Issues and Challenges of Modified-Texture Foods in Long-Term Care: A Workshop Report : Page 2 of 3
Dysphagia, Malnutrition, and Fortification
Dysphagia is a major comorbidity among LTC residents. It is reported to exist in as many as 74% of residents, with higher prevalence rates in those with dementia.26 A variety of conditions can result in dysphagia, including weakness of the muscles responsible for mastication and swallowing, leading to an increased risk of aspiration. To minimize this risk, MTFs and thickened liquids are frequently recommended.12 In addition to prescribing MTFs for physiological reasons, these foods are also used for several nonphysiological issues, such as slow eating, self-feeding difficulties, and refusal to eat.27,28 In such cases, the use of MTFs may not be warranted, as they should only be administered when there are safety concerns. Use of a simple screening checklist can ensure MTFs are used appropriately. One such tool, the Nutrition and Swallowing Checklist,12 was designed to help front-line staff identify dysphagia and nutrition and swallowing risks in individuals with intellectual disabilities. The 24-item checklist assesses for observable signs of potential dysphagia, such as choking, coughing, and regurgitation, and evaluates for nutrition issues, such as weight loss, self-feeding challenges, and reduced food intake. When concerns are noted, the Nutrition and Swallowing Checklist is meant to trigger further assessment by a multidisciplinary team; thus, it could be used to screen patients who are then assessed to determine if MTFs are an appropriate means of nourishing the resident. Testing to this point has only been preliminary, and the usefulness of this tool in LTC settings and for research purposes requires further study.
Nutritional quality of MTFs needs to be assured for those residents who require these foods. There is some evidence that MTFs, specifically pureed varieties, have fewer calories and are lower in nutritional value than unmodified foods.14,15,29 In a study of 25 patients receiving regular foods and 30 receiving MTFs, Wright and colleagues30 found that those on MTFs consumed significantly fewer calories, with more than half of these individuals requiring oral nutritional supplements to compensate for low nutritional intake. Although several studies have examined the inadequate dietary intake among LTC residents on MTFs,31,32 research on fortifying pureed and minced foods with vitamins and minerals to improve intake is limited. A study by Adolphe and colleagues32 that included a small group of LTC residents (n=11) assessed the impact of a fortification procedure on nutrient intakes and serum vitamin levels, and examined whether the fortification process affects food flavor. During the study, four palatable fortified foods were incorporated into the participants’ daily pureed menu. When examining these individuals’ nutrient intakes and serum vitamin B12, folate, and 25-hydroxyvitamin D levels at baseline versus 8 weeks after the intervention, the authors found improvements in all of these measures except for serum vitamin B12, which remained the same. Based on their findings, the authors concluded “The development of acceptable vitamin-fortified puréed foods is feasible and is an effective way to increase the micronutrient status of LTC residents.”32 Building on this research, the MTF Research Group has considered using its time-series study33 on MTF intake to further investigate the micronutrient intake of individuals consuming these foods, with an objective to establish baseline fortification levels that could be assessed in a larger fortification study.
Future Research Recommendations for Dysphagia, Malnutriton, and Fortification
Validated screening tools are required to prevent the unnecessary prescribing of MTF-based diets to patients who do not have aspiration risks or other safety concerns that would warrant the use of these diets, as this practice can compromise the nutritional status of these patients. To facilitate the use of such tools by LTC staff, they must be reliable and easy to administer. In addition, research is needed to adapt and expand the use of these tools to the home care and acute hospital settings.
Fortification appears to be an effective method for improving the micronutrient profile of MTFs. Further research is needed to determine what effect fortification has on MTFs with regard to sensory properties, stability with food production methods, and feasibility of mass production in a commercial kitchen. This research is necessary before conducting randomized clinical trials to demonstrate the usefulness of fortification for preventing malnutrition in patients on MTF diets.
Standardized Production and Delivery of Modified-Texture Foods
Currently, many LTC facilities use both in-house–prepared and commercially available MTF products for a variety of reasons, including to meet mandated menu choice requirements, save on costs (commercially produced products are more expensive), and increase acceptability and palatability (some foods are challenging to modify in-house). Although there are standards for producing commercially available MTFs, there are no national, provincial, or state standards in either the United States or Canada for guiding the preparation of MTFs in-house. This lack of standardization results not only in confusion on terminology (eg, minced, chopped, soft, puree) and food particle size, but also leads to variation in nutritional quality, sensory quality, and safety.15 A study by Beck and Hansen15 that assessed food prepared at 10 LTC facilities found that none of them used consistent recipes with calculated nutrient content for their residents on MTF diets. In a study by Dahl and Whiting,34 food particle size and consistency were found to be more uniform in commercially prepared products. These studies suggest that in-house preparations of MTFs are less standardized than commercial products and could potentially cause disparities in nutrients, palatability, and safety. Hall and Wendin35 examined the impact of ingredient profile and particle size on the sensory characteristics of in-house–prepared MTFs. In their study, various meat- and carrot-based MTFs were produced that varied in food particle size, fat content, and starch and egg composition. Of these samples, those that contained a high proportion of egg yolk and a low amount of starch were deemed by a panel of experts to be optimal. These products were tried by older consumers, who reported them to be easy to chew and swallow. The authors concluded that “Optimization of factors influencing food quality through the use of experimental designs in combination with sensory and consumer studies is required in order to meet the needs and demands of older people.”35
Although current literature has thus far shown commercially produced products to be more consistent in texture than those prepared in-house, palatability and nutritional content have yet to be compared. Members of the MTF Research Group from the University of Guelph and the University of Waterloo are conducting additional research in the area of standardized production of MTFs. One study is examining the preparation procedures used to puree foods in LTC facilities, with an objective to determine the reasons behind the lack of standardization for in-house MTF production procedures. Another study is comparing the nutrient profiles and sensory properties of commercial brands. Because consumers’ perception of the sensory experience of pureed food has been identified as a key area for improvement in both commercial and in-house MTFs, these studies will provide insights on how the nutrient profile of MTFs can be improved while also making these foods more palatable.
Future Research Recommendations for Standardized Production and Delivery of Modified-Texture Foods
Lack of standardized procedures for producing MTFs is a major concern. Government agencies and professional bodies need to be involved in standardizing the production of in-house and commercially prepared foods. Textures and particle size that are consistent with safe and efficacious swallowing among persons with differing levels of disability need to be determined. This information would guide the development of safe and acceptable products, both in-house and commercially. Further research is also needed to examine consumers’ perception of the sensory experience of MTFs produced commercially compared with those prepared in-house. Nutrient analysis of commercial and in-house MTFs, specifically pureed foods, is needed to identify how they compare with unmodified foods and how they should be enhanced.
Complexities of Researching Modified-Texture Foods in LTC Settings
The principal difficulty involved in conducting MTF research in LTC facilities is the ability to obtain and maintain a large enough sample size over a sufficient length of time to demonstrate a clinically significant change. Faced with a multitude of comorbidities, the LTC population has high rates of mortality and experiences multiple transfers to supportive and acute care settings, resulting in high study withdrawal rates.
Further research limitations involve the collection of accurate and consistent clinical research outcome data, such as study participants’ weight and food intake. Accurate assessment of food intake through a visual observation, photographic method, or plate-weighing procedure is time- and resource-intensive, and weight-measuring procedures are often poorly performed. The MTF Research Group has been working on standardizing these procedures.36 In addition, invasive outcome measures, such as questionnaires that are too long, can pose a problem when dealing with this vulnerable population, affecting the feasibility, acceptability, and accuracy of these measures within this population.
Future Research Recommendations for Complexities of Researching Modified-Texture Foods in LTC Settings
When conducting research on MTF use in the LTC setting, multicenter collaboration is essential to ensure a large enough sample size to be clinically significant. Research staff require training and need to work closely with interprofessional clinical teams to determine the best means of successfully accomplishing the research objectives. As such, the involvement of both clinical dietitians and speech language pathologists in the research process is imperative in determining and measuring outcome indicators.
Researchers must also be sensitive to the “home” concept established in LTC facilities. Residents have often lived for many years in these homes and have set patterns of behavior, routines, and socialization, which should be respected. Extra care must be taken when including patients with cognitive impairment in any research initiatives, as these individuals may struggle when presented with strange new faces and activities.
Finally, greater use of laboratory-based research (eg, sensory and nutritional testing) is needed to carry out some of the research questions related to MTFs, as there are considerable challenges in obtaining this information from the clinical population. Several key questions are ideally answered outside of the clinical environment, such as what food textures are optimal for safe swallowing. Answers to these questions would shed light on how to improve the MTF products currently being prepared in-house and commercially.