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.