Issues associated with the use of modified texture foods

Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?

BACKGROUND

Although modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach.

DISCUSSION

There is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners.

CONCLUSION

The disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.

Texture-modified foods and thickened fluids used in dysphagia: Israeli standardised terminology and definitions

BACKGROUND

Texture-modified foods and thickened fluids are used as a strategy that aims to compensate for dysphagia and improve the safety and efficiency of swallowing. Currently, in Israel, there are no standardised terminologies and definitions for texture-modified diets. The inconsistent terminology adversely affects patient safety and the efficiency of communication between staff members both within and between health institutions. This present study describes a project of the Israeli Ministry of Health in which the labels and definitions of prevalent foods and fluids used in health institutions are mapped to develop a consensus on national standards.

METHODS

A multidisciplinary committee of speech-language pathologists (SLPs) and registered dietitians (RDs) was appointed. A questionnaire was developed to identify the labels of texture-modified foods and fluids used in the Israeli healthcare system. The questionnaire included questions on knowledge, attitudes and barriers related to the need for a consistent national terminology for texture-modified diets. Questionnaires were sent to 120 institutions. The project was conducted between September 2016 and December 2017.

RESULTS

Twenty-six SLPs and 42 RDs responded. The answers revealed that there were 50 labels in use for texture-modified foods. When asked to describe the texture of a particular food item, up to 17 different labels were used. There was broad support for a standardised terminology.

CONCLUSIONS

The results of the present study confirm the lack of national standards in clinical practice and the need for a consistent terminology. A consensus was achieved between the committee members and the committee adopted the International Dysphagia Diet Standardization Initiative (IDDSI) recommendations and adapted the terminology to Hebrew.

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.

Texture-dependent effects of pseudo-chewing sound on perceived food texture and evoked feelings in response to nursing care foods

Because chewing sounds influence perceived food textures, unpleasant textures of texture-modified diets might be improved by chewing sound modulation. Additionally, since inhomogeneous food properties increase perceived sensory intensity, the effects of chewing sound modulation might depend on inhomogeneity. This study examined the influences of texture inhomogeneity on the effects of chewing sound modulation. Three kinds of nursing care foods in two food process types (minced-/puréed-like foods for inhomogeneous/homogeneous texture respectively) were used as sample foods. A pseudo-chewing sound presentation system, using electromyogram signals, was used to modulate chewing sounds. Thirty healthy elderly participants participated in the experiment. In two conditions with and without the pseudo-chewing sound, participants rated the taste, texture, and evoked feelings in response to sample foods. The results showed that inhomogeneity strongly influenced the perception of food texture. Regarding the effects of the pseudo-chewing sound, taste was less influenced, the perceived food texture tended to change in the minced-like foods, and evoked feelings changed in both food process types. Though there were some food-dependent differences in the effects of the pseudo-chewing sound, the presentation of the pseudo-chewing sounds was more effective in foods with an inhomogeneous texture. In addition, it was shown that the pseudo-chewing sound might have positively influenced feelings.

A Dedicated Nutritional Care Program (NUTRICARE) to reduce malnutrition in institutionalised dysphagic older people: A quasi-experimental study

AIMS AND OBJECTIVES

To assess the effects of a texture-modified food program for dysphagia on the nutritional, biochemical and functional profile in a cohort of institutionalised older people in Italy.

BACKGROUND

Dysphagic institutionalised older people, often also affected by dementia, are frequently exposed to malnutrition. Malnutrition in older people has negative effects on mortality, days of hospitalisation, infection, wound healing and risk of pressure injuries. Therefore, it is very important to prevent malnutrition in this frail population.

DESIGN

A pre-post study without a control group.

METHODS

The study included 479 dysphagic institutionalised older people from 20 nursing homes. Anthropometrical, biochemical, nutritional and functional parameters were collected retrospectively, 6 months before the study intervention, at time zero and, prospectively for 6 months after implementing the NUTRICARE food programme, for a total of nine evaluations. The NUTRICARE programme includes meals without nutritional supplementation, and personalised levels of density, viscosity, texture and particle size.

RESULTS

The total mean body mass index of our sample passed from 17.88-19.00; body weight averagely improved by 7.19%, as well as their nutritional and biochemical profiles. There was a progressive improvement of total protein and serum albumin values. Nutritional parameters (serum transferrin and lymphocytes) displayed similar changes. Plasma lymphocytes reached normal levels in 98.23% of the sample. Plasma creatinine levels remained steady throughout the study and within the normal range. No side effects were reported.

CONCLUSION

The NUTRICARE food programme with a adequate proteins, calories, balanced nutritional and bromatological properties, and appropriate texture and palatability significantly improved the nutritional, biochemical and functional profile in a cohort of institutionalised dysphagic older people.

RELEVANCE TO CLINICAL PRACTICE

The introduction of a balanced nutritional programme, using high-quality natural ingredients, appropriate texture and palatability can significantly improve health and quality of life in dysphagic older people.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BACKGROUND

Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.

METHODS

A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.

DISCUSSION

This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.

TRIAL REGISTRATION

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

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.

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.

Characterizing commercial pureed foods: sensory, nutritional, and textural analysis

Dysphagia (swallowing impairment) is a common consequence of stroke and degenerative diseases such as Parkinson's and Alzheimer's. Limited research is available on pureed foods, specifically the qualities of commercial products. Because research has linked pureed foods, specifically in-house pureed products, to malnutrition due to inferior sensory and nutritional qualities, commercial purees also need to be investigated. Proprietary research on sensory attributes of commercial foods is available; however direct comparisons of commercial pureed foods have never been reported. Descriptive sensory analysis as well as nutritional and texture analysis of commercially pureed prepared products was performed using a trained descriptive analysis panel. The pureed foods tested included four brands of carrots, of turkey, and two of bread. Each commercial puree was analyzed for fat (Soxhlet), protein (Dumas), carbohydrate (proximate analysis), fiber (total fiber), and sodium content (Quantab titrator strips). The purees were also texturally compared with a line spread test and a back extrusion test. Differences were found in the purees for sensory attributes as well as nutritional and textural properties. Findings suggest that implementation of standards is required to reduce variability between products, specifically regarding the textural components of the products. This would ensure all commercial products available in Canada meet standards established as being considered safe for swallowing.

The association between chewing and swallowing difficulties and nutritional status in older adults

BACKGROUND

The aim of this study was to investigate the associations of chewing and swallowing dysfunctions to nutritional status in older adults.

METHODS

This cross-sectional study comprised a convenience sample of 1065 community-dwelling older adults living in rural United States. Dietary assessment included the Block Full Length Food Frequency Questionnaire, 24-hour Food Intake Recall and Mini Nutritional Assessment. Classification of chewing and swallowing difficulties was determined by a criterion of outlined factors.

RESULTS

In our sample, 113 (11%) had chewing difficulties, 51 (5%) had swallowing difficulties, and 11 (1%) had both. Compared to the Dietary Reference Intakes (DRIs), the study population was deficient in calories and several nutrients. Mean daily intake in individuals reporting chewing, swallowing, or difficulties with both were 1489 ± 360, 1461 ± 374 and 1374 ± 240 calories respectively. There was no statistically significant difference between the groups. Vitamin A, vitamin E and manganese were significantly lower in those with chewing difficulties while vitamin E and magnesium were significantly lower in individuals with swallowing difficulties (p < 0.05).

CONCLUSIONS

These results emphasize the importance of chewing and swallowing difficulties in modulating nutritional outcomes in older adults. These co-morbidities should be monitored in this population and intake of nutrient dense foods should be increased in those at risk.

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.

Speech-language pathologist-led fiberoptic endoscopic evaluation of swallowing: functional outcomes for patients after stroke

BACKGROUND

Dysphagia is a common complication after stroke and is associated with the development of pneumonia. Early detection of dysphagia and specifically aspiration is, therefore, critical in the prevention of pneumonia. Fiberoptic endoscopic evaluation of swallowing (FEES) is a safe bedside instrumental tool for detecting dysphagia and aspiration and, therefore, has the potential to inform dysphagia management. This study investigated the clinical utility of a speech-language pathologist-led FEES service on functional outcomes for patients after acute stroke.

METHODS

A retrospective file audit was carried out on 220 patients before FEES was introduced and on 220 patients after the implementation of a speech-language pathologist-led FEES service. The primary outcome measure was incidence of pneumonia, and secondary outcome measures included mortality, diet on discharge, discharge destination, duration nil-by-mouth, incidence of nonoral feeding, and length of stay.

RESULTS

There was a significant increase in instrumental assessment use in the group that had access to FEES (P < .001). There was a significant reduction of pneumonia rates in the group that had access to FEES (P = .037). Patients were also significantly more likely to leave hospital on standard diets (P = .004) but had longer periods of nonoral feeding (P = .013) and increased length of hospitalization (P < .001).

CONCLUSION

When used selectively, FEES services have potential for improving functional outcomes for patients after stroke.

The Need for International Terminology and Definitions for Texture-Modified Foods and Thickened Liquids Used in Dysphagia Management: Foundations of a Global Initiative

Conservative estimates suggest that dysphagia (difficulty swallowing) affects approximately 8 % of the world's population. Dysphagia is associated with malnutrition, dehydration, chest infection and potentially death. While promising treatments are being developed to improve function, the modification of food texture and liquid thickness has become a cornerstone of dysphagia management. Foods are chopped, mashed or puréed to compensate for chewing difficulties or fatigue, improve swallowing safety and avoid asphyxiation. Liquids are typically thickened to slow their speed of transit through the oral and pharyngeal phases of swallowing, to avoid aspiration of material into the airway and improve transit to the esophagus. Food texture and liquid modification for dysphagia management occurs throughout the world. However, the names, the number of levels of modification and characteristics vary within and across countries. Multiple labels increase the risk to patient safety. National standardization of terminology and definitions has been promoted as a means to improve patient safety and inter-professional communication. This article documents the need for international standardized terminology and definitions for texture-modified foods and liquids for individuals with dysphagia. Furthermore, it documents the research plan and foundations of a global initiative dedicated to this purpose.

Association of the oral health impact profile with malnutrition risk in Spanish elders

The objective of this study was to determine any relationship between oral health-related quality of life (OHR-QoL) and malnutrition risk in the elderly using the oral health impact profile (OHIP). We studied 250 institutionalized elderly people, 162 females and 88 males, with and without teeth. Data were gathered on: general health; oral health; malnutrition risk, measured with the Mini Nutritional Assessment (MNA); and OHR-QoL, evaluated with the OHIP. A multivariate binary logistic regression model was constructed with malnutrition presence/risk as dependent variable. Mean age was 82.7 ± 8.2 years. Malnutrition or malnutrition risk was shown by 36.8% of the sample. OHIP was associated with malnutrition/risk after adjustment for age, sex, functional status, and mild dementia diagnosis. Malnutrition/risk was 3.43-fold more likely in participants with OHIP-reported "problems" than in those with none. The conclusion of the study was that OHIP-measured OHR-QoL is associated with malnutrition risk.

A mix of bulk and ready-to-use modified-texture food: impact on older adults requiring dysphagic food

Ready-to-use modified-texture food (rMTF) products are commercially available and may have greater appeal than conventional in-house or commercial bulk modified-texture food (cMTF) products. A nine-month pilot study using a prospective interrupted time-series design where participants (n = 42) served as their own controls investigated the impact of cMTF + rMTF on weight goals, weight, food intake, and co-morbidity. Seventy-four per cent of participants achieved their weight goals at the end of six months on rMTF and, although insignificant, participants did have a trend towards weight gain while on rMTF (OR 3.5 p = .16). Main-plate food intake (grams) was not significantly different over time, but a downwards trajectory suggests decreased consumption that was compensated for by a significantly higher fat intake during the intervention period (p = .01). Increased co-morbidity and a decreasing volume of food consumed are common in older adults with dysphagia, and enhanced food products are needed to meet nutrient needs. Methodological issues encountered in this study can provide guidance for future work.