Transcript
Ash de Neef: Okay Ngaire thank you so much for joining us on the show today.
Ngaire Hobbins: Very fine to be here.
Ash de Neef: And can we start maybe with a little bit about yourself and about the work that you do?
Ngaire Hobbins: Yeah. Look, I’ve been a dietician for coming up for 40 years now, but the last 20 of them I’ve been working specifically with older people. It came about when I was doing a stint as a community care worker in between careers, you know, little changes you have. And I actually spent some time assisting older people living in the community. And I was really aware of that time, that the information that was going to people who are older was is basically the same information as goes to the general population. But unfortunately, some of that is either unhelpful or harmful if you’re instead an older person.
So I tried to access information to give to people, and there really wasn’t anything. And there still isn’t very much. It’s increasing, it’s getting better, but for people who are now living in their late sixties onwards. So I spent a lot of time doing research and I’ve written a couple of books about this, basically to give the information to older people.
So I combined my time between working on trying to share that message. That almost every health message out there that we get, in the popular media and the press and most magazines and newspapers and whatever is actually for people who are 20, 30, 40. And we need to change your thinking once you are late sixties onwards. And so that I spend my time talking about that.
And as well as that, I work in aged care settings to support the needs of people who are in supported care. So it’s a bit of a blend, probably roundabout 50/50 in that work. Because I often say that older people who are now in their later years, not only have they got to their later years, because they actually probably ate the way we would like all the youngsters to eat fresh, seasonal, local, and were physically active and all that stuff.
But also those people, who are now in their older years have given us everything that we youngsters, I’m not as young as you, but you know. Other youngsters might be listening, or that anyone is younger. Everything that we just take for granted, the life we have, the technological devices we have, our ability to do things in non-COVID times. All sorts of stuff even the medical advances.
They’re down to those people who are now older and it’s our responsibility as a society to support them. So that’s my sort of area of work. And in aged care, there are challenges with food and nutrition. And so that’s what I work with to try and help people to get through those.
Ash de Neef: Very nicely put and we will circle back on some of those challenges in a little bit. But just talking about the differences between what’s good advice for younger adults, and what’s good advice for older adults. We’re talking about nutritional and dietary information, right?
Ngaire Hobbins: It is obviously I’m a dietician so my focus is that. The last book that I wrote, which is called Brain Body Food, the subtitle is it’s a guide to thriving into later life and reducing dementia risk.
Ngaire Hobbins: So when you put together that information, it combines the difference in nutritional needs for older people compared to younger with all the other things that go with it. You can’t separate out food when it comes to living well into later life and in dementia risk food is important.
And it’s just one component, but as well as that, unless you’re also physically active as much as possible your whole life, socially engaged. Spending time giving your brain a break, whether that’s in sleep or actually in meditative practice. You don’t necessarily have to meditate, but anything that you do that gives your brain a break, that’s good.
So there’s a whole lot of things. And I talk about all of that as a combined thing. And I write I – I take the science and I put it in everyday language because that’s what people need, you know, ways to understand practical strategies.
So the reason why nutrition is different when people are older, actually comes down to there’s a number of things, but I always talk about, the pivotal thing is what your muscles too.
Ngaire Hobbins: So your muscles are much more than what you need to move around. We take them for granted to get us out in the battle and move around. But as well that they actually act as your reserve of your body’s reserve protein for a whole lot of activities that we have to do every day.
Because we don’t eat 24 hours a day, but 24 hours a day, we need protein to be doing things. And the things that it’s doing include fighting off any sort of illness. So it’s working your immune system, so protein is always required. If you’re not eating your muscles give up a little bit of protein that supplies that system as it’s needed.
As well as that, you’re always making new cells. You’re always replenishing blood cells. You know, heart, kidney, lung lining of your digestive tract, hair and skin in the like. So that’s always happening with your eating or not. Any sort of repair, whether that’s a scratch or a graze or surgery or anything that happens, that can be huge amounts of protein.
And the really interesting thing is your brain, which is only about 2% of your body weight, is consuming about close to a quarter of the energy that you’re burning at any point in time. So your body is always turning over calories, but your brain is doing much more of it. And it’s, amazing because we just don’t think about just the amount of work that it’s doing.
Now your brain is completely dependent on a fuel called glucose, which we get from carbohydrate foods we eat, and a very small amount that we store in our bodies. But because we’re not eating 24 hours a day, and because therefore there are times when we’re not supplying that glucose. If you don’t eat at all or are eating very small amounts, what happens is that your brain has to get the fuel and it’s going to take precedent over everything else in the body.
And there’s a really inconvenient physiological truth that we cannot make glucose that the brain needs out of stored body fat. You can use stored body fat to run your muscles. And other systems in your body, but you can’t use stored body fat so much to run your brain. And so what happens is that your brain takes protein from the muscles and converts it into glucose to keep itself going.
So you’ve got enough carbohydrate supplies in your body for a couple of days, most people. But if someone isn’t eating very well, or if they’re eating nothing for more than that time, and I think of lots frail older people that I might see who are unwell. After a couple of days your brain is eating up your muscles to keep itself going.
Okay, so that’s good because your brain has to keep going. But what happens is if you’re younger, you have a whole lot of drivers that tell you, as soon as you eat protein to pop it back in your muscles if it’s been taken out.
When you’re older, that drive isn’t there anymore because that drive is designed to make you grow. And once you become an adult, you don’t need to grow anymore. So a lot of those drivers that when you eat the protein meal, go “quick throw it back in the muscles”, aren’t there.
The end result, long explanation, but the end result is once you’re older, you’re more likely to lose body muscle. And they might come a time then down the track, when you don’t have adequate muscle to support your immune system, your body organ repair. Your muscle, your repair work and your brain.
And so that is where I see this step-wise sometimes decline in capacity and people aren’t aware. So I say, “you have to realize in your older years that things are different.”
You must eat protein more often, at every meal basically. You must remain physically active. And interestingly, you must at that stage, actually avoid losing weight. Because if you lose weight and you’re older, you lose muscle. If you lose weight when you’re younger, you lose fat.
So it’s a whole different picture. And if I can’t get that message to people, I see people decline all the time. They think, “oh, it’s fine. You know, I’m overweight at 80 and I’ll lose some weight.” But actually the weight you’re going to lose might be not a benefit, it’s so different.
So that’s what I do in a general message and that sort of area, that’s not the aged care area exactly. But it’s complex to explain, but so important to understand.
And not long ago, 70 was really old, and if you only had to live till 70, the growth you’d got to your mid-forties or whatever would be enough to get you through. But now you want to live 20, 30 years beyond that, you have to think differently.
Ash de Neef: Wow that’s a really important message. And when I think about some of the older adults in my life, who’ve said the opposite to me about, you know, “I need to lose some weight”, and now I have justification to go back and say, “no, you don’t. You’re great. Stay where you are.”
Ngaire Hobbins: Tell them to look up my book and see why they’re like. But you know, it is just such an important thing. And I, spend my time saying this and people always, I often am interviewed. I do a lot radio work and things like that. And often the interview is just completely incredulous, and go, “that can’t be true.” It is true. If you look at the physiology and you understand what’s going on, this is the issue. And that how culture, rightly so, is concerned about overweight, And overweight in middle age increases your risk of a whole of health conditions as well as dementia interestingly.
But once you get into later age, there seems to be a concept that maybe that additional body fat that people might hold is actually protecting against frailty. It’s a different thing altogether. Physical activity remains the important thing all the time. Physical activity underpins all of this, no matter what. No matter how old you are, whatever you can do, you have to keep on doing.
But understanding this difference. And so for your grandma, she should say to you “no, no, no. I’m okay. I can have the cake, you can’t. Because I need to keep going.”
And you know, there’s whole lot of other things your appetite’s affected, which is an aged care thing as well.
Ash de Neef: You mentioned aged care there and I wanted to tie this in. So when you’re working with aged care providers. And I know that at the moment, you’re on assignment in an undisclosed location, working with an undisclosed provider. Are you finding in general, this kind of knowledge about the different dietary requirements of older adults, is reflected in the menu and the offerings in residential aged care?
Ngaire Hobbins: In some place. These particular people I’ve been working with, we’ve been working with this project for a number of years, so it’s slightly different.
But yes, in general in aged care I find as a dietician, over the last 20 years, I’ve been working at it, immense frustration. If I can get in the door and if I can help them with their-. When we do a menu review, it’s not about, what’s actually written down on the menu day to day. That’s a short term for it. It’s actually menu and the dining experience.
Because what I’m looking at is this is the systems and processes in place. Not just the nutritional content of the menu. But every little step from purchasing to cooking, to delivery. To make sure that the nutrition that is purchased by the organization at great cost of course ends up in people’s mouths. Because so often that’s what falls down.
So if I get into an aged care home, I really think that we can-. You know, there’s plenty of evidence that a dietician doing this sort of work. Making sure not only that the menu is nutritionally adequate, but that people end up being able to eat it.
So the nutrition actually gets to where it’s meant to get to and enjoy it. because these people deserve to be enjoying life. And I often say, and I’ve stolen this from friend of mine, but basically a lot of when I see people in aged care and I talked to them, I would say that a vast majority, there are six things that they look forward to every day. And that is breakfast morning, tea, lunch, afternoon, tea, dinner, and supper. That’s it. Often there’s not many other things that people are looking forward to apart from visits from family.
So it has to be good. So if I can get in the door, we can reduce the cost of wound care. We can reduce the likelihood of falls. Complaints, which cost the industry, huge amounts of money.
We can do all those things and make people’s quality of life better. But sometimes getting in the door in an aged care home is very difficult. I think what happens is they go and you’re going to cost us money. But actually, I’m going to make them money, save them money, but it’s very hard to get that message across.
But once I am in the door and once we’re doing this, we’re looking at two things. Firstly, educating the staff and the consumer as the aged care quality and safety commission calls them or the resident. Educating them in their unique needs. Because a lot of those people don’t understand the difference and might accidentally say things like, “oh, you could lose a few kilos”. Or “don’t eat that”, or “that’s bad for you”, you know, “don’t have that chocolate” or whatever it happens to be.
Those things might apply to the staff member, who’s inadvertently saying it, but they don’t necessarily apply to the person in the bed or the chair or whatever. So it’s educating people about that, including the residents. But it’s also looking at individual needs and making sure that they’re accommodated.
If I see someone, there was someone yesterday who isn’t vegetarian, but prefers a lot of the time to not have meat dishes that are on the meal that were on the menu. But if the menu alternative dish, which is often plant-based. It’s fine, there’s no problems with that at all. But if the alternative dish is not the same amount of protein as the meat dish, then those people are not getting the protein they need. And that often happens.
People will might make, say, vegetable patties out of, which you or I would love, you know, with cauliflower and various things. But unless they actually add a protein addition that brings the protein content up, what ends up happening is that person may be eating something, they quite like, but they’re not getting the nutrition.
So we work with the recipes to make sure that we’re getting the protein in there, however that happens. And we’re going to get onto texture modified stuff, not everyone’s on that.
And also things like talking to the chefs the other day, you know, sometimes there’s something on the menu, which is lovely and soft. I tried a meal the other day and I always eat the meals. And I try to meal the other day where they’ve made a potato bake to go with the dish. And the potato bake was so beautifully, soft and creamy. Easily could be used for someone with a soft diet or even on a mince, a moist diet. Because the way you test that is if you can push us folks through it easily, which you could.
But unfortunately, sometimes the thinking is, “oh they’re in a soft diet”, so they give them something different. It’s not necessary. You can go, “Okay that, everyone can have.” So when you’re sitting at the table with 60 of your other residents, And if you’re on a soft diet, you’re getting something different to that person next to you.
And you can look at that potato bake and go “well, how come I I didn’t get that?” And sometimes that is enough to reduce the intake of the person because they feel a bit “mm. Right. I don’t get that.” And if they don’t put that in their mouth and eat that food, then we’ve wasted the food. I can’t stand waste. We’ve wasted the food, and we’ve wasted the opportunity.
So I’m always working on getting every opportunity, for every mouthful to get in then. So it’s tweaking those things and getting people to basically think about the resident at the end. They get lost in process sometimes.
Ash de Neef: Wow there’s so much there. And so many little, little steps that need to be looked at to see why the food may not getting into the bodies of the people who need it. Do you think, cause I know you’ve been working with the Royal commission as part of an expert advisory panel. And one of the final report’s recommendations was about food and nutrition, I think it was 68% of residents are either malnourished or on their way to malnutrition. What do you think is the biggest obstacle to overcome to improve that percentage?
Ngaire Hobbins: Yeah, the Royal commission did identify that, and there’s two things here. One thing is the rhetoric around this is often based on observations that sometimes family members have made taking photos, sent to the media whatever of dishes that don’t look good. Fair enough. These people deserve to have good quality food that they enjoy and some meals are not great and don’t present well and whatever.
So there is a focus as a result of the Royal commission and the sort of popular rhetoric that all we need to do is improve the quality of food. We just train the chefs, we just get them understanding things better. That’s all we need to do and everything will be better. And that is a very important component, but it is in my experience, only a part of the picture.
And unfortunately, I would say, yes I work with the expert advisory group of the quality and safety commission. But I would say that in general, unfortunately, there’s been a little bit too much focus on improving quality of food, of training chefs, whatever, and not enough on the process. Because what I would see is it does not matter how good the food is, whether it’s good quality or bad quality.
I see some great quality meals that don’t get eaten. I see some poor quality meals that do, and some that don’t of course, as well. So it doesn’t matter how good the food is, unless it goes in someone’s mouth it’s wasted, and it’s no benefit to that person. So unfortunately, I would say to some extent, we’ve missed an opportunity to focus on the process a bit more. But we’re getting there, you know, it’s much better than it used to be.
And in the years gone by, there was a process where an aged care home could technically take a menu written down on a piece of paper. So, something that says, “on Monday it’s this and this, on not Tuesday it’s this. And there’s a four week cycle.“ And that would be sent to somebody as a piece of paper or is it email, you know, document whatever. And someone offsite would look at that go, oh there’s meat here and this chicken here and this fish there, and that’s all great.” And tick all the boxes and send it back and say the menu’s great.
But unfortunately that’s completely useless unless you actually go into the place. Because I can see the menu on paper and it looks fabulous. But when you turn up and you look at what’s actually happening.
So you can cook some really lovely things in the kitchen, and in a lot of places they might have a servery area. So the meal goes in a Bain Marie to a servery and it’s served up. That’s where it can fall down at times either the person who’s serving doesn’t have skills or understanding of plating.
You know, it’s just putting it on the plates or it looks appealing. Like look at Instagram. Instagramable food. You need Instagramable food in aged care because often it’s slopped onto the plate. There’s a hurry. They’re rushed. Not always, but sometimes that happens. No chef would send in a restaurant would say that a meal without wiping the edge of the plate, if it slopped on the edge, that may not happen.
So we haven’t gotten into appetite, but in older people and particularly in aged care, appetites can be tiny. And they’re impacted by medications, loneliness, grief, physical incapacity, not being able to get around a whole lot. Thousands of medications affect appetite.
So once they’re on these things, their appetites can be small. And we don’t want to miss the opportunity to get that mouthful in. So if the plating is bad, if it’s slow, so the meal is not hot enough or not cold enough. And the other way around, if it’s meant to be cold. If the services not empathetic.
A friend of mine talks about the plonkers and the engagers. So if you’re not feeling great, you’re sitting at a table, someone plunks the plate in front of you and then goes onto the next person. You just might go “uhh” and not even try it.
I actually saw the four ladies at this table, I was going to yesterday. The meal was actually a roast chicken. It was very nice. I’d eaten it before I went out and talked to them. It was tasty and pleasant and whatever it was soft. Three of them had eaten them and cleaned their plates, and one lady hadn’t eaten anything. And I said to her, how was the meal?” She said, “terrible.”
Now she might have tasted it. You have to tweak out why she’s saying that. It’s not actually my job. In this particular job that I’m doing, It’s not my job to fix that. It’s my job to identify it. There was actually nothing wrong with that meal. And there’s something else going on, but that person hasn’t eaten. Maybe she to a room and has snacks in the room who knows. But the thing is that-. And that’s a waste, I can’t stand the wastage is incredible.
There’s so many little things that the audit process that dieticians carry out teases out and then sent-. And what we do is we provide a report that gives ideas for continuous improvement. And it’s not slamming people for doing the wrong thing all the time. It’s going, “right this was an issue and this is how you could fix it. Or can you look at a system that you could fix this?”
Because if that woman doesn’t eat, then she’s more likely to get an infection. She’s more likely to get a pressure injury if she’s sitting around lot. She’s more likely to fall. And all those things are appalling for her quality of life, of course, but also costly to the system. And if she ends up not doing as well, she’s in bed more. That’s more staff hours to help her do all the things that she actually could, should and would want to and should be able to do herself.
So there’s so many flow on things, but that’s the issue in nutrition is it’s very hard to-. People just see food on the plate, that’s it, dietician says this. And that they don’t actually see the enormous web of things that you have to pull into place to achieve what we hope to achieve.
Ash de Neef: Yeah, that’s really great. And I know that I need no motivation at all to eat food, That’s not a problem that I have. But to understand that as you age, that might become a different challenge. And looking at all the kind of situations around eating and dining and how can that encourage people to eat.
Now, there’s something I have a, I have a hunch this might be relevant. I remember hearing that people in France and Italy and sort of Mediterranean cultures that cook and eat together are healthier because of the process of doing that altogether. Is there some value in making the dining experience, a shared and community experience within residential care?
Ngaire Hobbins: Absolutely. It’d be fantastic. There are many people that I run into who say, “oh, I love living here. I don’t have to cook anymore.” People who’ve for six children all their lives and whatever. And many people interestingly will say to me, “It’s the best thing I ever did moving in here, I’ve got people to talk to, someone to look after me if I’ve got a problem.”
People very negative feeling, but actually it’s not always that experience for people, it’s actually often good. So yes having that opportunity to share meals and to be involved in the cooking process and places should have a good food focus process. And that’s not just sitting there and going, “I hate meal, I don’t like that meal and change this.”
It’s actually maybe saying, “you know, are there any recipes you would like to give to me, you know, to the kitchen, we’ll give it a go and see if everyone likes it.” They can run days where they might do, I don’t know, a day of all Indian food, all Italian or Mexican or something for something different. Making sure you make a birthday cake and other people are involved.
They often have things like happy hour which is great. And I always say, “that’s great. Have a happy hour. And people might have a glass of wine or a beer, or they might just have something else to drink. But make sure they have cheese and biscuits, give them some protein at the same time”. Like that’s an opportunity for snacks as well.
All those things make things a bit more interesting and absolutely being physically involved in cooking would be fabulous. Many places don’t have that set up. I personally am a gardener. I would love people to be able to grow, and a lot of people would love to be able to grow vegetables and use them. Sometimes somewhat irritating health guidance that you can’t actually use the vegetables that you grow in your garden without all sorts of processes which is annoying. And I think we’ll get past that.
If you had chickens, if you had enough chickens, you could get rid of all of the waste. You could recycle the waste, which would be fabulous. Otherwise it’s just going to landfill and I hate that. There’s a whole lot of things that actually engage people in the process and they are spectacularly important to find out in each individual situation.
If you have those meetings and people are listened to, then you can think, “Okay why don’t we try this? Or there’s an orange tree in the yard. Why don’t we get the people together and make marmalade and sell it in the shop” or whatever. You know, do something just as an engagement.
In some places, boredom is a big issue. The cost of people to come and provide distractions, entertainment, things to do is, another cost.
As you said before, you can’t imagine not eating. I can’t imagine a time that when I’ve got a piece of food in front of me and my brain is not going to go, “you’re very hungry. Must eat.”You know, that’s what happens to me all time, even though I know I’m not hungry. But my clients have the opposite to something sitting on a plate in front of him so often. And when that’s the case, boredom is going to make that worse.
Ash de Neef: You mentioned there about, maybe crowdsourcing food ideas the residents and, and trying to understand what they want to eat. We had Daniella Greenwood on the podcast a few months back, and she was responding to the Royal Commission’s reports and she was talking about paternalism in the way that we describe the food that’s provided.
And, and this idea that before anything else comes nutrition. But if somebody wants a pizza or they want fish and chips, shouldn’t we be able to give them something like that?
Ngaire Hobbins: Oh, god yes. I would say absolutely. My thinking is, and because appetite is such an important thing. If I’ve got someone who’s frail, who’s maybe they’re missing their family at the moment this is a big problem. Maybe one of their loved ones has passed away, one of their friends passed away. But if those sort of things are impacting them. If their appetite is small, usually, amazingly treats can help them.
So if I can find out what their favourite thing is, might be chocolate might be ice cream might be whatever potato chips, whatever it happens to be. If we give the those treats, then often that is enough to do something in the brain that goes, “this is okay”, and then they will start eating.
It’s more important that you eat than that we worry about nutrition. So yes, of course I’m a dietician, but the most important thing is that people enjoy and that they actually eat the food. So if someone, for example, often in dementia, peoples liking for sweet things increases and people go, “oh my goodness, you can’t have the sugar, whatever.”
And you go, well first of all this is a life limiting illness. So, you have to think about the risk versus benefit. So when I saw a lady few weeks ago who the staff were freaking out, because when she was having her porridge in the morning she wanted to have about five great big spoonfuls of brown sugar on top. And the fact is that if she didn’t do that, she didn’t eat the porridge. But if she did that, she ate it.
And now it’s much more important that she eats the porridge. We’re not going to worry. I mean, I just try and tease it out and go, okay what is the worst thing that can happen? The worst thing that can she’s not going to eat. The best thing that can happen…
Like the worst thing, certainly if someone’s got diabetes that might be slightly different, but I would say nutrition’s very important across the whole organization, but I’m a minute by minute basis with each meal it’s actually most important. Absolutely not.
It’s making sure that people enjoy that. They get the best quality of life. That they get those treats you deserve. You’re allowed have treats when you’re 90 something that’s important. And all I do is I tweak the meals to put nutrition into if possible.
So for example, lots of people like ice cream. Ice cream is not particularly high in protein or has some, you’d have to eat a fair bit to get enough. So, you know, I will say to people “we’ll just sprinkle it with one of those high protein chocolatey things,” I won’t use a brand name, that most are well aware of. Sprinkle that on top. Mix that in, it’s chocolatey, it’s malt-y and it’s higher in protein and then people enjoy it. Or add ground nuts into recipes, add more protein foods.
And we often fortify foods with milk based protein. That means some of the texture foods are protein added and fortified with things. Because sometimes people who are eating foods that aren’t in their original texture are eating smaller amounts. So you need to make sure that there’s more in every mouthful.
But it’s a blend. It’s a mixture of tweaking things to make sure you get the nutrition, but absolutely the most important thing is the quality and the enjoyment.
Ash de Neef: Awesome.
Ngaire Hobbins: Can I just add a little thing about texture modified foods. I see places where they are using moulded foods, which are great, and I see places where they’re not. And I see places where they piping and we’re making cornells, you know, making things look a bit different on the plate. But again, the same as with any meal, it’s what happens to it when it leaves the kitchen. It looks great when it’s moulded like that in the plate.
What happens often, depending on how it’s delivered is, if it’s delivered into a servery area and they’ve got plastic wrap over the top. They put it in the microwave or the re-heating device. And what happens is the plastic breath tends to rise up, but as it cools back down again, it sucks down onto the meal. And it makes no difference whether you have made a beautiful presentation in the kitchen, you can end up with a flattened mush in the bowl.
And that is another little process that I have to follow and make sure works. Because you can do all that great work and waste it again. It’s not just the actual process of making the food look good in the first place, it’s what happens to it at the end, the same as everything else.
Ash de Neef: Wow. Ngaire, so much information here and so many little things for people to think about it and check out in their own processes, if they’re providing food. Where can people find more about, you mentioned you, you have a book?
Ngaire Hobbins: Yeah well, the book that’s available at the moment and it actually I’ve just turned it into an audio book as well. So the book is called Brain Body Food. And you can get it through my website, which is in my name, ngairehobbins.com. Or actually usual eBooks and audio books and the usual stores that you would go to.
But I wrote it to try and get this message out because I can’t talk to every person, but I want every older person to understand this. And as I say, if you read most of the regular diet books that are around, you actually only getting information that’s good for younger people. And could actually be unhelpful if you’re older.
Ash de Neef: Awesome. Ngaire thank you so much for your time today.
Ngaire Hobbins: Pleasure. Thanks Ash.
