Annals of Long Term Care

Key words: Dysphagia, feeding dependency, food satisfaction, fortification, malnutrition, mealtime experience, modified-texture foods, undernutrition. 

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.