Vitamin D and Calcium Supplementation in Nursing Homes-A Quality Improvement Study.

Even though dietary supplements with vitamin D and calcium are recommended to nursing home residents, we recently reported a low adherence to this recommendation. The objective of this 20-week quality improvement study was to use the Model for Improvement and Plan-Do-Study-Act (PDSA) cycles to improve adherence in Danish nursing homes. We included two nursing homes with 109 residents at baseline. An information sheet including the rationale for the recommendation was developed for the nurses to urge residents to take the supplements and seek approval by the general practitioner afterwards (PDSA cycle 1). Moreover, it was included in admission meetings with new residents to address supplementation (PDSA cycle 2). A nurse reviewed patient records for number of residents prescribed adequate doses of vitamin D (≥20 µg) and calcium (≥800 mg) before, during and after the intervention. At baseline, 32% (n = 35) of the residents had adequate doses of vitamin D and calcium. After implementation of the information sheet and adjustment to admission meetings, this increased to 65% (n = 71) at endpoint (p < 0.001). In conclusion, in this quality improvement study, we improved the number of prescriptions of adequate doses of vitamin D and calcium over 20 weeks using the Model for Improvement and PDSA experiments.

Adherence and barriers to the vitamin D and calcium supplement recommendation at Danish nursing homes: a cross-sectional study.

BACKGROUND: Nursing home residents are in high risk of vitamin D deficiency, which negatively affects bone health. Vitamin D and calcium supplements haves shown to increase bone density and reduce fracture risk. Therefore, The Danish Health Authority recommends all nursing home residents a daily supplement of 20 µg vitamin D and 800-1000 mg calcium. However, adherence to the recommendation and knowledge of it is unknown. The aims of this study were to investigate adherence, knowledge, and potential barriers to this recommendation in Denmark. METHODS: A cross-sectional electronic survey was conducted in May-June 2020 among 50 randomly selected nursing homes widely distributed in Denmark. Questions included degree of adherence to the recommendation at each nursing home as well as respondent's knowledge and attitudes towards it, and experienced barriers in relation to adherence. RESULTS: Respondents from 41 nursing homes answered the questionnaire, and these were mainly nurses (63%) or nursing home leaders (20%). Low adherence (≤ 40% of residents receiving both supplements) was reported at 35% of nursing homes, and only 8% of the nursing homes had a high adherence (> 80% of residents receiving both supplements). Most respondents (88%) had knowledge of the recommendation and 62% rated importance of increased implementation as high. Common explanations of low implementation were a lack of prescription by the general practitioner in the central electronic database (60%), resident-refusal to eat tablets (43%), chewing-swallowing difficulties (40%), and a high number of tablets given to the residents daily (34%). CONCLUSIONS: The recommendation of daily vitamin D and calcium supplements to Danish nursing home residents is poorly implemented even though knowledge of the recommendation is relatively high. Barriers relate to an ambiguity of responsibility between the general practitioners and the nursing home staff, as well as the high number of tablets to be consumed in total by the residents. These barriers must be targeted to improve adherence in this vulnerable group of institutionalized older adults.

A multimodal nutritional intervention after discharge improves quality of life and physical function in older patients - a randomized controlled trial.

BACKGROUND: Many older hospitalized patients are at nutritional risk or malnourished and the nutritional condition is often further impaired during hospitalization. When discharged to own home, a "Nutrition Gap" often occurs, causing inadequate dietary intake, and potentially impeded recovery. Previously, cross-sectorial studies of single component nutritional intervention have shown a limited effect on clinically relevant outcomes. We hypothesized that a multimodal nutritional intervention is necessary to elicit a beneficial effect on clinically relevant outcomes. METHODS: A randomized controlled trial was performed for a period of 16 weeks. At discharge, the intervention group (IG) received dietetic counselling including a recommendation of daily training, an individual nutrition plan and a package containing foods and drinks covering dietary requirements for the next 24 h. Further, a goodie-bag containing samples of protein-rich milk-based drinks were provided. Information regarding recommendations of nutritional therapy after discharge was systematically and electronically communicated to the municipality. The dietician performed telephone follow-ups on day 4 and 30 and a home visit at 16 weeks. The control group (CG) received standard treatment. The primary outcome was readmissions within 6 month, secondary outcomes were Length of Stay (LOS), Health Related Quality of Life (EQ-5D-3L), nutritional status, physical function (30s-CST) and mortality. This trial was registered under ClinicalTrials.gov Identifier no. NCT03488329. RESULTS: We included 191 patients (IG: n = 93). No significant difference was seen in readmissions within 6 month (IG: 45% vs. CG: 45%, Risk Ratio (RR): 0.96 0.71-1.31, p = 0.885). At the 16-weeks follow-up more patients in the IG reached at least 75% of energy and protein requirements (82% vs. CG: 61%, p = 0,007). The energy (kcal) and protein intake (g) per kg was significantly higher in the IG (26.4 kcal/kg (±7.4) vs. 22.6 (±7.4), p = 0.0248) (1.1 g/kg (±0.3) vs. 0.9 g/kg (±0.3). Furthermore, significant lower weight loss was seen in IG (0.7 (±4.3) vs. -1.4 (±3.6), p = 0.002). A significant and clinically relevant difference was found in the EQ-5D-3L VAS-score (IG: mean 61.6 ± 16.2 vs. CG: 53.3 ± 19.3, p = 0.011) (Δ14.3 (±15.5) vs. Δ5.6 (±17.2), p = 0.002). A significant difference in mean 30s-CST in IG was also found (7.2 (±4.3) vs. 5.3 (±4.1), p = 0.010). The improvements in physical function were of clinical relevance in both groups, but significantly higher in the IG (Δ4.2 (±4.4) vs. Δ2.2 (±2.5), p = 0.008). In fact, 86% in IG experienced improvements in the 30s-CST compared with 68% in the CG (p = 0.022). LOS was found to be lower at all time points, however not significant (30 days: -3 (-8.5 to 2.5), p = 0.276, 16 weeks: -4 (-10.2 to 2.2, p = 0.204), 6 months: -3 (-9.3 to 3.3, p = 0346)). All-cause mortality was not different between groups, however RR showed a non-significantly 47% reduction at day 30 (0.53 (0.14-2.05, p = 0.499)) and a 17% reduction at 16 weeks (0.83 (0.40-1.73, p = 1.000)) in IG. Per protocol (PP) analysis revealed a non-significant decrease of 32% in readmission at 6 months (RR: 0.68 (0.42-1.08), p = 0.105). CONCLUSION: The present study, using a multimodal nutritional approach, revealed no significant effect on readmissions however a significant positive effect on nutritional status, quality of life and physical function was found. The improvements in quality of life and physical function were of clinical relevance. No significant effect was found on LOS and mortality.

Effect of two different nutritional supplements on postprandial glucose response and energy- and protein intake in hospitalised patients with COPD: A randomised cross-over study.

INTRODUCTION: Oral nutrition support is frequently used in treatment of malnutrition in patients with chronic obstructive pulmonary disease (COPD). Considering the use of corticoidsteroids in patients with COPD, little is known about the effect on postprandial glucose response and if they might interfere with glucose control. Our aims were to compare the effect of a liquid oral nutritional supplement (ONS) and semi solid inbetween meal snack (snack) on postprandial glucose and energy- and protein intake, and to compare the effect of timing of each intervention on postprandial glucose and energy- and protein intake. METHODS: Patients with COPD (n = 17) admitted to the Department of Pulmonary Medicine, Iceland and defined as at low or medium nutritional risk (score 0-3) were recruited. In a randomised cross-over design, subjects consumed ONS or snack either in a fasting state (study 1) or following breakfast (study 2) and postprandial glucose responses were assessed at regular intervals for two hours (t = 15, t = 30, t = 45, t = 60, t = 90, t = 120 min). Energy- and protein intake was estimated using a validated plate diagram sheet. Wilcoxon Signed-Rank test was used to compare the two interventions. RESULTS: In study 2, following breakfast, postprandial glucose was significantly higher after consuming ONS than the snack after 60 min (9.7 ± 2.4 mmol/L vs. 8.2 ± 3.2 mmol/L, p = 0.013 and 120 min 9.2 ± 3.2 mmol/L vs. 7.9 ± 2.4 mmol/L, p = 0.021, respectively). No difference was found in postprandial glucose concentrations between ONS and the snack when consumed after overnight fasting (study 1). No difference in energy or protein intake from hospital food was seen between supplement types neither in study 1 or 2. CONCLUSION: Lower postprandial glucose concentrations were associated with the snack compared to ONS when taken after a meal compared to either type directly after overnight fasting. The clinical relevance of higher postprandial blood glucose after consuming a liquid ONS after breakfast compared with a semi solid snack needs to be studied further.

Protein supplementation combined with low-intensity resistance training in geriatric medical patients during and after hospitalisation: a randomised, double-blind, multicentre trial.

Sarcopenia (loss of muscle mass/strength) burdens many older adults - hospitalised older adults being particularly vulnerable. Treating the condition, protein supplementation (PrS) and resistance training (RT) may act synergistically. Therefore, this block-randomised, double-blind, multicentre intervention study, recruiting geriatric patients > 70 years from three medical departments, investigated the effect of PrS combined with RT during hospitalisation and 12 weeks after discharge. Participants were randomly allocated (1:1) to receive PrS (totally 27·5 g whey protein/d, about 2000 kJ/d) or isoenergetic placebo-products (< 1·5 g protein/d) divided into two servings per d to supplement the habitual diet. Both groups were engaged in a standardised, progressive low-intensity RT programme for the lower extremities (hospital: supervised daily/after discharge: self-training 4×/week). From April 2016 to September 2017, 2351 patients were screened, 462 were eligible, and 165 included. Fourteen were excluded and ten dropped out, leaving 141 participants in the intention-to-treat analysis. The average total protein intake during hospitalisation/after discharge was 1·0 (interquartile range (IQR) 0·8, 1·3)/1·1 (IQR 0·9, 1·3) g/kg per d (protein-group) and 0·6 (IQR 0·5, 0·8)/0·9 (IQR 0·6, 1·0) g/kg per d (placebo group). Both groups improved significantly for the primary and secondary endpoints of muscle mass/strength, functional measurements and quality of life, but no additional effect of PrS was seen for the primary endpoint (30-s chair stand test, repetitions, median changes from baseline: (standard test: 0 (IQR 0, 5) (protein group) v. 2 (IQR 0, 6) (placebo group) and modified test: 2 (IQR 0, 5) (protein group) v. 2 (IQR -1, 5) (placebo group)) or any secondary endpoints (Mann-Whitney U tests, P > 0·05). In conclusion, PrS increasing the total protein intake by 0·4 and 0·2 g/kg per d during hospitalisation and after discharge, respectively, does not seem to increase the adaptive response to low-intensity RT in geriatric medical patients.

Oral nutrition supplements and between-meal snacks for nutrition therapy in patients with COPD identified as at nutritional risk: a randomised feasibility trial.

Introduction: Intervention studies have mainly used oral nutritional supplements (ONS) for the management of patients with chronic obstructive pulmonary disease (COPD) identified as at nutritional risk. In this 12-month randomised feasibility trial, we assessed the (1) feasibility of the recruitment, retention and provision of two interventions: ONS and between-meal snacks (snacks) and (2) the potential impact of the provision of snacks and ONS on body weight and quality of life in patients with COPD. Methods: Hospitalised patients with COPD, at nutritional risk, were randomised to ONS (n=19) or snacks (n=15) providing 600 kcal and 22 g protein a day in addition to regular daily diet. The intervention started in hospital and was continued for 12 months after discharge from the hospital. Results: Study recruitment rate was n=34 (45%) and retention rate at 12 months was similar for both groups: n=13 (68%) in the ONS group and n=10 (67%) in the Snacks group. Both groups gained weight from baseline to 12 months (2.3±4.6 kg (p=0.060) in the ONS group and 4.4±6.4 kg (p=0.030) in the Snacks group). The St George's Respiratory Questionnaire total score improved from baseline to 12 months in both groups (score 3.9±11.0 (p=0.176) in the ONS group and score 8.9±14.1 (p=0.041) in the Snacks group). Discussion: In patients with COPD who are at nutritional risk snacks are at least as feasible and effective as ONS, however, adequately powered trials that take account of the difficulties in recruiting this patient group are required to confirm this effect.

Effectiveness of nutritional interventions in older adults at risk of malnutrition across different health care settings: Pooled analyses of individual participant data from nine randomized controlled trials.

BACKGROUND & AIMS: Protein-energy malnutrition is a health concern among older adults. Improving nutritional status by increasing energy and protein intake likely benefits health. We therefore aimed to investigate effects of nutritional interventions in older adults (at risk of malnutrition) on change in energy intake and body weight, and explore if the intervention effect was modified by study or participants' characteristics, analysing pooled individual participant data. METHODS: We searched for RCTs investigating the effect of dietary counseling, oral nutritional supplements (ONS) or both on energy intake and weight. Principle investigators of eligible studies provided individual participant data. We investigated the effect of nutritional intervention on meaningful increase in energy intake (>250 kcal/day) and meaningful weight gain (>1.0 kg). Logistic generalized estimating equations were performed and ORs with 95% CIs presented. RESULTS: We included data of nine studies with a total of 990 participants, aged 79.2 ± 8.2 years, 64.5% women and mean baseline BMI 23.9 ± 4.7 kg/m2. An non-significant intervention effect was observed for increase in energy intake (OR:1.59; 95% CI 0.95, 2.66) and a significant intervention effect for weight gain (OR:1.58; 95% CI 1.16, 2.17). Stratifying by type of intervention, an intervention effect on increase in energy intake was only observed for dietary counseling in combination with ONS (OR:2.28; 95% CI 1.90, 2.73). The intervention effect on increase in energy intake was greater for women, older participants, and those with lower BMI. Regarding weight gain, an intervention effect was observed for dietary counseling (OR:1.40; 95% CI 1.14, 1.73) and dietary counseling in combination with ONS (OR:2.48; 95% CI 1.92, 3.31). The intervention effect on weight gain was not influenced by participants' characteristics. CONCLUSIONS: Based on pooled data of older adults (at risk of malnutrition), nutritional interventions have a positive effect on energy intake and body weight. Dietary counseling combined with ONS is the most effective intervention.

Protein-enriched, milk-based supplement to counteract sarcopenia in acutely ill geriatric patients offered resistance exercise training during and after hospitalisation: study protocol for a randomised, double-blind, multicentre trial.

INTRODUCTION: Age-related loss of muscle mass and strength, sarcopaenia, burdens many older adults. The process is accelerated with bed rest, protein intakes below requirements and the catabolic effect of certain illnesses. Thus, acutely ill, hospitalised older adults are particularly vulnerable. Protein supplementation can preserve muscle mass and/or strength and, combining this with resistance exercise training (RT), may have additional benefits. Therefore, this study investigates the effect of protein supplementation as an addition to offering RT among older adults while admitted to the geriatric ward and after discharge. This has not previously been investigated. METHODS AND ANALYSIS: In a block-randomised, double-blind, multicentre intervention study, 165 older adults above 70 years, fulfilling the eligibility criteria, will be included consecutively from three medical departments (blocks of n=20, stratified by recruitment site). After inclusion, participants will be randomly allocated (1:1) to receive either ready-to-drink, protein-enriched, milk-based supplements (a total of 27.5 g whey protein/day) or isoenergetic placebo products (<1.5 g protein/day), twice daily as a supplement to their habitual diet. Both groups will be offered a standardised RT programme for lower extremity muscle strength (daily while hospitalised and 4×/week after discharge). The study period starts during their hospital stay and continues 12 weeks after discharge. The primary endpoint is lower extremity muscle strength and function (30 s chair-stand-test). Secondary endpoints include muscle mass, measures of physical function and measures related to cost-effectiveness. ETHICS AND DISSEMINATION: Approval is given by the Research Ethic Committee of the Capital Region of Denmark (reference no. H-16018240) and the Danish Data Protection Agency (reference no. HGH-2016-050). There are no expected risks associated with participation, and each participant is expected to benefit from the RT. Results will be published in peer-reviewed international journals and presented at national and international congresses and symposiums. TRIAL REGISTRATION NUMBER: NCT02717819 (9 March 2016).

Nutritional interventions among old people receiving support at home.

With the focus of care shifting from the hospital to the community, supportive nutritional care to old people is to become an important issue to address in the community, since undernutrition has serious consequences, both for the quality of life and for the health care costs. Several modifiable nutritional risk factors relate to undernutrition. Unfortunately, the problem with (risk of) undernutrition is aggravated due to a lack of alertness among e.g. health care staff, leading to insufficient attention for systemic screening and nutritional care. Only a few of the existing screening tools have been validated among old people receiving support at home. Few studies have assessed the beneficial effect of nutritional support among old people in their own home, and recently, it was concluded that such have shown limited effects. One reason may be that the nutritional interventions performed have not taken the multiple nutritional risk factors afore-mentioned into consideration when formulating the action/treatment plan and hence not used a multidisciplinary approach. Another reason may be that the intervention studies have not used validated screening tools to identify those old people most likely to benefit from the nutritional support. However, three recent studies have used a multidisciplinary approach and two have proven a beneficial effect on the quality of life of the old people and the health care costs. These findings suggest that when planning nutritional intervention studies for old people receiving support at home, modifiable nutritional risk factors should be taken into consideration, and a multidisciplinary approach considered.

[Focus on nutrition improves the effect of rehabilitation in geriatric patients].

As a consequence of the loss of physical function more than half of the geriatric patients are discharged with a physical rehabilitation plan. Only a few patients are, however, discharged with a nutritional rehabilitation plan. Data suggest that about 60% of the geriatric patients who are discharged with a physical rehabilitation plan never start the rehabilitation, often due to readmissions. Presumably, this figure could be lowered if a nutritional intervention was initiated. Hence, geriatric patients discharged with a physical rehabilitation plan should simultaneously be discharged with a nutritional rehabilitation plan.

Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge: a randomized controlled trial.

OBJECTIVE: To assess the additional benefits of individualized nutritional counselling by a registered dietitian in geriatric patients' home after discharge from hospital, in relation to risk of re-admissions, functional status, nutritional status, use of social services and mortality. DESIGN: Twelve-week single-blind randomized controlled study. SETTING AND SUBJECTS: Geriatric medical patients (65+ years) at nutritional risk. INTERVENTIONS: Participants were randomly allocated to receive a visit in their homes, either three individualized nutritional counselling by a registered dietitian complemented with three follow-up visits by general practitioners or three follow-up visits by general practitioners alone. MAIN MEASURES: Primary outcome was risk of re-admissions. Secondary outcomes were functional status (hand grip strength, chair stand, mobility, disability and tiredness in daily activities, rehabilitation capacity), nutritional status (weight, BMI, energy and protein intake), need of social services (home care, home nursing, meals-on-wheels) and mortality. RESULTS: One hundred and fifty-two patients were included; 132 (87%) completed the first and 124 (82%) the second data collection after 12 weeks. Ten per cent of the participants had three contacts with their general practitioner, while compliance with the dietetic intervention was almost 100%. Odds ratio for re-admission and mortality after 26 weeks was 1.62 (95% confidence interval (CI) 0.85 to 3.10) and 0.60 (95% CI 0.17 to 2.13). The intervention had a positive effect on functional status (i.e. mobility, P = 0.029), and nutritional status (i.e. weight, P = 0.035; energy intake, P < 0.001; protein intake, P = 0.001) and the use of meals-on wheels was reduced (P = 0.084). CONCLUSION: Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge.

Physical and social functional abilities seem to be maintained by a multifaceted randomized controlled nutritional intervention among old (>65 years) Danish nursing home residents.

The purpose was to test the hypothesis that a multifaceted 11 weeks randomized controlled intervention would have a significant influence of functional abilities in old nursing home residents. Participants were 121 old (>65 years) residents in seven Danish nursing homes. The intervention consisted of nutrition (chocolate, homemade oral supplements), group exercise (moderate intensity) and oral care. Measurements taken were weight, body mass index (BMI), energy and protein intake, and functional abilities (activities of daily living=ADL, cognitive performance, and social engagement). The results showed that the nutrition and exercise were well accepted. After 11 weeks the change in % weight (1.3 vs. -0.6%, p=0.005), % BMI (0.4 vs. -0.2%, p=0.003), energy intake (0.7 vs. -0.3 MJ/day, p=0.084) and protein intake (5 vs. -2g/day, p=0.012) was higher in the intervention group than in the control group. Also, after 11 weeks, social and physical function had decreased in the control group but was unchanged in the intervention group. The difference between groups was significant in relation to social engagement (p=0.009). After the end of the intervention both groups had lost weight and physical function. Cognitive performance did not change, at any time. In conclusion, it seems possible to maintain social (and physical) functional abilities in old nursing home residents by means of a multifaceted intervention.

Lack of compliance of staff in an intervention study with focus on nutrition, exercise and oral care among old (65+ yrs) Danish nursing home residents.

BACKGROUND AND AIMS: Lack of compliance on the part of old participants has been reported in several randomised nutritional intervention studies. However, lack of compliance by staff may also have a significant impact on the effect of interventions. The aim of this paper is to test the hypothesis that, in an intervention study with focus on nutrition, exercise and oral care in old nursing home residents, lack of compliance by staff rather than residents is the major problem. METHODS: An eleven week randomized, controlled trial in seven nursing homes, with nutrition, exercise and oral care strategies, and 62 residents in the intervention group. Staff and researchers documented compliance of residents with the various strategies, including notes about problems. RESULTS: The nutrition and exercise strategies were well accepted by participating residents. The main reason for non-compliance may be related to staff problems. Up to one-sixth of the planned nutrition interventions were not documented as having been given to the residents. CONCLUSIONS: Lack of compliance by staff rather than residents seemed to be the main problem. In order to improve compliance in future studies, more focus should be put on the effect of practical implementation on staff. Insight into these matters may give valuable information to counteract staff problems, facilitate implementation in long term, and hence improve the benefits of nutrition interventions.

Multifaceted nutritional intervention among nursing-home residents has a positive influence on nutrition and function.

OBJECTIVE: We tested the hypothesis that a multifaceted 11-wk intervention comprising nutrition, group exercise, and oral care would have a significant influence on nutrition and function in elderly (>or=65 y) nursing-home residents. METHODS: The study was an 11-wk randomized controlled intervention study with nutrition (chocolate and homemade oral supplements), group exercise twice a week (45-60 min, moderate intensity), and oral care intervention one to two times a week, with the aim of improving nutritional status and function in elderly nursing-home residents. A follow-up visit was made 4 mo after the end of the intervention. Assessments were weight, body mass index, dietary intake, handgrip strength, Senior Fitness Test, Berg's Balance Scale, and the prevalence of plaque. RESULTS: A total of 121 subjects (61%) accepted the invitation and 62 were randomized to the intervention group. Six of these dropped out during the 11 wk. At the 4-mo follow-up there were 15 deaths in the intervention group and 8 in the control group. The nutrition and exercise were well tolerated. After 11 wk the change in percentage of weight (P = 0.005), percentage of body mass index (P = 0.003), energy intake (P = 0.084), protein intake (P = 0.012), and Berg's Balance Scale (P = 0.004) was higher in the intervention group than in the control group. In addition, the percentage of subjects whose functional tests improved was higher in the intervention group. Both groups lost the same percentage of weight after the intervention (P = 0.908). The total percentage of weight loss from baseline to follow-up was higher in the control group (P = 0.019). Oral care was not well accepted and the prevalence of plaque did not change. CONCLUSION: It is possible to improve nutrition and function in elderly nursing-home residents by means of a multifaceted intervention consisting of chocolate, homemade supplements, group exercise, and oral care.

Home-made oral supplement as nutritional support of old nursing home residents, who are undernourished or at risk of undernutrition based on the MNA. A pilot trial. Mini Nutritional Assessment.

AIMS: The aim of this pilot study was to examine the effect of a home-made oral supplement on body weight and energy intake of old people residing in a nursing home. METHODS: Sixty-six old (65+ years) nursing home residents were included and divided into three classes according to their Mini Nutritional Assessment (MNA) scores. Participants who scored 17-23.5 MNA points (at risk of undernutrition) and had a BMI <24 kg/m2 were randomly allocated (block randomization) to two groups: B and C. Participants with <17 MNA-points (undernourished) were allocated to group A. The participants allocated to groups A and B received a home-made oral supplement every evening for two consecutive months. RESULTS: The results after two months showed that compliance with the supplement was good and daily intake from the supplement averaged 1.6 MJ. The total energy intake in group A significantly increased (p<0.001), without suppressing the intake of energy from normal food. Group B experienced a decrease in the intake of normal food and hence no overall change in food intake. Body weight was unchanged in all groups. CONCLUSIONS: Our limited data suggest that a home-made oral supplement can improve the total energy intake of nursing home residents who are undernourished according to the MNA.