Issues and Challenges of Modified-Texture Foods in Long-Term Care: A Workshop Report

Key words: Dysphagia, feeding dependency, food satisfaction, fortification, malnutrition, mealtime experience, modified-texture foods, undernutrition. 
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Malnutrition in long-term care (LTC) residents is a growing concern among LTC providers, as it can negatively impact functional ability and quality of life, and can lead to increased risk of morbidity and mortality.^1-3 Malnutrition is defined as a state in which a deficiency, excess, or imbalance of energy, protein, or other nutrients causes adverse effects on body form, function, and clinical outcomes.⁴ In Canadian and US LTC facilities, the prevalence of malnutrition among older adults ranges between 40% and 80%.^1,5,6 There are numerous causes of malnutrition in older adults, including dysphagia, which is commonly seen with advanced age or attributed to comorbidities.^3,7 Older adults may also experience eating difficulties due to tooth loss, fatigue, or an inability to self-feed because of physical or cognitive impairments.^8-10 To assist residents who have difficulty chewing or swallowing food, many LTC facilities feed these individuals modified-texture foods (MTFs), referring to the mechanical alteration of a food’s consistency (ie, puree, mash, chop, mince) so that it is easier to consume.¹¹ Although MTFs should make it easier for elders to consume their food, the use of MTFs, particularly pureed diets, has been implicated in the high prevalence of undernutrition in the LTC population.¹² Undernutrition is a form of malnutrition in which inadequate nutrition results from lack of food or failure of the body to absorb or assimilate nutrients properly.¹³

There is little clinical evidence to explain how the use of MTFs causes undernutrition, but previous studies have found that MTFs, specifically pureed types, offer poor nutritional value compared with regular foods.^14,15 In addition, LTC residents may resist consuming MTFs because they are often unappealing in their appearance, texture, and taste.¹⁶ These issues may stem from a lack of quality control and standardization of MTFs used in LTC facilities. Furthermore, satisfaction survey results of LTC residents indicate that food is the topic with the most variability, reflecting not only a high level of interest in this important daily activity, but also a range in satisfaction.¹⁷

To explore these issues further, the Modified Texture Food Research Group, an interprofessional team of researchers, gathered with clinicians and policymakers from across the province of Ontario for a 1-day MTF Research Planning Workshop in Ontario, Canada, in November 2010; the Canadian Institutes of Health Research funded this workshop. The MTF Research Group includes founding members from the Bruyère Research Institute, the University of Guelph, and the University of Waterloo, who collectively have frontline experience and expertise in epidemiology, clinical intervention research, nutrition, food sensory evaluation, food services, and gerontological nursing. From 2008 to 2010, the MTF Research Group received financial support from Canadian provincial agencies and federal government agencies to fund preliminary research on MTF use in LTC settings. The critical objectives of the MTF Research Planning Workshop were to identify, interpret, and set priorities on key themes emerging from the MTF Research Group’s work to date and to bring together various stakeholders to build a collaborative research network that could move forward this area of research. For example, various collaborations with the Canadian Malnutrition Task Force (www.nutritioncareincanada.ca), another group interested in understanding the causes of malnutrition in the LTC setting, were suggested.

During the workshop, our team of researchers identified four major issues related to MTFs in which further research is needed: mealtime experience and food satisfaction; connection between dysphagia and malnutrition and the efficacy of food fortification; production and delivery of MTFs; and challenges associated with conducting MTF research in LTC settings. We generated recommendations for each of these four areas based on the elements of practicality, feasibility, scalability, capacity to conduct quality research, impact on government policy, and direct benefit to resident outcome. This article provides an overview of the four major issues of MTF use, outlines our recommendations for further research, and reviews some of the promising current endeavors in the field of MTF research, as discussed during the workshop. 

Mealtime Experience and Food Satisfaction

When modifying food texture, many solid foods are pureed or minced to make swallowing easier for patients; however, this food can become visually unappetizing (eg, gray matter in the shape of an ice cream scoop), which is a major concern, as it can negatively impact residents’ quality of life. Some studies have shown that patients may be embarrassed eating pureed foods in front of other people, resulting in social isolation.^8,18,19 For foods with low fluid content, liquids (ie, water, gravy) are added to help the food blend or puree, but this process may cause fluids to leak out and mix with other food products on the plate, making for an especially unappetizing meal.²⁰

Despite food satisfaction being crucial to the mealtime experience and in ensuring adequate nutrition, it is rare to find LTC facilities using validated questionnaires to determine residents’ satisfaction with MTFs. An ideal questionnaire would examine the domains of meal choice, food characteristics, feeding and mealtime experience, anxiety or worry with eating, global satisfaction, and swallowing or chewing difficulties, and would also consider residents’ cognitive well-being and the type of LTC environment they are in.²¹ In addition to the food provided, we identified several situational factors that affect residents’ mealtime experience, including social interaction, feeding dependency, and interactions with mealtime helpers or caregivers. These factors add complexity to the assessment of MTF in intervention studies. To gain a more comprehensive assessment of the impact of the entire mealtime experience on undernutrition, the MTF Research Group has several initiatives underway, including the Q-Meals LTC questionnaire, the Mealtime Social Interaction Measure for Long-Term Care, and the Eating Together project.

The Q-Meals LTC questionnaire, which is currently undergoing validity testing, has the potential for both clinical and research applications. This 33-item, interviewer-administered questionnaire takes about 15 to 20 minutes to complete and examines the mealtime experience, feeding assistance provided, and quality of food. It specifically asks about issues associated with MTF use. Residents require sufficient cognitive status to answer these questions. The Q-Meals LTC questionnaire shows promise for assessing aspects of mealtime satisfaction that are not currently covered in other available tools.

To examine the psychosocial aspects of the mealtime environment, the Mealtime Social Interaction Measure for Long-Term Care, a standardized instrument to measure the frequency and nature of social interactions during mealtimes in LTC facilities, was developed by a member of our group. This observation-based tool involves a research assistant observing a table to determine the types and extent of interaction among tablemates and staff during an entire meal.²² Scoring considers both the nature, frequency, and partners in social interaction. Primarily designed as a research tool to demonstrate if interventions influence mealtime social interaction, the Mealtime Social Interaction Measure for Long-Term Care can also provide LTC facilities with a means of gauging the social environment during mealtimes, enabling them to identify deficiencies and improve the mealtime experience for their residents. The tool has demonstrated good inter-rater reliability, especially for more experienced observers²²; a training and scoring manual ensures replicability.

The Eating Together project focuses specifically on the mealtime experiences of persons with dementia and those of their family members.²³ Initially, all participants resided in the community, but during the 6 years of the study, several persons with dementia moved into retirement homes and LTC facilities. The study investigators continued to evaluate the mealtime experiences of these individuals in their new settings. Using qualitative interviews with persons with dementia and their family caregivers, mealtime experiences were identified as being meaningful, serving as key points in the day for these families to connect socially, emotionally, and psychologically. To these families, meals were more than just food on the plate, demonstrating the importance of the meal to family life. The Life Nourishment Theory^24,25 was developed from this work and can be used to guide meal planning and food presentation in LTC settings. This theory emphasizes the need to consider the whole mealtime experience, while attempting to understand how to improve MTFs and the acceptance and consumption of these foods.

Future Research Recommendations for Mealtime Experience and Food Satisfaction 

To improve satisfaction with food and the overall mealtime experience, further work needs to be done to enhance the appearance and palatability of MTFs, while taking into account the physiological changes that occur with aging, such as decreased taste, hunger, and appetite. Limited research has demonstrated that the appearance and palatability of MTFs can be enhanced,¹¹ and commercially produced MTFs are now available that may be more pleasing to residents because they preserve flavor, enhance color and texture, and offer some improvement in nutritional quality. A benefit to using these products is that they overcome the lack of standardization found with MTFs produced in-house in LTC facilities, which is a problem we discuss later in this article.

Research also needs to be conducted to more closely examine the role of mealtime helpers, which may include facility staff, family members, and other caregivers. Training these helpers to provide assistance to both cognitively intact and cognitively impaired individuals in a manner that maintains residents’ dignity and a quality mealtime experience is imperative.¹⁰ Training methods need to be developed to enable mealtime helpers to achieve this objective, and the Life Nourishment Theory^24,25 can be included in this training. When producing training guidelines, differences in skill level between helpers, including registered and unregulated nursing staff, should be accounted for.

Additionally, validated assessment tools to measure residents’ satisfaction should be produced and implemented in LTC facilities. Use of an instrument, such as the Mealtime Social Interaction Measure for Long-Term Care, to evaluate the impact of adapting the LTC environment to promote social interaction with the intention of improving appetite and quality of life is recommended.

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. 

Conclusion

The MTF Research Planning Workshop sought to identify, interpret, and set priorities on key themes emerging from work conducted on MTFs in LTC facilities. We reached a consensus that a better understanding of the prevalence of malnutrition, particularly undernutrition, and the use of commercially and in-house prepared MTFs in LTC facilities is needed to provide segue into further research. Fortification of MTFs with supplemental vitamins and minerals is an additional area for consideration. Future studies should focus on interprofessional, multicenter collaborations that provide large enough sample sizes to demonstrate statistically and clinically significant changes, while remaining sensitive to LTCs being “home” environments for their residents. Laboratory research should be used whenever possible to answer some key MTF research questions in preparation for clinical research. Reliable and validated tools are required that are sensitive in identifying changes in outcome measures, such as satisfaction, weight gain or loss, and food intake, and that can be used in both cognitively intact and cognitively impaired populations. Additional factors, including the physiology of aging, dysphagia, overall mealtime experience, need for feeding assistance, standardization of MTF production and delivery, and cost of MTFs, must be considered when determining the feasibility, sustainability, and policy implications of using MTFs in LTC facilities. 

Acknowledgment

Funding for the Modified-Texture Food Research Planning Workshop was provided in part by the Canadian Institutes of Health Research Meeting, Planning and Dissemination Grant, and a grant from the Bruyère Research Institute.

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Disclosures: 

The authors report no relevant financial relationships.

Address correspondence to:

Helen Niezgoda, BScN, MSc

Bruyère Research Institute

43 Bruyère Street

Ottawa, Ontario, Canada K1N 5C8

hniezgoda@bruyere.org