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

Impact of pureed and liquidised diets on health-related quality of life scores in older patients during postacute rehabilitation: A pilot study

BACKGROUND

Consuming texture-modified diets was considered to negatively affect health-related quality of life (HR-QoL). However, the precise relationship between the levels of food texture consumed and HR-QoL remains uncertain. The present study aimed to determine the association between levels of food texture consumed and HR-QoL.

METHODS

This cross-sectional study included 122 hospitalised patients aged ≥ 65 years (mean ± SD age 78.9 ± 7.9 years; 48.4% female) who required postacute rehabilitation. Consumed food texture levels were classified using the International Dysphagia Diet Standardization Initiative (IDDSI) framework 2.0. HR-QoL was evaluated using the five-level EuroQoL five-dimension (EQ-5D-5L). The association between food texture levels and HR-QoL was analysed using a multivariate linear regression model.

RESULTS

The lower food texture levels consumed were associated with significantly lower EQ-5D-5L scores. Consumption of pureed (IDDSI Level 4) and liqudised (IDDSI Level 3) diets were associated with lower EQ-5D-5L scores among older patients undergoing postacute rehabilitation (regression coefficient -0.304; 95% confidence interval = -0.472 to -0.137 and regression coefficient, -0.444, 95% confidence interval = -0.676 to -0.213, respectivly).

CONCLUSIONS

The findings suggest a link between the consumption of pureed and liquidised diets and lower HR-QoL scores in older hospitalised patients undergoing rehabilitation. To establish a clearer cause-and-effect relationship, future research should encompass multicentre and longitudinal studies, building upon the insights from the present study.

Characterizing Canadian long-term care home consumed foods and their inflammatory potential: a secondary analysis

BACKGROUND

Nutrient dense food that supports health is a goal of food service in long-term care (LTC). The objective of this work was to characterize the "healthfulness" of foods in Canadian LTC and inflammatory potential of the LTC diet and how this varied by key covariates. Here, we define foods to have higher "healthfulness" if the are in accordance with the evidence-based 2019 Canada's Food Guide, or with comparatively lower inflammatory potential.

METHODS

We conducted a secondary analysis of the Making the Most of Mealtimes dataset (32 LTC homes; four provinces). A novel computational algorithm categorized food items from 3-day weighed food records into 68 expert-informed categories and Canada's Food Guide (CFG) food groups. The dietary inflammatory potential of these food sources was assessed using the Dietary Inflammatory Index (DII). Comparisons were made by sex, diet texture, and nutritional status.

RESULTS

Consumption patterns using expert-informed categories indicated no single protein or vegetable source was among the top 5 most commonly consumed foods. In terms of CFG's groups, protein food sources (i.e., foods with a high protein content) represented the highest proportion of daily calorie intake (33.4%; animal-based: 31.6%, plant-based: 1.8%), followed by other foods (31.3%) including juice (9.8%), grains (25.0%; refined: 15.0%, whole: 10.0%), and vegetables/fruits (10.3%; plain: 4.9%, with additions: 5.4%). The overall DII score (mean, IQR) was positive (0.93, 0.23 to 1.75) indicating foods consumed tend towards a pro-inflammatory response. DII was significantly associated with sex (female higher; p<0.0001), and diet (minced higher; p=0.036).

CONCLUSIONS

"Healthfulness" of Canadian LTC menus may be enhanced by lowering inflammatory potential to support chronic disease management through further shifts from refined to whole grains, incorporating more plant-based proteins, and moving towards serving plain vegetables and fruits. However, there are multiple layers of complexities to consider when optimising foods aligned with the CFG, and shifting to foods with anti-inflammatory potential for enhanced health benefits, while balancing nutrition and ensuring sufficient food and fluid intake to prevent or treat malnutrition.

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).

Association between denture use and food form in older adults requiring long-term care: A multicenter cross-sectional study

PURPOSE

This study aimed to determine whether denture use contributes to maintaining and improving food forms in long-term care facility (LTCFs) residents.

METHODS

In 888 residents of 37 LTCFs in Japan, the following were investigated: nutritional intake status, food forms, age, sex, Barthel index (BI), clinical dementia rating (CDR), number of teeth present, number of occlusal supports, swallowing function, and use of dentures. Among all residents, those who were well-nourished and had ≤9 occlusal supports were analyzed. Based on standardized criteria, the food forms consumed by the subjects were divided into two groups: dysphagia and normal diet, which were further classified into four levels. Analysis was performed using a generalized estimation equation with the four levels of food forms as dependent variables and age, sex, BI, CDR, presence of dysphagia, number of teeth present, and use of dentures as independent variables.

RESULTS

The final analysis included 622 (70.0%) residents. Of these, 380 (61.1%) used dentures. The analyses revealed that food form was significantly associated with age (adjusted odds ratio [OR], 0.98), BI (OR, 1.04), number of teeth present (OR, 1.03), presence of dysphagia (OR, 0.44), and use of dentures (OR, 2.82).

CONCLUSION

Denture use was associated with food forms among Japanese LTCF residents. This indicates that the use of dentures is related to the maintenance of food forms, even in the elderly who participate in few activities of daily living, have reduced cognitive function, and require long-term care.

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.

Automated food intake tracking requires depth-refined semantic segmentation to rectify visual-volume discordance in long-term care homes

Malnutrition is a multidomain problem affecting 54% of older adults in long-term care (LTC). Monitoring nutritional intake in LTC is laborious and subjective, limiting clinical inference capabilities. Recent advances in automatic image-based food estimation have not yet been evaluated in LTC settings. Here, we describe a fully automatic imaging system for quantifying food intake. We propose a novel deep convolutional encoder-decoder food network with depth-refinement (EDFN-D) using an RGB-D camera for quantifying a plate's remaining food volume relative to reference portions in whole and modified texture foods. We trained and validated the network on the pre-labelled UNIMIB2016 food dataset and tested on our two novel LTC-inspired plate datasets (689 plate images, 36 unique foods). EDFN-D performed comparably to depth-refined graph cut on IOU (0.879 vs. 0.887), with intake errors well below typical 50% (mean percent intake error: [Formula: see text]%). We identify how standard segmentation metrics are insufficient due to visual-volume discordance, and include volume disparity analysis to facilitate system trust. This system provides improved transparency, approximates human assessors with enhanced objectivity, accuracy, and precision while avoiding hefty semi-automatic method time requirements. This may help address short-comings currently limiting utility of automated early malnutrition detection in resource-constrained LTC and hospital settings.

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

While the association between dysphagia and malnutrition is well established, there is a lack of clarity regarding the nutritional status and mealtime satisfaction of those consuming texture-modified diets (TMDs). This systematic review summarises and critically appraises the nutritional status and mealtime satisfaction of adults consuming TMDs. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE and Scopus. Nutritional status, mealtime satisfaction and costs were identified as primary outcomes. Eligible studies were grouped according to outcome measurement. In total, 26 studies met the inclusion criteria. Twenty studies evaluated the nutritional status by weight change or using malnutrition screening tools and found the consumption of TMDs correlated with weight loss or malnutrition. Nine studies evaluated mealtime satisfaction, with two reporting poor satisfaction for people on thickened fluids (TFs). Nutrition intervention through adjusting texture and consistency and nutrition enrichment showed positive effects on weight and mealtime satisfaction. The majority of the studies were rated as 'neutral' quality due to the limited number of experiments. TMD consumers had compromised nutritional status and poor mealtime satisfaction. More research input is required to identify promising strategies for improving the nutritional status and mealtime satisfaction of this population. Food services need to consider texture, consistency and fortification in designing menus for people on TMDs to avoid weight loss and malnutrition, and to enhance mealtime enjoyment.

Are Therapeutic Diets in Long-Term Care Affecting Resident Food Intake and Meeting their Nutritional Goals?

Purpose: To examine health characteristics of long-term care (LTC) residents prescribed therapeutic diets (promoting or restricting intake of key food components), to determine how these diets influenced intake and whether there were differences in food intake and malnutrition risk between residents with and without restrictive diets.Methods: Secondary analysis of the Making the Most of Mealtimes Study includes 435 residents with no/mild cognitive impairment in 32 LTC homes across 4 provinces. Health records were reviewed for diet prescriptions and other characteristics. Weighed and observed food and fluid consumption over 3 nonconsecutive days determined intake. Bivariate and multivariable linear regressions identified associations between therapeutic diets and intake and key nutrients.Results: Almost half (42%) of participants were prescribed a therapeutic diet. Residents receiving restrictive diets (28%) consumed absolute calories consistent with those receiving a regular diet, but kcal/kg was significantly lower (22.1 ± 5.5 vs 23.6 ± 5.3). Low sodium and weight-promoting diets were the only therapeutic diets associated with their corresponding key nutrient profiles. Restrictive therapeutic diets were not associated with energy or protein intake when adjusting for covariates.Conclusions: Restrictive therapeutic diets among those with mild to no cognitive deficits do not appear to impair food intake.

Is IDDSI an Evidence-Based Framework? A Relevant Question for the Frail Older Population

To delay impacts of aging, optimal nutritional status is essential. Several factors can reduce food intake, such as isolation, income, and cognitive/physical decline. Additionally, chewing and swallowing difficulties, or dysphagia, often disrupt the ability to consume life-long favorite dishes. Food and liquids could require modification of texture or consistency to ensure a comfortable or safe swallow. The food industry, foodservices facilities, and caregivers need quality control benchmarks to provide adequate nourishment and meet these new feeding challenges. The International Dysphagia Diet Standardisation Initiative (IDDSI) is proposing the IDDSI framework and testing methods to describe food used in nutritional care plans to circumvent dysphagia and improve communication among caregivers. This systematic review assesses the validity and reliability of the IDDSI testing methods using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). Two publications presented content validity whereas 19 publications looked at construct validity or reliability for the IDDSI testing methods. One study was conducted in older adults presenting dysphagia. This review concludes that there is insufficient evidence to recommend the IDDSI testing methods. Further research, conducted with robust methodological design and reporting, is needed to develop and assess nutritious adapted food for frail older populations.