Texture-Modified Diets, Nutritional Status and Mealtime Satisfaction: A Systematic Review

Nutritional and hydration interventions for people with dysphagia

Dysphagia (swallowing difficulties) is particularly common in older people and is associated with various health conditions. Dysphagia affects an individual's ability to eat and drink, and can have a significant effect on their clinical outcomes and quality of life. This article explores ways in which nurses can support people with dysphagia to minimise the effects of the condition and enhance their quality of life. The authors examine the role of commonly used strategies such as dietary texture modification and thickened fluids that aim to optimise nutrition and hydration. However, some of the management options for dysphagia do not have a strong evidence base, so nurses should consider whether any dietary restrictions are proportionate and ensure that their benefits outweigh the risks.

Effect of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke: A quasi-experimental study

BACKGROUND

Thickened water has been widely used in patients with dysphagia who receive oral feeding, but there is little evidence for tube-feeding patients.

OBJECTIVE

To explore the effects of thickened water swallow training in tube-feeding and dysphagia patients in the acute and early subacute phases of stroke.

METHODS

A quasi-experimental study. Hospitalised patients with acute and early subacute stroke who received tube feeding due to dysphagia were recruited from March to December 2021. Patients assigned to the intervention group (n = 23) received thickened water swallow training three times daily until the feeding tube was removed or they were discharged, and patients in the control group (n = 23) received usual care. The main outcomes were duration of tube feeding and rates of weaning at discharge.

RESULTS

Patients in the intervention group had a shorter tube-feeding duration (p = .046) and a higher rate of weaning at discharge (p = .017) than those in the control group. Significant interaction effects between time and group were detected regarding quality of life except for the swallowing burden dimension.

CONCLUSIONS

Thickened water swallow training is feasible and effective for stroke patients with tube feeding and can shorten the duration of tube feeding and improve the rates of weaning and quality of life. Healthcare providers in nonrehabilitation units should actively conduct swallowing function intervention training to maximise the potential for acute and early subacute phase rehabilitation.

Food Processing and Nutrition Strategies for Improving the Health of Elderly People with Dysphagia: A Review of Recent Developments

Dysphagia, or swallowing difficulty, is a common morbidity affecting 10% to 33% of the elderly population. Individuals with dysphagia can experience appetite, reduction, weight loss, and malnutrition as well as even aspiration, dehydration, and long-term healthcare issues. However, current therapies to treat dysphagia can routinely cause discomfort and pain to patients. To prevent these risks, a non-traumatic and effective treatment of diet modification for safe chewing and swallowing is urgently needed for the elderly. This review mainly summarizes the chewing and swallowing changes in the elderly, as well as important risk factors and potential consequences of dysphagia. In addition, three texture-modified food processing strategies to prepare special foods for the aged, as well as the current statuses and future trends of such foods, are discussed. Nonthermal food technologies, gelation, and 3D printing techniques have been developed to prepare soft, moist, and palatable texture-modified foods for chewing and swallowing safety in elderly individuals. In addition, flavor enhancement and nutrition enrichment are also considered to compensate for the loss of sensory experience and nutrients. Given the trend of population aging, multidisciplinary cooperation for dysphagia management should be a top priority.

Three-dimensional food printing: its readiness for a food and nutrition insecure world

Three-dimensional (3D) food printing is a rapidly emerging technology offering unprecedented potential for customised food design and personalised nutrition. Here, we evaluate the technological advances in extrusion-based 3D food printing and its possibilities to promote healthy and sustainable eating. We consider the challenges in implementing the technology in real-world applications. We propose viable applications for 3D food printing in health care, health promotion and food waste upcycling. Finally, we outline future work on 3D food printing in food safety, acceptability and economics, ethics and regulations.

A Comparative Evaluation of the Caloric Intake and Economic Efficiency of Two Types of Homogenized Diets in a Hospital Setting

The prevalence of malnutrition is increasing globally due to factors such as age-related pathological conditions and diseases that impact food and beverage intake. In hospital settings, older adult patients often require homogenised diets, which can lead to malnutrition due to poor palatability and limited variety. This study compared the Standard Homogenised Diet (HSD) and a Modified Homogenized Diet (HMD) proposed in a tertiary hospital in Northern Italy. A retrospective and observational design was used to analyse data from 86 adult patients with various conditions requiring a homogenised diet. The primary goal was to compare food intake, rheological characteristics, and palatability of the two diets. The secondary objective was to evaluate the economic impact by comparing costs and quantifying food waste from unused meals. Patients on HMD had a median daily caloric intake of 852 kcal (IQR 787-926 kcal) compared to 631 kcal (IQR 506-797 kcal) in the HSD group. Taste, texture, palatability, and ease of intake for HMD outperformed HSD with scores such as 3.7 ± 0.6 vs. 2.5 ± 0.4 for taste. Economically, HMD was EUR 0.53 less expensive per day than HSD, and food wastage costs were significantly lower for HMD (EUR 2.66 ± 0.81) than HSD (EUR 4.66 ± 1.27). Overall, HMD presented substantial benefits in patient satisfaction and cost-efficiency. This insight may aid diverse care settings to enhance meal acceptance and nutritional intake for patients needing homogenised diets.

Tongue Strength of Older Adults Requiring Long-Term Care Varies throughout the Day

Physical performance shows approximately 30% diurnal variation; however, diurnal variation in oral function remains unclear. This study aimed to determine the diurnal variation in oral and swallowing function in older adults requiring long-term care. The participants included 13 adults aged >60 years (3 men and 10 women, mean age: 77.2 ± 6.3 years, age range: 62-90 years) requiring long-term care. Tongue strength (TS) and oral mucosal moisture were measured as indices of oral and swallowing function, while hand grip strength was measured as an index of general muscle strength. The patients were asked to participate in a "test" after breakfast, lunch, and dinner on the same day. Multilevel linear regression analysis was used to examine diurnal differences in each item. Multilevel linear regression analysis with adjustment for age and sex revealed that TS was significantly higher at noon (p = 0.001) than in the morning. Therefore, caregivers who provide support during meals to older people requiring long-term care should consider the possibility of swallowing function differing according to the time of the day. In conclusion, it may be beneficial to establish a nutritional therapy that accounts for the diurnal variation in TS.

Gustatory stimulus interventions for older adults with dysphagia: a scoping review

BACKGROUND

Gustatory stimulus interventions have been shown to improve swallowing function in older adults with dysphagia. However, the optimal intervention strategies as well as their effects and safety remain unclear.

AIMS

To explore current evidence regarding gustatory stimulus interventions for dysphagia in older adults.

METHODS

Nine electronic databases (PubMed, Web of Science, Embase, CINAHL, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database, and Sinomed) were searched from their inception to August 2022.

RESULTS

This review identified 263 articles, and 15 met the inclusion criteria. The types of gustatory stimulus interventions included spicy (n = 10), sour (n = 3), and mixed (sour-sweet) stimuli (n = 2), with most studies focusing on spicy stimuli. The most frequently reported spicy stimulus was capsaicin. Further, the most commonly reported intervention frequency was thrice a day before meals for 1-4 weeks. The stimuli concentrations and dosages could not be standardized due to the among-study heterogeneity. These studies reported 16 assessment tools and 42 outcomes, which mainly included videofluoroscopy and swallowing response time respectively. More than half of the included studies reported no adverse effects of gustatory stimulus interventions.

CONCLUSION AND DISCUSSIONS

Gustatory stimulus interventions improved swallowing function in older adults with dysphagia. However, assessment tools and outcomes for dysphagia should be standardized in the future, and explore personalized interventions based on different diseases and their stages, to determine the most cost-effective interventions, and to prevent its complications.

RELATIONSHIP BETWEEN NUTRITIONAL STATUS, DYSPHAGIA, AND FUNCTIONAL EATING LEVEL IN ADULT PATIENTS WITH CEREBRAL PALSY IN LONG INSTITUTIONAL STAYS

BACKGROUND

Diets with modified consistencies for patients with dysphagia in long term care health institutions may be associated with malnutrition.

OBJECTIVE

: To assess the nutritional status of adult patients with cerebral palsy and dysphagia hospitalized in a health institution for more than 10 years.

METHODS

: This prospective investigation was performed in 56 patients with cerebral palsy (ages 25 to 71 years, mean: 44±12 years) and no other neurological diagnosis in hospital stay for more than 10 years had their nutritional status, dysphagia, and food ingestion capacity assessed in two moments with a 12-month interval in between them, respectively using the body mass index, the dysphagia risk assessment protocol (PARD), and the functional oral ingestion scale (FOIS).

RESULTS

: There were no differences between December 2015 and December 2016 in the patients' weight, nutritional status, diet consistency classification, PARD, and FOIS. The limits of prescribed diet consistency (IDDSI-FDS) and the assessments of dysphagia and functional eating level influenced the nutritional status. More intense dysphagia and greater eating restrictions were associated with a worse nutritional status.

CONCLUSION

: The nutritional status of adult patients with cerebral palsy hospitalized in a health long term institution who had modified diets according to their swallowing and mastication capacity did not worsen between assessments with a 12-month interval in between them. The severity of dysphagia and diet restrictions interfere with the patients' nutritional status: dysphagia and more intense eating restrictions are associated with a worse nutritional status.

The Provision of Texture-Modified Foods in Long-term Care Facilities by Health Professionals: Protocol for a Scoping Review

BACKGROUND

Malnutrition among older adults with dysphagia is common. Texture-modified foods (TMFs) are an essential part of dysphagia management. In long-term care (LTC) facilities, health professionals have implemented TMFs, but their application has not been fully elucidated, making them heterogeneous.

OBJECTIVE

We aim to explore the implementation of TMFs in LTC facilities, particularly focusing on the role of health professionals in nutritional care involving TMFs (eg, deciding the type of food, preparing and giving the food, and evaluating the outcomes).

METHODS

A scoping review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodological approach will be performed. A comprehensive search for published literature will be systematically performed in PubMed, CINAHL, MEDLINE, ProQuest, PsycINFO, and Science Citation Index (Web of Science). Data screening and extraction will be performed by 2 reviewers independently. The studies included will be synthesized, summarized, and reported, following the preferred reporting items of the Mixed Methods Appraisal Tool. Our review will consider the following study designs: mixed methods, quantitative, and qualitative. Studies with patients who are not older adults will be excluded.

RESULTS

Data extraction will be completed by February 2023. Data presentation and analyses will be completed by April 2023, and the final outcomes will be completed by June 2023. The study findings will be published in a peer-reviewed journal.

CONCLUSIONS

Our scoping review will consider studies related to TMF interventions for older adults in LTC residential facilities, with no exclusion restrictions based on country, gender, or comorbidities. Studies on interventions that address TMF-related issues, such as deciding the type of food, preparing and giving the food, and evaluating the outcomes, are qualified for inclusion.

TRIAL REGISTRATION

OSF Registries 79AFZ; https://osf.io/79afz.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44201.

Multidisciplinary Assessment and Individualized Nutritional Management of Dysphagia in Older Outpatients

INTRODUCTION

The evidence on the efficacy of nutrition therapy to prevent complications of dysphagia is based on observational studies that used different tools for nutritional and dysphagia assessment, and different scales for the definition of diet textures, rendering their results incomparable and the knowledge on dysphagia management inconclusive.

METHODS

This retrospective observational study was performed in 267 older outpatients who were assessed for dysphagia and nutritional status by a multidisciplinary team at the Clinical Nutrition Unit of IRCCS INRCA geriatric research hospital (Ancona, Italy) from 2018 to 2021. GUSS test and ASHA-NOMS measurement systems were used for dysphagia assessment, GLIM criteria for the assessment of nutritional status, and the IDDSI framework to describe the texture-modified diets. Descriptive statistics were used to summarize the characteristics of the subjects evaluated. Sociodemographic, functional and clinical parameters were compared between patients with and without BMI improvement overtime by an unpaired Student's t test, Mann-Whitney U test or Chi square test, as appropriate.

RESULTS

Dysphagia was diagnosed in more than 96.0% of subjects; 22.1% (n = 59) of dysphagic subjects were also malnourished. Dysphagia was treated exclusively by nutrition therapy, prevalently by individualized texture-modified diets (77.4%). For the classification of diet texture, the IDDSI framework was used. The follow-up visit was attended by 63.7% (n = 102) of subjects. Aspiration pneumonia was registered only in one patient (less than 1%), and BMI improved in 13 of 19 malnourished subjects (68.4%). The improvement of nutritional status was primarily reached in subjects whose energy intake was increased and texture of solids modified, in younger subjects, and in those taking less drugs and not reporting any weight loss before the first assessment.

CONCLUSIONS

The nutritional management of dysphagia must guarantee both an adequate consistency and energy-protein intake. Evaluations and outcomes should be described with universal scales, in order to allow for comparison between studies and contribute to the collection of a critical mass of evidence on the efficacy of texture-modified diets in the management of dysphagia and its complications.

The risk of malnutrition in patients with spinal cord injury during inpatient rehabilitation-A longitudinal cohort study

Background and aim

Patients with spinal cord injury (SCI) show an increased risk of malnutrition. Studies found that about 50% of patients with a recent SCI are affected by malnutrition when they enter a rehabilitation institution. However, there is a lack of data during the course and at discharge of initial rehabilitation as well as missing knowledge about the factors promoting such a risk. The aim of this study was to assess the risk of malnutrition in individuals with SCI 3 months post injury and at the end of inpatient rehabilitation and to identify factors associated with a high risk of malnutrition.

Methods

Retrospective, monocentric, longitudinal cohort study, using the data set of the Swiss Spinal Cord Injury Cohort Study and additional data from the patients' medical records. Individuals with SCI were assessed for the risk of malnutrition using the Spinal Nutrition Screening Tool 3 months post injury and at discharge from initial inpatient rehabilitation. Odds ratios (OR) for potential risk parameters were calculated.

Results

Of the 252 participants included, 62% were at risk for malnutrition 3 months post injury and 40% at discharge (p = 0.000). Moderate to high risk of malnutrition was found regardless of age and BMI. The highest odds for an increased risk at 3 months post injury was identified in ventilator-dependent persons (OR 10.2). At discharge from inpatient rehabilitation, pressure injury (OR 16.3) was the most prominent risk factor.

Conclusion

In the population with SCI the risk of malnutrition is widespread during inpatient rehabilitation, but also at discharge. Ventilated persons and persons with pressure injuries are clear risk groups and need special attention. Based on these findings and the known negative impact of malnutrition on clinical outcomes, the awareness of malnutrition should be increased in the population with SCI. Therefore, a regular and standardized screening of the malnutrition risk is highly recommended.

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).

Exploring Meal Provision and Mealtime Challenges for Aged Care Residents Consuming Texture-Modified Diets: A Mixed Methods Study

Dysphagia has become more prevalent with age. Thus, the demand for texture-modified diets (TMDs) has increased. While the nutritional perspectives have been studied, the provision of TMDs and mealtime practice has received less attention. This study aimed to explore the TMD provision and mealtime challenges of residents requiring TMDs in aged care facilities. The study was conducted across five aged care facilities using a mixed methods design involving 14 TMD menu audits by a foodservice dietitian, 15 mealtime observations, and semi-structured interviews with residents and staff (n = 18). TMD menus failed to meet all nutrition requirements and foodservice and clinical standards based on the dietitian NZ foodservice and nutrition audit tool. A content analysis offered three main themes: (1) Foodservice production. Inconsistent quality and meal portions were observed. The variety, choice, and portion size of TMDs required improvement based on the residents’ preferences; (2) Serving procedures. There was a lack of standardisation of meal distribution and feeding assistance; and (3) Dining environment. The dining room set-up varied across facilities, and residents expressed different preferences towards the dining environment. There is a need to improve staff awareness of mealtime consistency and optimise feeding assistance. The dining environment should be individualised to accommodate residents’ psychosocial needs. Standardised policies and continuous training can facilitate quality mealtime implementation.

A Comparison of Dietary Intake and Nutritional Status between Aged Care Residents Consuming Texture-Modified Diets with and without Oral Nutritional Supplements

Oral nutritional supplements (ONS) are high-energy and protein-rich nutrition drinks that are commonly prescribed to individuals with compromised nutritional status. Aged care residents requiring texture-modified diets are exposed to poor oral intake and malnutrition. This study aimed to investigate the dietary intake and nutritional status of residents consuming texture-modified diets with and without ONS. This multicentre cross-sectional study included 85 residents consuming texture-modified diets (86.0 ± 8.7 y; n = 46 requiring ONS and n = 39 without ONS). A one-day dietary record was completed using a validated visual plate waste estimation method. To determine the adequacy, nutrition intake was then calculated using FoodWorks (Xyris Ltd., Brisbane, Australia) and compared to the recommended dietary intake for Australia and New Zealand. The Mini-Nutritional Assessment Short Form was collected to assess nutritional status. Residents receiving ONS had significantly higher energy, protein, carbohydrates and fat intake than those who did not consume ONS (p < 0.05). No significant differences were found in saturated fat, fibre or sodium intake. With the administration of ONS, residents were able to meet their protein requirement but fell short of their energy and carbohydrates requirements. Both groups had inadequate fibre intake and a high saturated fat intake. A total of 48% of the residents were at risk of malnutrition and 38% were malnourished. Aged care residents requiring texture-modified diets are at high risk of malnutrition as a result of inadequate dietary intake. Administration of ONS may be an effective strategy to optimise nutrition intake.

Short-Term Therapeutic Adherence of Hospitalized Older Patients with Oropharyngeal Dysphagia after an Education Intervention: Analysis of Compliance Rates, Risk Factors and Associated Complications

Oropharyngeal dysphagia (OD) is associated with adverse outcomes that require a multidisciplinary approach with different strategies. Our aim was to assess the adherence of older patients to dysphagia management recommendations during hospitalization, after a specific nurse guided dysphagia education intervention and to identify short term complications of OD and their relationship with short-term adherence. We carried out a prospective observational study in an acute and an orthogeriatric unit of a university hospital over ten months with a one-month follow-up. Four hundred and forty-seven patients (mean age 92 years, 70.7% women) were diagnosed with dysphagia using Volume-Viscosity Swallow Test (V-VST). Compensatory measures and individualized recommendations were explained in detail by trained nurse. Therapeutic adherence was directly observed during hospital admission, after an education intervention, and self-reported after one-month. We also recorded the following reported complications at one month, including respiratory infection, use of antibiotics, weight loss, transfers to the emergency department, or hospitalization). Postural measures and liquid volume were advised to all patients, followed by modified texture food (95.5%), fluid thickeners (32.7%), and delivery method (12.5%). The in-hospital compliance rate with all recommendations was 37.1% and one-month after hospital discharge was 76.4%. Both compliance rates were interrelated and were lower in patients with dementia, malnutrition, and safety signs. Higher compliance rates were observed for sitting feeding and food texture, and an increase in adherence after discharge in the liquid volume and use of thickeners. Multivariate logistic regression analysis showed that adherence to recommendations during the month after discharge was associated with lower short-term mortality and complications (i.e., respiratory infection, use of antibiotics, weight loss, transfers to the emergency department, or hospitalization). One-third of our participants followed recommendations during hospitalization and three-quarters one month after admission, with higher compliance for posture and food texture. Compliance should be routinely assessed and fostered in older patients with dysphagia.

Modifying Puree Meals in Residential Aged Care Facilities: A Multi-Centre Feasibility and Acceptability Study

Purees are often recommended for older adults in residential aged care facilities (RACFs) to target swallowing difficulties and nutrition. However, they lack appeal and may have negative impacts on nutritional intake. This study investigated the subjective experiences and objective swallowing function and safety of older adults in response to a modified puree. Twenty-eight residents from three RACFs whose regular diets consisted of purees were recruited. Purees were modified to improve visual appeal by adding a commercial enzyme gellant. Each participant was observed during three puree and three modified puree meals, and completed a brief questionnaire after each meal. A videofluoroscopic swallowing study (VFSS) was performed with 16 of the participants. Compared to purees, modified purees were observed to be easier for oral processing and intake amount was higher, but participants required assistance more often and mealtimes were longer. Participants did not show preference for either type of puree. VFSS showed similar swallowing responses between the two puree types; however, a distinction was observed for modified pureed meat compared to other ingredients. Modifying puree meals in RACFs is a feasible approach to improve nutritional intake while maintaining swallowing safety, but their appeal to consumers is not definitive.

The Perspective of Nectarine Fruit as a Sugar Substituent in Puddings Prepared with Corn and Rice Starch

It has been long recognized that fruits are healthy diet compounds as they are excellent sources of health-beneficial bioactive components (polyphenols, minerals, vitamins, organic acids, etc.). The diversification of the consumer’s taste calls for an expansion of food options and novel ingredients. Puddings are a well-known food choice introduced in the human diet at a very early age because of their easy and high digestion. Four formulations with two types of starch (corn and rice) were selected as object of analysis. Nectarines were incorporated as a purée, and lyophilized powder. The nectarine variety “Gergana”, used for the preparations, is a local variety with proven beneficial properties. The study aimed at analyzing the physical (moisture, ash, color, water-holding capacity, water activity, density and syneresis), textural (firmness, gumminess, cohesiveness, springiness, and chewiness), nutritional, and sensory characteristics of the nectarine-enriched puddings. The outcomes obtained from this study provided significant information about the possible application of the formulations in the children’s daily menus. All four formulations had distinct peachy aroma. The formulations prepared with nectarine purée resulted in a better sensory perception about their texture, and better water-holding capacity. At this point, the formulation prepared with lyophilized fruit and rice starch has the most promising results. Sufficient evidence leads to further exploration of the perspective of fruit-enriched puddings in order to improve their technological and health-promoting properties.