Vitamin fortification of puréed foods for long-term care residents

Newly developed care food enhances grip strength in older adults with dysphagia: a preliminary study

BACKGROUND/OBJECTIVES

Maintaining total muscle mass in the older adults with swallowing difficulty (dysphagia) is important for preserving swallowing function. Increasing protein intake can help sustain lean body mass in the older adults. The aim of this study was to evaluate the effect of various high-protein texture-modified foods (HPTMFs) on muscle mass and perform dietary assessment in ≥ 65-yrs-old patients with dysphagia.

SUBJECTS/METHODS

Participants (n = 10) received the newly developed HPTMFs (average 595.23 ± 66.75 kcal/day of energy, 54.22 ± 6.32 g/day of protein) for 10 days. Relative hand-grip strength (RHS), mid-upper arm circumference (MUAC), body composition, mini nutritional assessment (MNA), mini dietary assessment (MDA), and Euro Quality-of-Life questionnaire 5-dimensional classification (EQ-5D) were assessed.

RESULTS

After 10 days, an increase in MUAC (26.36 ± 2.35 cm to 28.50 ± 3.17 cm, P = 0.013) and RHS (0.38 ± 0.24 kg/kg body weight to 0.42 ± 0.22 kg/kg body weight, P = 0.046) was observed. Although MNA, MDA, EQ-5D, subjective health status, muscle mass, and calf circumference showed a tendency to increase after intervention, no significant differences were found.

CONCLUSIONS

These results suggest that the HPTMFs can be used for improving the nutritional and health status in patients with dysphagia.

Effects of hydrolysed meat on dietary intake and nutritional status in aged care residents requiring pureed diets: a crossover randomised controlled trial

BACKGROUND

As a result of the high prevalence of dysphagia in aged care facilities, demand for pureed diets is increasing. One of the biggest challenges for pureed diets is the reduced nutritional density due to the cooking process, such as when blending or softening with liquid. This study aimed to investigate the impact of innovative energy and protein-enriched meat puree on the nutrition intake and nutritional status of aged care residents requiring pureed diets.

METHODS

This is a single-blinded randomised controlled trial conducted in two aged care facilities using a crossover design. Twenty-two residents aged 83.2 ± 7.3 years participated in a 12-week study. Participants were blocked randomised into two groups and received a 6-week of either control (unaltered freshly made pureed diets by facilities) or intervention diet, followed by a 2-week washout and then 6-week of alternative treatment. During the intervention, freshly made meat pureed portions were swapped to hydrolysed meat, which contained 144 -392 kcal and 5.6-6.8 g more energy and protein per 100 g. Nutrition intake was collected using a validated visual estimation method over 24 h on two non-consecutive days during the control and intervention phases. A two-tailed t-test was used to compare the significance.

RESULTS

The intervention diet significantly increased energy (147 ± 285 kcal, p = .02), protein (4 ± 7 g, p = .04), and fat (3 ± 8 g, p = .07) intake in comparison to the control diet. Nutritional status was improved by the end of the intervention as evidenced by a higher nutritional assessment score using Mini-Nutritional Assessment - Short Form (9.1 ± 1.8) and a weight gain of 1.3 ± 1.7 g, p = .04. No significant differences were found in body composition using bioelectrical impedance analysis, calf circumference and mid-upper arm circumference. Though handgrip strength did not differ at the end of control and intervention, significance was found between the changes in control and intervention period. Plasma branched-chain amino acid increased significantly with hydrolysed meat consumption.

CONCLUSIONS

As a dietary enrichment, hydrolysed meat is a promising intervention for pureed diet consumers in aged care facilities, improving residents' dietary intake and reducing malnutrition risk. Future larger multicentre studies with longer intervention periods are required to confirm the effectiveness and residents' acceptance.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12622000888763).

Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents' nutrition and well-being is required.

Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis

Texture-modified diets (TMDs) play an important role in ensuring safety for those with dysphagia but come with risks to nutrition and quality of life. The use of TMDs has been addressed with the increasing prevalence of dysphagia in previous decades. However, there is limited literature that investigates the nutrition perspectives of TMD consumers. This review summarises the nutrition outcomes of adults consuming TMDs and thickened fluids (TFs) and identifies the limitations of TMD and TF productions. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE, and Scopus databases. Nutrition intake, meal consumption, adequacy, and meal composition were identified as relevant outcomes. 35 studies were included for analysis. Consumption of TMDs demonstrated a poorer intake compared to regular diets, in particular significant in energy and calcium. Meta-analysis of mean differences showed favourable effects of shaped TMDs on both energy (-273.8 kJ/d; 95%CI: -419.1 to -128.6, p = 0.0002) and protein (-12.4 g/d; 95%CI: -17.9 to -6.8, p < 0.0001) intake compared to traditional cook-fresh TMDs. Nutrition intake was compromised in TMD consumers. Optimisation of nutrition intake was achievable through enrichment and adjusting meal texture and consistency. However, the heterogeneity of studies and the missing verification of the consistencies lead to difficulty in drawing conclusions regarding particular texture or intervention.

Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review

OBJECTIVES

This paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs.

DESIGN

Nestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources.

SETTING

OD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs.

RESULTS

This report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed.

CONCLUSION

There is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some 'best practice' approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.

Diet quality is associated with malnutrition and low calf circumference in Canadian long-term care residents

Background

Older adults living in long-term care (LTC) are nutritionally vulnerable. The purpose of this study was to determine diet quality of Canadian LTC residents and its association with malnutrition and low calf circumference.

Methods

A cross-sectional study was undertaken in 32 LTC homes across four Canadian provinces. Nutrient adequacy ratios (NARs) were calculated for seventeen nutrients; mean adequacy ratio (MAR) was calculated to describe overall diet quality. Malnutrition risk was assessed with the Mini Nutritional Assessment-Short Form (MNA-SF) and diagnosis of protein/energy malnutrition with the Patient-Generated Subjective Global Assessment (PG-SGA). Calf circumference (CC) was also assessed. Linear and logistic regressions for these outcomes with diet quality as the predictor were conducted adjusting for covariates.

Results

Average MNA-SF score was 10.7 ± 2.5. Residents (43.5%) had mild/moderate to severe malnutrition based on the PG-SGA and 32.6% had a CC of < 31 cm. Mean MAR score was 0.79 ± 0.09 with significant differences between those requiring eating assistance (0.77 ± 0.11) and those that did not require assistance (0.80 ± 0.07) (p < .05). MAR score was significantly associated with malnutrition in fully adjusted models: MNA-SF scores [β = 5.34, 95% Confidence interval (CI) (2.81, 7.85)] and PG-SGA [Odds ratio (OR) = 0.49, 95% CI (0.38, 0.64)]. Those who had better diet quality were more likely to be well nourished or not at risk. Although several individual nutrients were associated with low CC (< 31 cm), there was no association between overall diet quality (MAR) and low CC.

Conclusions

Diet quality is associated with malnutrition and individual nutrients (NARs) with a low CC. In addition to calories and protein, nutrient dense diets that promote adequate micronutrient intake are required in LTC.

Intake and Factors Associated with Consumption of Pureed Food in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

Residents living in long term care (LTC) who consume a pureed diet tend to have inadequate intake; understanding factors associated with poor intake in this group of residents is not well established. This study examined the adequacy of nutrient intake among LTC residents consuming a pureed diet and the factors associated with this intake (n = 67). Data was collected as part of a cross-sectional study conducted in 32 LTC homes. Weighed food intake was measured on three non-consecutive days and analyzed using Food Processor software. Intake of nutrients were adjusted for intra-individual variability and compared to the Estimated Average Requirement or Adequate Intake for women only. Consumers of a pureed diet had low micronutrient intakes. Multivariate analysis found that the average number of staff assisting with a meal was associated with energy and protein intake. Overcoming eating challenges, careful menu planning and nutrient-dense options for pureed diets in LTC are recommended.

Prevalence of inadequate micronutrient intakes of Canadian long-term care residents

This study determines the prevalence of inadequate micronutrient intakes consumed by long-term care (LTC) residents. This cross-sectional study was completed in thirty-two LTC homes in four Canadian provinces. Weighed and estimated food and beverage intake were collected over 3 non-consecutive days from 632 randomly selected residents. Nutrient intakes were adjusted for intra-individual variation and compared with the Dietary Reference Intakes. Proportion of participants, stratified by sex and use of modified (MTF) or regular texture foods, with intakes below the Estimated Average Requirement (EAR) or Adequate Intake (AI), were identified. Numbers of participants that met these adequacy values with use of micronutrient supplements was determined. Mean age of males (n 197) was 85·2 (sd 7·6) years and females (n 435) was 87·4 (sd 7·8) years. In all, 33 % consumed MTF; 78·2 % (males) and 76·1 % (females) took at least one micronutrient pill. Participants on a MTF had lower intake for some nutrients (males=4; females=8), but also consumed a few nutrients in larger amounts than regular texture consumers (males=4; females =1). More than 50 % of participants in both sexes and texture groups consumed inadequate amounts of folate, vitamins B6, Ca, Mg and Zn (males only), with >90 % consuming amounts below the EAR/AI for vitamin D, E, K, Mg (males only) and K. Vitamin D supplements resolved inadequate intakes for 50-70 % of participants. High proportions of LTC residents have intakes for nine of twenty nutrients examined below the EAR or AI. Strategies to improve intake specific to these nutrients are needed.

Modified Texture Food Use is Associated with Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

OBJECTIVE

Modified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered.

DESIGN

Making the Most of Mealtimes (M3) is a cross-sectional multi-site study.

SETTING

32 LTC homes in four Canadian provinces.

PARTICIPANTS

Regular (n= 337) and modified texture food consumers (minced n= 139; pureed n= 68).

MEASUREMENTS

Malnutrition risk was determined using the Mini Nutritional Assessment short-form (MNA-SF) score. The use of MTFs, and resident and site characteristics were identified from health records, observations, and standardized assessments. Hierarchical linear regression analyses, accounting for clustering, were performed to determine if the prescription of MTFs is associated with malnutrition risk while controlling for important covariates, such as eating assistance.

RESULTS

Prescription of minced food [F(1, 382)=5.01, p=0.03], as well as pureed food [F(1, 279)=4.95, p=0.03], were both significantly associated with malnutrition risk among residents. After adjusting for age and sex, other significant covariates were: use of oral nutritional supplements, eating challenges (e.g., spitting food out of mouth), poor oral health, and cognitive impairment.

CONCLUSIONS

Prescription of minced or pureed foods was significantly associated with the risk of malnutrition among residents living in LTC facilities while adjusting for other covariates. Further work needs to consider improving the nutrient density and sensory appeal of MTFs and target modifiable covariates.

Nutritional quality of regular and pureed menus in Canadian long term care homes: an analysis of the Making the Most of Mealtimes (M3) project

Background

Long term care (LTC) menus need to contain sufficient nutrients for health and pureed menus may have lower nutritional quality than regular texture menus due to processes (e.g., recipe alterations) required to modify textures. The aims of this study were to: determine adequacy of planned menus when compared to the Dietary Reference Intake (DRI); compare the energy, macronutrients, micronutrients and fibre of pureed texture and regular texture menus across LTC homes to determine any texture, home or regional level differences; and identify home characteristics associated with energy and protein differences in pureed and regular menus.

Methods

Making the Most of Mealtimes (M3) is a cross-sectional multi-site study that collected data from 32 LTC homes in four Canadian provinces. This secondary analysis focused on nutrient analysis of pureed and regular texture menus for the first week of the menu cycle. A site survey captured characteristics and services of each facility, and key aspects of menu planning and food production. Bivariate analyses were used to compare menus, within a home and among and within provinces, as well as to determine if home characteristics were associated with energy and protein provision for both menus. Each menu was qualitatively compared to the DRI standards for individuals 70+ years to determine nutritional quality.

Results

There were significant provincial and menu texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed (p < 0.01). Alberta and New Brunswick had lower nutrient contents for both menu textures as compared to Manitoba and Ontario. Within each province some homes had significantly lower nutrient content for pureed menus (p < 0.01), while others did not. Fibre and nine micronutrients were below DRI recommendations for both menu textures within all four provinces; variation in nutritional quality existed among homes within each province. Several home characteristics (e.g., for-profit status) were significantly associated with higher energy and protein content of menus (p < 0.01).

Conclusions

There was variability in nutritional quality of menus from LTC homes in the M3 sample. Pureed menus tended to contain lower amounts of nutrients than regular texture menus and both menus did not meet DRI recommendations for select nutrients. This study demonstrates the need for improved menu planning protocols to ensure planned diets meet nutrient requirements regardless of texture.

Trial registration

ClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.

Electronic supplementary material

The online version of this article (10.1186/s40795-017-0198-3) contains supplementary material, which is available to authorized users.

Micronutrient Food Fortification for Residential Care: A Scoping Review of Current Interventions

PURPOSE

Malnutrition is common in residential care environments, primarily due to poor intake. Micronutrient deficiency, although poorly investigated to date, is also reported to be high. Improving the nutrient density of consumed foods is a potential mechanism to promote increased nutrient intake. A scoping review was conducted to: (1) explore the evidence on micronutrient food fortification strategies, (2) identify candidate nutrients and food vehicles for successful food fortification, and (3) identify gaps for future research.

METHODS

The scoping review framework of Arksey and O'Malley was used. A comprehensive search strategy of 4 electronic databases (MEDLINE, EMBASE, CINAHL, and Web of Science) was completed. Two reviewers were involved in screening and data extraction for all selected articles.

RESULTS

A total of 4394 relevant articles were identified for screening, and application of inclusion/exclusion criteria resulted in 6 food fortification studies (8 citations; 1 study had 3 citations). Overall, vitamin D (n = 5 studies) and calcium (n = 4 studies) were the most common micronutrients fortified; milk products, margarine, bread, and pureed foods were fortification vehicles. Most studies fortified below the RDA recommendation and did not include clinical outcomes. Samples were small and intervention periods were short (3-6 months).

CONCLUSIONS

Fortification is a viable strategy for improving the nutrient density of foods consumed in residential care. Although disparate, this literature suggests the potential for further undertaking of fortification to prevent micronutrient deficiencies among residents and future research should consider multinutrient preparations and clinical outcomes.

"Test me and treat me"--attitudes to vitamin D deficiency and supplementation: a qualitative study

OBJECTIVE

Lay interest in vitamin D and the potential benefits of supplementation is considerable, but little information exists concerning lay knowledge, beliefs and attitudes towards vitamin D to inform public health initiatives and professional guidance.

DESIGN

Qualitative focus group study.

PARTICIPANTS

58 adults capturing diversity in disease status, gender, age and ethnicity.

SETTING

A large general practice in east London.

RESULTS

Many respondents lacked knowledge about vitamin D, including dietary sources and government recommendations. Most were positive about sun exposure, but confused by ambiguous health messages about risks and benefits of sunshine. Medicalised views of vitamin D were prominent, notably from those in favour of supplementation, who talked of "doses", "side effects" and "regular testing." Fortification of food with vitamin D was controversial, with opposing utilitarian (better overall for the majority) and libertarian (freedom to choose) views.

CONCLUSIONS

Knowledge about vitamin D was limited. Clearer messages are needed about risks and benefits of sun exposure. Testing and supplementation by health professionals, while potentially useful in some high-risk groups, have contributed to a medicalised view of vitamin D. Health policy should address the public's need for clear information on sources and effects of vitamin D, including risks and benefits of sun exposure, and take account of divergent views on fortification. Professional guidance is needed on testing and supplementation to counter inappropriate medicalisation.

What do consumers think of pureed food? Making the most of the indistinguishable food

This qualitative study is based on in-depth interviews with 15 consumers (+4 family members) of pureed food. Transcripts were thematically analyzed to summarize and interpret these data. Although no consumer enjoyed eating pureed food, some were grateful to be able to be nourished orally. Food was described as being poor in terms of sensory appeal, and products were often indistinguishable from each other. Consistency in production, delivery, and approach to presentation was identified to be a challenge that affected the acceptance of products, and variety was often lacking. However, consumers saw the necessity of the texture and provided several suggestions that are practicable and feasible for improving their experience and "making the best of it." This is the first in-depth study on consumer perception of pureed food. It not only provides insights into their experience and the impacts on their quality of life but also provides information about ways providers can improve upon these products.

Keeping consumers safe: food providers' perspectives on pureed food

Twelve focus groups were conducted in five sites with 80 allied health providers to identify their perspectives on providing pureed food to consumers. Thematic care analysis was completed to summarize and interpret these data. Providers' greatest concern was keeping consumers safe, and the right texture was prioritized over sensory appeal and acceptance. Providers recognized that these foods impacted the quality of life of consumers and worked to rationalize these diets with residents/patients and their families. In addition, offering foods they knew to be poorly accepted affected their self-concept as providers. As a result of these challenges, they did whatever they could in the kitchen and tableside to promote intake of pureed foods. Those in the "food chain" of pureed food provision suggested several ways to further improve these products. Greater communication between those who assist consumers with eating and those who produce the pureed food they consume is needed to promote acceptable pureed products.

In-house pureed food production in long-term care: perspectives of dietary staff and implications for improvement

Texture modification of foods to a pureed consistency is a common management approach for older adults with dysphagia. Long-term care (LTC) facilities commonly produce some pureed food in-house. This study investigated challenges and preferred practices associated with the production of pureed food in LTC facilities. Nutrition Managers (n = 27) and cooks (n = 26) from 25 Ontario LTC facilities were recruited for one-on-one, semistructured interviews. Interviews were digitally recorded, transcribed, and analyzed using inductive thematic analysis. Four themes arose from the data to exemplify challenges in production, including (a) difficulty in using standardized recipes, (b) varied interpretation of governmental guidelines, (c) lack of consistency in terminology and texture, and (d) wanting to improve the visual appeal. These challenges were reported to reduce the quality of in-house produced pureed food. Preferred practices to overcome these challenges were also provided by participants, such as involving cooks in pureed recipe improvements and tailoring to the specific needs of residents. Incorporation of these practices into pureed food production may help to shape and improve future practice and pureed food products.

The effect of varying ingredient composition on the sensory and nutritional properties of a pureed meat and vegetable

The objective of this research was to investigate the effects of ingredients and preparation methods on the sensory and nutritional properties of pureed turkey and carrots. Turkey samples varying in added liquid and muscle composition were developed. Seasoning application methods were also studied. Pureed carrots were formulated with no added thickener, added modified corn starch, rice cereal, or skim milk powder. Small changes in added liquid and seasoning application altered the perceived texture of the turkey. Pureed carrots with added modified corn starch were more slippery and firm than other samples. The addition of skim milk powder or rice cereal did not alter sensory properties but led to higher protein contents when compared to unthickened carrots. In-house formulations did not differ in sensory ratings of appearance and flavor when compared to commercial products but contained more carbohydrates. Modest changes in recipes for pureed products can improve sensory appeal and nutrient density; quality in-house products are feasible with only minor alterations.

Issues associated with the use of modified texture foods

Use of modified texture foods (MTF) is common in the geriatric population. There is a potential for increased prevalence of use of MTF due in part to longer survival of persons with dementia, those who have suffered from a stroke, as well as other degenerative diseases that affect chewing and swallowing. Unfortunately, little clinical, nutritional and sensory research has been conducted on MTF to inform practice. This review highlights issues identified in the literature to date that influence nutritional and sensory quality and acceptability of these foods. Use of MTF is highly associated with undernutrition, however causality is difficult to demonstrate due to confounding factors such as the requirement for feeding assistance. Knowledge gaps and considerations that need to be taken into account when conducting research are identified.