A Survey of Modified-Texture Food and Beverage Practices in Long-Term Care Facilities in Florida

In US long-term care facilities (LTCFs), chewing and swallowing difficulties affect 35% of residents and are strongly associated with undernutrition.¹ Dysphagia-related problems include poor tongue control; reduced oral sensation or awareness; dry mouth; inflammation of the oral cavity; and delayed, absent, or uncontrolled swallowing as well as difficulties with the movement of food through the esophagus to the stomach. Dysphagia can lead to choking, aspiration, pneumonia, decreased food intake, dehydration, weight loss, and malnutrition.² Modified-texture foods, such as puréed foods, are used in the management of dysphagia to decrease risk of choking and aspiration.³ Modified-texture foods may also be recommended for LTC residents who lack dentition or have poor-fitting dentures. However, serving modified-texture foods is not without its challenges, as these foods have been shown to negatively impact health-related quality of life of those with dysphagia.⁴

To promote safe swallowing, food texture characteristics including viscosity, cohesiveness, adhesiveness, and food particle size are important. In 2002 in the United States, the National Dysphagic Diet Task Force developed the National Dysphagia Guidelines to standardize the terminology used to describe texture modification of foods intended for the management of dysphagia.⁵ The guidelines provide four recommended levels of diets: (1) dysphagia puréed (homogenous, very cohesive, pudding-like, requiring very little chewing ability); (2) dysphagia mechanically altered (cohesive, moist, semisolid foods, requiring some chewing); (3) dysphagia advanced (soft foods that require more chewing ability); and (4) regular (all foods allowed).⁵ However, the applicability of the National Dysphagia Guidelines has been challenged, given that the modified-texture diets prepared in acute and LTCFs have likely not undergone any texture testing,⁶ and standardized quality control methods suitable for the evaluation of modified-texture foods prepared in LTCFs have not been outlined. From a food service perspective, level 1 (dysphagia puréed) is the most difficult to prepare,⁷ and, from a consumer perspective, puréed foods may be the least acceptable of all diet textures.⁸ Therefore, it has been suggested that guidelines are needed for the preparation and classification of modified-texture foods.³ 

Research shows that LTC residents with swallowing problems are more likely to consume modified-texture foods, eat less than their counterparts without swallowing problems, and are more likely to be malnourished.⁹ As the in-house (from scratch) preparation of modified-texture food, specifically a puréed consistency, is challenging, the resulting meals may be less than acceptable. Quality control measures may be needed to ensure acceptable texture and taste. Research exploring the prevalence of in-house preparation vs the use of commercially prepared puréed foods in LTCFs is limited, and gathering this data is the first step to determining the need for quality control measures. 

The purpose of this study was to determine the current practices related to the preparation and purchase of modified-texture foods and thickened beverages in Florida’s LTCFs as an exploratory first step toward a potential quality improvement initiative, with the ultimate goal of improving food intakes, nutrition, and quality of life of at-risk residents.

Methods

A list of licensed LTCFs was obtained from the Agency for Health Care Administration of Florida website,¹⁰ which also provided the licensed bed capacity. In the spring of 2014, there were a total of 682 active and registered LTCFs in Florida. For ease of survey implementation, 171 homes were systematically sampled (every fourth on the list) following a random start. Ethics approval for the study was sought and deemed exempt by the Institutional Review Board 2 at the University of Florida.

The survey was carried out by a senior study coordinator and three trained undergraduate nutritional sciences/dietetic students. The students were provided a script and were required to observe the study coordinator making calls and role-playing prior to conducting the survey. Contact attempts were made up to three times per facility, requesting to speak to the supervisor or individual in charge of the menu/food preparation or an informed designate. Although a cold-call method was used, the survey administration was rescheduled to a convenient time at the request of the respondent. 

For the study, an existing questionnaire—originally developed to explore food and nutrition education, modified-texture food and supplement use, and menu planning in adult family care homes (AFCHs) in the United States^11,12—was revised to a 20-item questionnaire focusing on the use and purchase practices of modified-texture food and beverages. Due to the exploratory nature of this study, most questions were designed to collect yes/no responses; for example: “At your facility, are commercially prepared puréed foods purchased?” Other questions were designed to assess the frequency of practices within a facility; for example: “Are standardized recipes used to prepare the puréed foods?” for which respondents were given the response choices of “never,” “rarely,” “sometimes,” “often,” and “always.” All questions had categorical responses. No open-ended questions were posed; however, respondents’ comments were noted.

Results

Food service representatives of 97 facilities (57%) responded to the survey. Puréed foods were served in 96 homes (99%) to a mean (standard deviation) of 17 ± 11 residents on a given day, which represented, on average, 14% of total LTC residents (mean licensed beds = 122). Fourteen (14.6%) facilities reported purchasing commercial puréed foods, including vegetables (n = 9; 9.4%); fruits (n = 7; 7.3%); meats, poultry, and fish (n = 11; 11%); and bread, rice, and other grains (dry mixes; n = 7; 7.3%). At most LTCFs (n=83; 86.5%), puréed foods were “always” prepared from scratch, whereas 7.3% (n = 7) and 2.1% (n = 2) of LTCFs prepared puréed foods from scratch “sometimes” and “never,” respectively. In 73.9% (n = 70) of the facilities, standardized recipes were used to prepare puréed foods “always,” whereas 10.4% (n = 10) of facilities used standardized recipes “often” and 6.2% (n = 6) “sometimes”; respondents at 10 (10.4%) of the facilities did not answer this question. Eight-five percent of respondents (n = 82) reported serving ground- or minced-texture foods, with most of these facilities preparing these types of foods in-house (n = 80; 98%).

Respondents were asked: “In your opinion, which of the following is the most economical way to provide a puréed diet?” and were given three responses to choose from: (1) prepare puréed foods in-house; (2) purchase commercially made bulk frozen puréed foods; or (3) purchase commercially made individual portioned puréed foods. The majority (n = 82; 85.4%) indicated that puréed foods from scratch was most economical. Only four (4.2%) respondents chose the second or third options, with 11 (11.5%) providing no response to the question.

Three facilities (3.1%) reported purchasing molded (shaped to be similar in appearance to the regular-texture food) purées. In-house molding of puréed foods was carried out in 14 LTCFs (14.6%), with meats, vegetables, and breads being the foods commonly molded. In 57 (59.4%) of the facilities, low-sodium puréed foods were prepared (n = 56; 58.3%) or purchased (n = 3; 3.1%). 

Thickened beverages were served to one or more residents in most facilities (n = 82; 85.4%); however, the nonresponse rate for this question was 14.4%. Of those serving these beverages, 88% (n = 73) purchased commercial, prethickened beverages.

Nineteen respondents provided additional unsolicited comments, and these comments centered around three issues. The first issue was the expense, time, and difficulty required for molding purées, although some comments mentioned plans to begin molding puréed foods. The second issue was the challenge of achieving standardized thicknesses (viscosities) for thickened beverages. The third issue was low-sodium puréed foods; it was noted that the regular-texture foods used to make the purées were lower in sodium, so there was no need to specifically prepare low-sodium purées.

Discussion

There is limited research related to the prevalence of the use of modified-texture diets in LTCFs¹³ as well as to the quality and acceptability of these food and beverages.⁸ In our study of modified-texture food practices in Florida LTCFs, 99% of survey respondents reported serving puréed foods to residents. 

Findings of the current study indicate that, in the majority of LTCFs in Florida, puréed foods are prepared in-house, with only 15% of the facilities purchasing any commercial puréed foods. This finding is similar to a previous study we conducted to survey adult family care homes (AFCHs) in Florida¹¹ and in 26 other states¹² regarding the need for and use of modified-texture foods and thickened beverages. In the national study, 58% of AFCHs that reported having residents with chewing and swallowing problems served puréed foods, and, of these, 97% prepared homemade puréed foods, whereas only 9% purchased commercially prepared puréed foods.¹²

The preparation of puréed foods offers considerable food service challenges.¹⁴ For example, certain fruits and vegetables with high water content become runny with puréeing and, thus, require thickening to achieve a pudding-like consistency that resists water separation. Also, for some vegetables with seed coats (eg, corn) and pods (eg, snow peas), it may be difficult to achieve a smooth, homogeneous consistency with processing. Preparing smooth, meat-based purées with small, particle size is particularly challenging¹⁵ due to the structure and relative toughness of the muscle fibers. Starchy foods, such as potatoes, can result in a product with significant adhesiveness when puréed,¹⁶ which may result in a stickiness similar to foods contraindicated in dysphagia management.⁵

In some LTCFs, commercial puréed foods have been incorporated for the purpose of forgoing some of these challenges and to lessen the potential risks that inappropriately textured puréed foods may pose to residents with dysphagia.¹⁷ Of the few Florida LTCFs we surveyed that used commercial purées, a variety were purchased (fruits, vegetables, meats, and grains); however, specific reasons for the commercial puréed purchases were not sought. In a convenience sample of 25 LTCFs in Ontario, Canada, 48% used only in-house preparation of puréed foods, whereas 52% used a combination of in-house and occasional or regular inclusion of commercial puréed foods.¹⁷ Nutrition managers in this study indicated commercial puréed foods were purchased for safety reasons; ie, choking prevention due to issues with limited staff skills for in-house puréed preparation.¹⁷ Commonly purchased puréed foods included: vegetables (eg, corn, peas, and beans) that were difficult to achieve a smooth texture and needed thickeners; some fruits, particularly those that were “watery” on preparation; puréed starches, such as pasta and rice as these become “gluey” with puréeing; and meats, purchased as a base flavor to match the regular menu.¹⁷

A positive finding of this study was that almost three-quarters of LTCFs used standardized recipes to prepare puréed foods. In a study by Ilhamto and colleagues,¹⁴ nutrition managers and cooks from 25 LTCFs, of which 22 had only in-house preparation of puréed foods, were interviewed, and major issues with nonstandard puréed food production were reported.¹⁴ The National Dysphagic Diet Task Force describes the ideal puréed texture as “homogenous, very cohesive, [and] pudding-like;”⁵ yet, while most of the nutrition managers and cooks described an ideal purée as a pudding-like consistency, some described an inappropriate texture target (eg, baby food).¹⁴ No objective measures were used to determine the consistency/texture of the puréed foods, instead tasting, the sound of the blender, and “eyeballing” were used as signs that the processing of the puréed food was adequate.¹⁴

The textural characteristics of puréed foods prepared in-house in LTCFs is important to the health and safety of LTC residents with dysphagia. Given that larger food particles can pose a choking risk,¹⁸ and food residue can remain in the pharynx after swallowing,³ certain puréed foods that are underprocessed or too sticky may pose risk. Additionally, if the puréed foods being served are not acceptable in terms of flavor and texture, residents are also at risk of poor food intake, malnutrition, and associated complications.² Finally, even when standardized recipes are used for production, food quality and nutritional content of the final puréed food products may not be known. It has been previously reported that even where there are regulations that the puréed diet must closely match the regular diet, in-house puréed foods may still not provide adequate protein.¹⁹ 

Education on the importance of achieving an appropriate purée consistency and on techniques for optimizing puréed food preparation has been shown to be effective in the community.²⁰ Education of food service and care staff as well as managers of LTCFs may be needed to communicate the goal texture for puréed foods and its importance to the health and welfare of residents with chewing and swallowing problems. Further research is needed to determine if standardized recipes for puréed foods pose challenges to cooks in US LTCFs. Research is also needed to determine if any quality control methods to ensure appropriate textural characteristics for safe swallowing are employed in LTCFs. Sensory studies, evaluating the acceptability of in-house vs commercially prepared puréed food and beverages, may be needed to inform food service decision-making.

A limitation of this study is that, though we asked for respondents’ opinions on the most economical modified-texture food preparation practices, we did not directly determine the cost effectiveness of preparing modified-texture food and beverages in-house vs purchasing commercially available products. The majority of respondents stated that preparing puréed foods from scratch was most economical. Only a single study has shown that nursing staff preparation of thickened beverages in acute care is much more costly than purchasing prethickened commercial products; however, the cost of food service production was not examined.²¹ Further research is needed to determine the cost differential between commercially prepared puréed foods prepared in-house, including labor, food, and equipment costs, as well as taking into consideration such factors as nutrient content and availability.

In this study, purchasing of molded puréed foods was reported as uncommon, as was in-house molding. Also, a few respondents commented on molding of puréed foods, such as failed attempts at molding and concerns about the expense. A recent study compared the acceptability of scooped (using an institutional scoop to plate) vs molded puréed vegetables and meat in young and older adults, and no preference for molded purées was found.²² Indeed, the sensory panelists in both age groups preferred the puréed foods presented simply from an institutional scoop.²² In a small study by Stahlman and colleagues, similar results were found.²³ If molded puréed foods are not more acceptable than standard plating practices, that may suggest that the low rate of purchasing or preparing molded purées found in this study is appropriate. Further research is needed to examine the preferences of LTC residents with dysphagia. 

More than 85% of surveyed LTCFs reported serving thickened beverages to one or more residents, with the vast majority purchasing commercial, prethickened beverages. The results of the present study indicate that in Florida LTCFs, it is much more common to purchase commercial prethickened beverages than to prepare in-house. Difficulties in achieving appropriate “thickness” of in-house products were noted. This finding is not surprising given that thickening beverages with various commercial thickeners, even when the manufacturer’s product instructions are followed, do not necessarily result in recommended viscosities.^24,25 However, commercial pre-thickened beverages also have been shown to exhibit significant variability in viscosity.²⁶ The relevance of this variability is unclear, however, given that there is inadequate evidence to support specific viscosity limits that relate to clinical outcomes in individuals with dysphagia.³

Conclusion

This study reports that in-house production of puréed foods is commonplace in LTCFs in Florida, whereas thickened beverages are often outsourced. The findings of this study have practical implications for LTCFs and suggest a need for further research. Given the inherent risks of inappropriate food texture for residents with dysphagia,³ the textural qualities and acceptability of puréed foods and thickened beverages, and the extent of quality control measures used for the preparation of in-house puréed foods, should be further investigated. Additionally, staff education may be needed to incorporate safe food and beverage modification practices in LTCFs.

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