her Masterclass. When I explained my project to them I saw their faces light up. To them, I was a rockstar.

One chef said with enthusiasm, "Finally, someone who gets it!".

Don't get me wrong, I'm thrilled to be researching in the field that I am but it was so nice to see first hand the impact that my research will have on the people that it is relevant too.

For the first time, I felt a little less like this...

and a little more like this...

This is why industry engagement is so important during your PhD process. It's very easy to get lost in the dry dusty world of data but, if you do, there is a danger of losing your perspective. Of losing sight of your own value. Of losing your enthusiasm and that, my friends is how you end up in the valley of sh*t.

There are people out there who think you are a rockstar. There are people who value your work, who will be impacted by your work, whose lives will be changed by your work.