Food first, not food alone - summary report

Evaluating combined approaches to combating malnutrition in older adults

Foreword

By Roger Wertheim-Aymes, Founder, AYMES

“Building on preliminary research by AYMES on Food First, AYMES commissioned UCL to conduct market research into the effectiveness of a Food First approach. The research has been undertaken by Clinical Dietitian, Haya Hani Khalaf, in collaboration with London care home, Nightingale Hammerson, and co-authored by Associate Professor, Dr. Adrian Slee.

Key findings underpin the importance of Food First, which AYMES fully endorses. However, and importantly, it also highlights that a Food First approach does not always work. In some cases, oral nutritional supplement (ONS) intervention is necessary, either as a full ONS application or as a combined approach.

We hope this report supports healthcare providers and key decision-makers in gaining a deeper understanding of the challenges surrounding the Food First approach, as well as the opportunities within malnutrition care. Our aim is to spark meaningful discussion and inspire improvements to the processes that matter most for those who truly need them.”

Executive summary

• Malnutrition affects up to one in ten older adults in the UK, and the risks in specific populations, e.g. care home residents, can be significantly greater, driven by age-related appetite loss, sarcopenia, frailty, and chronic illness. Yet, malnutrition remains under-recognised despite its profound impact on recovery from illness, independence, and overall mortality.
• A stronger, well-resourced Food First approach must remain the foundation of malnutrition care, and we must challenge the system to ensure people receive adequate food and the support needed to eat it. With improved access, choice and quality, most individuals can meet their nutritional needs through real food alone. ONS have a role, but should be reserved for exceptional situations where, despite comprehensive person-centred efforts, food is not enough. Integrating this combined approach for those that require more than food alone, supported by physical activity, behavioural strategies, regular monitoring, and multidisciplinary teamwork, may improve quality of life, reduce hospital admissions, and offer a cost-effective pathway to healthier ageing.
• AYMES is currently collaborating with experts at University College London and Nightingale Hammerson care homes in London to investigate the effectiveness of different approaches to tackle malnutrition with an aim to improve nutritional status and quality of life of residents.

Introduction

Malnutrition is a widespread clinical challenge commonly faced by an ageing population, yet it often remains unrecognised or poorly diagnosed. Defined by the Global Leadership Initiative on Malnutrition (GLIM) as "undernutrition due to a lack of intake or absorption of nutrients", 1 in 10 individuals aged above 65 in the UK are estimated to be malnourished as per Age UK.¹

According to the British Association for Parenteral and Enteral Nutrition’s (BAPEN) 2022 Malnutrition and Nutritional Care Survey of Adults, almost half of assessed individuals were identified to be at risk of disease-related malnutrition and when assessed based on different settings, the highest risk was identified amongst people living in their own homes (56%) and care home residents (55%) followed by hospital settings, where 44% of patients were at risk.²

Consequently, malnutrition is associated with adverse outcomes, such as higher infection rates, longer hospital stays, extended periods of recovery following an acute illness, and a higher mortality risk.³ For example, recent research in multiple care homes in Lincoln, showed a significant relationship between malnutrition risk (using MNA–SF) and mortality.⁴ It is also a key contributing factor in the multifactorial development of sarcopenia and frailty.³ Sarcopenia being the progressive loss of muscle mass, strength and function, representing a form of muscle disease that compromises physical performance. Whilst frailty, which often coexists with sarcopenia, refers to a broader decline across multiple physiological systems leading to a decline in physical and functional capacity and diminishes resilience to stressors.

The economic burden of malnutrition in the UK is a staggering £23.5 billion per year as revealed by a national BAPEN survey in 2021.⁵ However, despite the high costs and overall aetiological complexity, one of the primary causes is that many older adults are not eating enough to meet their nutritional needs. This could result from multiple factors, including age-related physiological changes. ‘Anorexia of ageing’ refers to reduced appetite that leads to decreased hunger signals, early satiety, and diminished taste and smell. Additionally, dysphagia and dental problems can make the necessities of chewing and swallowing challenging. Functional changes, such as onset of frailty and poor physical function can often evolve into physical disability, turning cooking, shopping and even chewing into exhausting and sometimes impossible tasks. Finally, psychological factors, such as depression and loneliness can turn mealtimes and eating into an effort rather than pleasure. This may lead to a gradual decline in intake and as a result, malnutrition may take root. Furthermore, chronic disease conditions, such as cancer, and its treatment, can further increase nutritional demand and exacerbate the risk of deficiencies.

Nutrition strategies to combat malnutrition - moving beyond ‘food vs supplements’

The standard approach to tackle malnutrition in the UK begins with a Food First policy which is the first-line nutrition care strategy recognised by BAPEN and the British Dietetic Association (BDA) for disease-related malnutrition.⁶ The Food First strategy aims to improve protein and energy intake by enhancing or fortifying regular everyday foods or modifying their texture to make them more palatable and easier to consume. Some strategies include adding calorie dense foods to soups, porridges and drinks, or offering small frequent meals at regular intervals to make meals more manageable and enjoyable. For people living with swallowing difficulties, texture modifications following the international dysphagia diet standardisation initiative (IDDSI) standards helps to ensure that the food consumed is both safe and nutritious. The benefits of this approach are about more than just nutrition; it is about preserving dignity and pleasure as well, however, guidance on the wider Food First approach, including mealtime setting, food choice, familiarity, and support with eating, is almost non-existent, leaving a critical gap in nutritional care.

Many older adults consider food as one of the last few remaining daily rituals that carries cultural and emotional significance along with comfort and identity. Therefore, the Food First approach should encourage social eating by providing familiar flavours and enhancing appetite in people with reduced desire to eat.

However, although food first is essential, age-related changes often create practical barriers that may make it difficult for older adults to follow this approach in everyday life. Essential daily activities, such as shopping for food can turn into major obstacles for older individuals with poor mobility, limited transport, and/or low energy levels.

Even with ingredients available, those living independently may lack motivation, adequate kitchen facilities or the culinary confidence to prepare high calorie, high protein meals on a regular basis. Furthermore, specific dietary needs, such as vegan or texture modified diets may cause a struggle to meet requirements through food alone due to limited availability of options. Within care homes, time constraints, staffing pressures, and varying levels of appetite and stamina of residents, often mean that individuals consume too little and may struggle with chewing or experience early fatigue while eating, even when foods are fortified.

This is where ONS play a crucial role. ONS are energy dense and protein rich formulations available as drinks, powders or puddings. Designed for efficiency and convenience, they deliver a predictable and measurable boost in intake when food alone cannot meet an individual’s requirement. However, it is often debated that ONS are intended to replace, rather than support, regular meals. Whereas, in reality the issue does not lie with ONS themselves, but with how they are implemented into an individual’s daily routine. When offered as a replacement for a meal, it is highly likely that it will be rejected. When individuals are involved in selecting the flavour and format of their ONS, acceptance tends to improve significantly. Likewise, if it is served as a pudding-style dessert following a meal or sipped slowly between meals, it may be seen more as part of their dietary intake rather than a medical intervention.

Evidence supporting a combined approach

A 2021 systematic review and meta-analysis including 17 randomised control trials, with an average participant age of 81.9 years evaluated the effects of ONS combined with standard dietary strategies. The findings proved a significant increase in overall energy and protein intake along with notable improvements in body weight and BMI. These results show that ONS can improve intake in controlled trials, although translating these findings into real-world settings requires careful consideration to avoid displacing appetite for food or reducing the pleasure and dignity associated with mealtimes.⁷ Furthermore, the 2022 ESPEN Guidelines on Clinical Nutrition and Hydration in Geriatrics also support this evidence, recommending the use of ONS as an adjunct to dietary strategies, but not as a stand-alone replacement.³

Implementation is the real challenge

A thoughtful integration of a combined strategy of Food First and ONS provides what neither can offer alone. Although feasibility, cost and adherence remain key considerations, particularly in populations where appetite loss, dysphagia and low physical activity are prevalent, such challenges can be mitigated by staff education, regular review, and tailored meal planning. Furthermore, routinely monitoring body weight and composition as well as relevant outcomes, such as quality of life and physical function helps ensure that the interventions implemented remain effective and individualised. Additionally, promoting regular physical activity in the form of endurance and resistance exercise, plays a crucial role in preserving muscle mass and strength as part of a more holistic approach to care. Training staff in appetite monitoring, protected mealtimes, food fortification and social dining is as important as access to supplements. System-level investment is required to ensure Food First strategies can be delivered consistently and effectively, and not as a long-term solution to the burden of malnutrition.

Conclusion

The Food First approach remains the foundation of nutrition care in adults, preserving identity, pleasure and cultural connection. However, when ONS are introduced alongside enhanced meals, the two can work synergistically, when implemented appropriately, to provide both person-centred care and evidence-based clinical precision. When this combined strategy is further supported by physical activity, behavioural support and multidisciplinary teamwork, it may lead to a better quality of life, faster recovery and potentially a greater resilience to the challenges of ageing and frailty.

Consequently, an improved overall nutritional and functional status may lead to decreased hospital admissions, shorter lengths of stay and a reduction in mortality, eventually offering cost efficiencies for the health and social care system.⁸ Continued research comparing different nutrition strategies is essential to build a stronger evidence base and guide best practice. However, the question is not whether to prioritise food or supplements, but whether we are doing all we can to keep food as the foundation of malnutrition treatment, supporting adults to eat well, maintain strength, and preserve dignity.