European Journal of Clinical Nutrition (2007) 61, 1226–1232

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ORIGINAL ARTICLE
The effects of nutrition education on professionals’
practice and on the nutrition of aged residents in
dementia wards
MH Suominen1, SM Kivisto1 and KH Pitkala1,2

1
The Central Union for the Welfare of the Aged, Helsinki, Finland and 2Department of General Practice and Primary Health Care;
University of Helsinki, Helsinki University Hospital, Unit of General Practice, Helsinki, Finland

Objective: (1) To develop nutrition education for professionals in dementia wards. (2) To evaluate the effects of education and
determine the outcome of the education on the nutrition of aged residents.
Design: Educational intervention with before and after measurements. Both the learning outcomes of the professionals and the
effect on the aged residents were assessed.
Setting: Nursing home residents in dementia wards and professionals.
Subjects and methods: Twenty-eight professionals completed half-structured feedback questionnaires that were analysed
quantitatively and qualitatively. Assessments of 21 residents’ energy and nutrient intake and 19 residents’ nutritional status with
the MNA before and after the education.
Results: The learning process included six half-day training sessions. The professionals learned to use and interpret the MNA and
detailed food diaries. Keeping the food diaries and analysing them in multi-professional teams was experienced as the main
source for learning insights. After calculating the diets and discussing with others, professionals felt easier about responding to
the nutritional problems of the residents. After 1 year, the residents’ mean energy intake had increased 21% from 1230 to
1487 kcal. Before the education none but after 1 year 16% had a good nutritional status according to the MNA.
Conclusions: We used the constructive learning theory to educate professionals. Keeping and analysing food diaries and
reflecting on nutritional issues in small group discussions were effective training methods for professionals. The education had
positive effects on the nutrition of the residents in dementia wards.
European Journal of Clinical Nutrition (2007) 61, 1226–1232; doi:10.1038/sj.ejcn.1602639; published online 24 January 2007

Keywords: nursing home resident; dementia ward; malnutrition; nutrition care; MNA; food diary; education; constructive
learning theory

Introduction
Malnutrition, low body mass index and unintentional weight
loss are common problems among the elderly and nursing
home residents (Mattila et al., 1986; Beck and Ovesen 1998;
Saletti et al., 2000; Suominen et al., 2005), who typically have
many illnesses and clinical problems associated with malnu-
Correspondence: MH Suominen, The Central Union for the Welfare of the
Aged, Malmin kauppatie 26, FIN-00700 Helsinki, Finland.
E-mail: merja.suominen@vanhustyonkeskusliitto.fi
Guarantor: MH Suominen.
Contributors: MHS, SMK and KHP have all participated in planning and
organizing the study and writing the article.
Received 26 July 2006; revised 30 November 2006; accepted 30 November
2006; published online 24 January 2007
trition, for example, dementia, depression, stroke, falls and hip
factures (Morley and Kraenzle, 1994; Compan et al., 1999).
Good nutritional status is essential for aged residents because
of its importance in maintaining a functional status (Crogan
and Pasvogel, 2003) and preventing illnesses such as infections
and pressure ulcers (Lesourd, 1997; Frias Soriano et al., 2004).
Malnutrition seems to be widely underdiagnosed and under-
treated among nursing home residents (Abbasi and Rudman,
1993). Nutrition treatment seems to reduce mortality and
have an effect on preserving the functional capacity of elderly
persons with multiple disorders (Akner and Cederholm, 2001;
Milne et al., 2006). Some studies with enriched food have
positive outcomes in terms of energy intake (Barton et al.,
2000; Lorefält et al., 2005) and weight gain as well as physical
activity (Olin et al., 1996).

Low energy intake is common among aged nursing home
residents, and nurses often significantly overestimate resi-
dents’ actual food intake (Pokrywka et al., 1997; Simmons
and Reuben, 2000; Westergren et al., 2002; Suominen et al.,
2004). Professionals – both nurses and food service personnel
– need more education about the nutritional problems of
older people in order to be better able to understand and
respond to the individual nutritional needs of aged residents
(Pokrywka et al., 1997; Barton et al., 2000; Crogan et al.,
2001; Suominen et al., 2004). Some nutritional education
program studies have shown promising results in increasing
the nutritional knowledge among professionals and in
preventing weight loss and cognitive decline in Alzheimer’s
disease among residents (Faxen-Irving et al., 1999; Riviere
et al., 2001).
We developed an educational program for professionals
(nurses and food service personnel) in dementia wards to
improve their skills of assessing the nutrition of aged
residents and of responding to the problems in their
nutrition. The aims of this study were to evaluate the
effectiveness of the educational program on the learning of
the professionals, to clarify its impact on the nutrition of
aged residents.
Methods
Setting and participants
The education was directed to 28 professionals in five
nursing homes in various areas of Finland. Of the profes-
sionals, 23 were nurses and five were food service personnel.
In wards specialized in dementia care in one of these nursing
homes, 21 residents’ energy and nutrient intake was
calculated from food diaries, 20 residents’ nutritional status
was assessed, and 20 residents’ BMIs were calculated before
the education in January and February 2003 and after the
education in January and February 2004. The data of the
MNA and BMI for 19 residents were available both before
and after the education. All the studied residents were
females and their mean age was 85 years. The assessments
levels have been described in Figure 1.
Education for Learning
professionals outcomes
Satisfaction
with training Changes in knowledge
The feedback from the professionals
Figure 1 Evaluating the outcome levels of nutrition education.
Effects of nutrition education in dementia wards
MH Suominen et al
1227
Educational process
The aim of the nutrition education was to facilitate the
professionals’ understanding of aged nursing home residents’
nutritional problems and to internalize the aims of good
nutritional care. We wanted them to be able to intervene in
the nutritional problems of malnourished residents and to
enhance a good nutritional status for the residents.
The educational process took place in five nursing homes
and lasted for 6 months. The education included six training
sessions (each 2–3 h) with lectures, small group discussions,
homework tasks and personal feedback (Figure 2).
In the beginning, the nutritionist (MHS) motivated the
professionals with a lecture. She taught to the nurses and
food service personnel about the facts and problems of
nutrition and the nutritional assessment of aged people.
She instructed the nurses to complete the Mini Nutritional
Assessment test (MNA) (Guigoz et al., 2002) in a group
session and also with the help of a video tape. Between the
first and second sessions, the participants assessed their
residents with the MNA test. In the second session, the
results of the MNA tests were analysed in small groups. With
the aid of the observations of the residents and the results
of their MNA tests, the professionals decided whose food
consumption they would measure over three consecutive
days. The nutritionist showed how to weigh the foods, keep
the food diaries and use the computer-based food record
program AIVO (www.aivo.fi). Between the second and the
third sessions, the professionals weighed all the residents’
food before and the leftovers after eating with an electronic
scale. The food diaries were analysed by the food record
program AIVO, after which the results of the energy and
nutrient intake were available for individuals and the entire
group. The energy contents of the recipes were calculated as
they were prepared for meals by the food service.
In the third and fourth sessions, the participants and the
nutritionist discussed the results of the MNA tests and food
diaries in small groups. The most important topics in the
discussions were the residents’ BMIs, possible weight loss,
illnesses, problems in eating, special diets, energy and protein
intake on the basis of the food diaries, the selection of foods and
their nutritional value. The professionals and the nutritionist
discussed their observations, the residents’ favourite foods, and
the mealtime schedule. After the discussion, the professionals
planned adjusted individual changes to the residents’ diets.
The changes The effects of the
in practice professionals’ education
on residents’ nutrition
Measuring the BMI, MNA, energy
and protein intake of the residents
after the educational intervention
European Journal of Clinical Nutrition
 Effects of nutrition education in dementia wards
MH Suominen et al
1228
Session 1. Lecture on problems of older
Session 6. Discussing outcomes of people’s nutrition, assessment of the
the nutritional intervention nutritional status by the MNA and
measurement of food consumption and
nutrient intake

Homework: Follow-up Learning methods:

with the MNA, measuring Homework: Applying
food consumption when the MNA to the
Teamwork
needed residents
Learning by doing
Session 5. Discussing Small group discussion Session 2. Analysing the MNA
problems in applying results and recognising
nutritional assessments Personal feedback nutritional problems. Selecting
and interventions the residents to be assessed with
Studying literature food diaries

Lectures
Homework: Measuring the
Homework: Applying food consumption of the
the planned diets to the residents
residents
Session 3-4. Analysing energy and
nutrient intake and comparing them
to recommendations. Planning
changes in the residents’diets

Figure 2 Educational process: incorporating nutrition as a part of the good care of nursing home residents.

Between the third and fifth sessions, the professionals made
practical changes to the residents’ diets. The main idea was to
make the changes to their diets with the help of natural
foodstuffs instead of nutritional supplements. For instance,
the milk was changed to contain more fat. More fat was also
added to porridge and sandwiches. Snacks and evening meals
were added to the residents’ diets. The intake of protein was
discussed, and the suggestions of ways to add protein content
into the resident’s diets were implemented. In the fifth session,
the problems related to applying the new diets were discussed
with the nutritionist. The multi-professional team, including
the nurses and food service personnel, participated in this
discussion. After the fifth session, the professionals continued
to apply the new diets, following up on the residents with the
MNA and measuring food consumption if needed. After 6
months, the outcomes of the educational intervention were
discussed in the sixth session.
Small group discussion, teamwork and discussions with
the nutritionist were used in learning to respond individu-
ally to the problems in the residents’ nutrition. The
professionals were also able to study literature on nutrition
available to them so that they could apply the information
individually to the nursing home residents.
Measurements and data analysis
The nurses assessed the residents’ nutritional status with the
MNA test (Guigoz et al., 2002). The MNA is a simple and well-
validated scale to estimate the nutritional status of aged
individuals, and it has been used in numerous studies among
aged residents living in various settings (Guigoz et al., 2002).
According to the MNA, poor nutritional status has been
associated with impaired functioning, increased in-hospital
mortality, a higher rate of discharge to nursing homes, a
longer length of stay in hospitals, and also with residents
eating only a little from an offered food portion (Van Nes
et al., 2001; Suominen et al., 2005). The residents’ height and
weight were measured at the baseline and at one year, and
body mass index (BMI) was calculated, as described on the
website http://www.mna-elderly.com/clinical-practice.htm.
The professionals in one nursing home determined the
food consumption of the residents (N ¼ 21) in dementia
wards with a precise weighing method before and after the
education in January and February 2003 and in January and
February 2004. The time between the measurements was 1
year. The professionals weighed all the food before eating
and the leftovers after eating over 3 days. Any additional
snacks during the study period were investigated by making
an inventory of all the food the elderly residents had in their
rooms before and after the study days. In addition, the
nurses asked whether relatives had given the residents
something to eat when meeting them. The food diaries were
analysed by the AIVO program (www.aivo.fi).
After the educational process, the professionals completed
half-structured questionnaires regarding their experience of
the education. The questions consisted of views on their own

European Journal of Clinical Nutrition


learning and the usefulness of the various methods that were
used during the training. The professionals’ feedback ques-
tionnaire consisted both open and structured questions about
which learning methods were experienced as the most helpful.
The usefulness of the various learning methods was evaluated
by a Likert scale (‘not at all’, ‘very little’, ‘something’, ‘quite
much’, ‘very much’). The questionnaire also asked what the
barriers to changes in practice were in the nutrition care of the
residents. The answers to the questionnaires were analysed
both quantitatively and qualitatively.
The differences in categorical variables between pre- versus
postintervention were tested by a w2 test and for normally
distributed continuous variables by Student’s t-test. The
results were considered as statistically significant at the level
Pp0.05.
Results
The mean age of the residents was 85 years (range 62–95),
and they were all female. All residents suffered from
moderate or severe dementia, and lived permanently in a
dementia unit. Before the professionals’ education, the
energy intake of the residents was on average 1230 kcal/day,
and after the education 1487 kcal/day (Pp0.001). The
mean energy intake increased 21%. Before the education
42.9% of the residents (N ¼ 9) but after the education only
9.5% of the residents (N ¼ 2) received less than 1200 kcal/day
from their diets. Before the education, none of the residents
but after the education 29% of them (N ¼ 6) received the
minimum recommended energy intake (1570 kcal) for this
age group (Table 1). The residents’ mean intake of protein
Effects of nutrition education in dementia wards
MH Suominen et al
1229
increased from 50.4 g/day to 60.9 g/day (P ¼ 0.006). The
intake of nutrients also increased, for instance, the intake
of calcium increased from 896 mg/day to 1099 mg/day
(P ¼ 0.004) and the intake of folic acid increased from
177 mg/day to 219 mg/day (P ¼ 0.07).
The residents’ mean BMI was 21.7 kg/m2 before the
education and 21.4 kg/m2 after the education. Weight gain
occurred in 42% of the residents, but 42% of them also lost
weight. Before the education none but after the education
16% (3 of 21) of the elderly subjects had a good nutritional
status according to the MNA test. However, the number of
those who suffered from malnutrition increased from two to
four residents (Table 2).
On the feedback questionnaires concerning the learning
outcomes, the professionals responded that the most helpful
ways to learn the nutritional care of aged residents were
filling in the food diaries (mean 4.3 on the Likert scale) and
discussing these results in the learning sessions with the
multi-professional team and the nutritionist (mean 4.6)
(Figure 3). Learning to assess the residents with the MNA test
was also found to be useful (mean 3.9). Lectures and
studying alone were the least useful methods in the learning
process.
In the open-ended questions, the nurses and the food
service personnel expressed their surprise about how little
energy the residents had received before the education. It
was much less than they had thought. On the other hand,
the professionals had not understood before the education
the connection of nutrition to the comprehensive well-being
of aged residents. Starting to weigh precisely the residents’
food portions and to assess their energy and nutrient intake
was considered laborious. However, after learning these

Table 1 Nursing home residents’ energy intake before and after professionals’ the education. Compared to the reference values 1570 kcal/day for
women over 75 years (National nutritional council, 1999)

Energy intake (kcal) Before the education After the education P-value

n % n %

o1200 9 43 2 10 0.005
1200–1570 12 57 13 57
41570 0 0 6 29

Total 21 100 21 100

Table 2 The nursing home residents’ nutritional status indicated by the MNA test before and after professionals’ education

Malnutrition indicator score on the MNA test Before education After education P-value

n % n %

Not at risk of malnutrition 0 0 3 16 0.10

At risk of malnutrition 17 89 12 63
Malnourished 2 11 4 21

Total 19 100 19 100

European Journal of Clinical Nutrition

 Effects of nutrition education in dementia wards
MH Suominen et al
1230
Studying alone
Assessing residents by the MNA
Discussing the results of diaries in
multiprofessional team
Filling the food diaries
Lecture
0 1
Figure 3 The professionals’ evaluation of how useful various methods were for their own learning: ‘1 ¼ not at all’, ‘2 ¼ very little’,
‘3 ¼ something’, ‘4 ¼ quite much’, ‘5 ¼ very much’.
assessment methods, the professionals found them very
helpful in their work. The professionals were very motivated
to respond to residents’ nutritional problems after calculat-
ing their diets and nutritional status. After learning about
these issues, they felt that it was easier to respond to the
nutritional problems and accordingly to make the proper
changes to the residents’ diets. After the education, they
found that they had the facts and proper advice to
implement individual nutritional care. The professionals
also responded that during the education they had learnt to
evaluate how the residents’ meals correspond to the nutri-
tional recommendations given to this age group. The work
in multi-professional teams was found to be very useful. A
lack of time and problems in the flow of information were
the most difficult points of the project.
Discussion
The nutrition education for the professionals in nursing
homes had a positive impact on the mean energy and
protein intake, and on the results of the MNA tests of many
frail residents living in dementia wards. After the education
and the assessment of the residents’ food and nutrient
intake, the professionals were very surprised at their over-
estimation of the residents’ food intake. The professionals
felt that it was easier to respond to the residents’ nutritional
needs after calculating the energy content of the residents’
diets and discussing nutritional matters in their multi-
professional teams. To our knowledge, this outcome among
frail and old residents living in dementia wards has rarely
been examined in previous studies. Educational studies in
particular are scarce. It is easier to show the effect of
education on the learning outcomes of professionals than
its impact on changing the practice of nutritional care or,
especially, on the nutritional status and weight of elderly
residents. Our small study shows that adult education may
European Journal of Clinical Nutrition
2 3 4 5
also have real positive effects on the nutrition of older
residents.
Our study shows that it is possible to increase the energy
and protein intake of frail elderly residents. In addition, their
calcium intake increased significantly. However, it was
contrary to our hypothesis that even the nutritional status
of some elderly residents could be improved. The demented,
institutionalized residents represent the frailest part of the
aged population. Among them, the mean body weight
usually decreases at a mean rate of 2 kg/year (Muurinen
et al., 2003; Soini et al., 2004), and the mean BMI decreases at
the speed of 0.52 kg/m2/year among Alzheimer’s patients
(Cronin-Stubbs et al., 1997). Therefore, it was expected that
our study residents’ BMIs would decrease even more than
actually happened in our study. What is more, among old
and frail nursing home residents, the MNA test scores were
expected to decrease at the 1 year follow-up. Therefore, it is
surprising that some old residents’ nutritional status im-
proved before the 1 year follow-up. However, a proportion of
residents lost weight despite our intervention. The same
phenomenon has been observed in a previous study (Lauque
et al., 2004). Our dementia ward residents suffered from
moderate to severe dementia and were at the end stage of
the disease. Therefore, it can be speculated whether at some
point of the terminal stage the demented individuals no
longer respond to nutritional intervention.
Several studies show that nutritional treatment, particu-
larly balanced nutritional supplements, is beneficial to frail
elderly people (Akner and Cederholm, 2001; Milne et al.,
2006). The effects of enriched food is more controversial.
Our study is in line with previous ones showing that energy
intake may be increased with enriched food (Olin et al.,
1996; Barton et al., 2000; Lorefält et al., 2005). Very few
studies aim at training and changing the professionals’
practice in these issues, although standardized training
programs have been suggested (Pokrywka et al., 1997). The
few educational studies aiming at improving frail elderly

people’s nutrition via increasing professionals’ knowledge of
nutrition often report only outcomes on frail elderly people’s
nutrition (Riviere et al., 2001; Lauque et al., 2004) or the
outcomes on professionals’ learning (Crogan et al., 2001).
Two studies did report both outcomes (Faxen-Irving et al.,
1999, 2005). However, none of these studies have opened
up in detail the contents of the educational program. Thus,
they cannot be implemented into further practice. An educa-
tional intervention has several outcome levels, which should
be considered when developing and studying such programs
(Figure 1). This is the strength of our study.
In two controlled studies, the caregivers of home-dwelling
Alzheimer’s patients were trained in nutritional issues
(Riviere et al., 2001; Lauque et al., 2004). According to these
studies, the body weight of demented individuals could be
maintained more often in the intervention than in the
control group (Riviere et al., 2001; Lauque et al., 2004). In
two other studies, professional working for the elderly
subjects living in service flats showed positive learning
outcomes but no effects on the residents’ nutritional status
(Faxen-Irving et al., 1999; Faxen-Irving et al., 2005). Demen-
ted individuals residing in group-living gained weight after
the education of professionals (Faxen-Irving et al., 2002).
Our study confirms and extends the study results of these
previous studies. It is possible to educate professionals to
respond to the nutritional problems of demented elderly
residents. However, evidence-based educational methods
should be used. Adults learn and make changes in their
practice when the problems in their everyday work motivate
them (Knowles, 1990) and when they are able to test and
reflect the issues learned in their everyday practice (Kolb
1984; Schön, 1987). Lecture-based education has been
shown to be ineffective in changing professionals’ practices
(Davis et al., 1995). This may explain the mild results
reported by Faxen-Irving et al. (1999, 2005).
The basis of our education was constructive learning
theory (De Corte and Weinert, 1996; von Wright, 1996)
and the reflective learning model (Kolb, 1984; Schön, 1987).
We used consciously reflective learning cycles to facilitate
learning: experience – feedback – reflection – forming
theoretical concepts. The professionals were able to acquire
personal experience in assessing nutrition, to receive feed-
back and reflect on it, and to test new ideas in practice in
their own work. The valuable part of education was gaining
different perspectives from the multi-professional team.
The professionals felt that our education helped them
very much in their daily work. It resulted in many insights
in nutritional care. The professionals especially realized
that they had overestimated the energy intake of their
residents. The residents’ nutrient intake was assessed by a
precise weighing method that accurate results. After the
assessments and group discussions, the professionals found
it easier to figure out how to change the diets of residents
in a direction that better fulfilled their palatable and
nutritional needs. The whole process helped the profes-
sionals in their documentation of the residents’ nutrition
Effects of nutrition education in dementia wards
MH Suominen et al
1231
and also helped them to follow the nutritional recommen-
dations.
Our study shows that it is possible to educate professionals
in practice and near their daily work to pay attention to the
good nutritional care of demented nursing home residents.
This may be converted to better nutritional outcomes in a
short period of time. Our education and further changes in
nutritional care increased the mean energy intake and
improved the results of the MNA tests of many of the frail
residents. Before the professionals’ education, the energy
intake of these very old residents was considerably less than
is recommended.
The limitation of this study is the small sample size (21
residents and 28 professionals), thus we cannot generalize
our results to all nursing homes. However, it is laborious and
difficult to carry out an educational intervention and at the
same time to evaluate and follow-up outcomes on both old
demented residents and professionals’ practice. As our study
is not a randomized, controlled and the MNA assessments
were unblinded, the true effect of intervention cannot be
interpreted explicitly. In any case, our findings are consistent
with other studies. We have taken some steps forward to
develop a standardized training program for professionals to
prevent weight loss in very old, frail residents.
Acknowledgements
This study is part of a larger study which The Central Union
for the Welfare of the Aged in Finland has organized in order
to emphasize the nutritional aspects of good care of the
elderly on the levels of research, information and practice.
Finland’s Slot Machine Association supports this work. We
thank to the personnel of the nursing home for their
co-operation during the study.
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