Modified Texture Diet and Long Term Care: A Secondary Data Analysis of Making the Most of Mealtimes (M3) Project

Background: Research has suggested that modified texture diets (MTDs) are prevalent among older adults living in long term care (LTC). Additionally, previous research has also suggested that modified texture food, especially pureed food, contains fewer calories and offers less nutritional quality compared to unmodified food; plus these diets are associated with a high prevalence of under-nutrition and weight loss among older adults in LTC. Residents who require pureed food are often highly vulnerable, with eating challenges and cognitive impairment, requiring total eating assistance. To date, it has been challenging to disentangle these inter-related factors to understand how to improve food intake for those requiring food texture modifications. Purposes: 1) To examine the current prevalence of prescribed MTDs in Canadian LTC homes when applying standardized terminology and the resident characteristics that are associated with the prescription of a MTD. 2) To determine if the pureed diet provided as planned for one week is different in energy, macronutrients, micronutrients, and fibre as compared to the regular texture diet; and examine what home characteristics may be associated with these differences. 3) To examine the current dietary intake of residents in LTC homes consuming a pureed diet, compare this to the Dietary Reference Intake, and assess covariates that are associated with this intake. 4) To examine if prescription of a MTD as compared to a regular texture diet is independently associated with the risk of malnutrition in residents of LTC homes when diverse relevant covariates are considered. Methods and Findings: This thesis work is a secondary data analysis of the M3 project, a cross-sectional multi-site study across Canada, which collected data at the provincial, home, unit, staff, and resident levels from 639 residents across 32 LTC homes in four provinces (AB, MB, NB, ON). Four studies were part of this thesis work, and each method in more detail and respective findings are described below. 1) The use of MTDs and resident characteristics were identified from health records and standardized procedures. Homes used a variety of terms to describe MTDs. Diets were re-categorized using the International Dysphagia Diet Standardization Initiative (IDDSI) Framework: regular, soft, minced and moist, pureed, and liquidized. Modified texture (i.e., pureed, minced and moist, and soft and bite-sized) diets were prescribed to about 47% (n= 298) of residents in the M3 sample (n= 639) and prevalence was significantly different across provinces. Many resident characteristics that were found to be associated with the prescription of a MTD included: longer length of admission, risk of dysphagia, dementia diagnosis, lower number of oral agents (e.g., vitamin/mineral supplementation and drugs), decreased number of vitamins/minerals, prescription of oral nutritional supplementation, lower body weight, higher weight loss, lower body mass index, decreased calf circumference, higher risk of malnutrition, requirement of physical assistance, more eating challenges, poor oral health status, more cognitive impairment, and more impairment in the activities of daily living. 2) A nutrient analysis of pureed (n= 32) and regular (n= 32) menus for the first week of the menu cycle was completed using Food Processor software for all 32 LTC homes. Findings suggest there were significant province and diet texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed, with New Brunswick and Alberta having lower nutrient content for both menus as compared to Ontario and Manitoba. Within each province, similar trends were observed; some homes had significantly lower nutrient content for pureed diets, while others did not. Fibre and nine micronutrients were below DRI recommendations for both menus across the provinces, with variation existing across the sites within each province where some had more or less nutrients meet the specific DRI recommendations. Many home characteristics were found to be associated with a higher energy and protein provision from the regular and/or pureed texture menus, they included: for-profit status; larger homes; three, four, or five week menu cycles; a menu revision every 6−12 months; higher funding for raw food; and higher proportion of commercial food product use. 3) A three-day dietary intake was collected using weighed methods for main dishes and a standardized estimating protocol for side dishes and fluids; intake was analyzed using Food Processor software and only residents consuming a pureed diet (n= 67) were included. When protein, carbohydrate, and micronutrient intakes were compared to the appropriate DRI for females (n= 51) over the age of 70 years, this study found that the prevalence of inadequate intake for the sample widely ranged depending on the specific nutrient, although only six nutrients (vitamin B6, vitamin D, vitamin E, folate, calcium and magnesium) had potential inadequacy for 50% or more of the sample. Additionally, this study found that when adjusted for age and gender, only average number of staff assisting with a meal was independently associated with energy and protein intake for individuals consuming a pureed diet (n= 66). Specifically, as the number of staff increased during mealtimes the amount of energy and protein intake per kilogram of body weight decreased. 4) The MNA-SF score, use of MTDs, and resident characteristics were identified from health records and standardized procedures. This study found that prescribed diet texture, more specifically a pureed diet, was independently associated with risk of or malnutrition among residents living in LTC facilities (n= 364). Other independent covariates were being on oral nutritional supplementation, more cognitive impairment, more eating challenges (e.g., spitting food out of mouth), and a poor oral health rating, after adjusting for age and gender. Overall Conclusion: In conclusion, the prevalence of prescribed MTDs was high and significantly different across provinces in Canada, with a number of resident characteristics associated with a prescribed MTD. There was variability in menu planning across provinces and LTC homes in the M3 sample, plus pureed menus tended to offer a lower amount for many nutrients as compared to the regular menu with some exceptions (e.g., vitamin D and calcium). Among residents consuming a pureed diet, inadequate nutrient intake existed for several nutrients, and specifically of concern were vitamin B6, vitamin D, vitamin E, vitamin K, folate, calcium, magnesium, potassium, and fibre. The number of staff assisting at mealtimes was the only variable independently associated with food intake in this group. Lastly, prescribed diet texture, more specifically a pureed diet, was independently associated with risk of or malnutrition among residents living in LTC facilities. This secondary data analysis of the M3 Project offers a more in-depth and comprehensive contribution to the limited research around older adults and helps to address many of the confounding factors of prior work. Interventions can be targeted to key gaps in care identified in this work

Mixed methods developmental evaluation of the CHOICE program: a relationship-centred mealtime intervention for long-term care

Abstract Background Mealtimes are important to quality of life for residents in long-term care (LTC). CHOICE (which stands for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities, and Enjoyment) is a multi-component intervention to improve relationship-centred care (RCC) and overall mealtime experience for residents. The objective of this developmental evaluation was to determine: a) if the dining experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required. Methods A mixed methods study conducted between April–November 2016 included two home areas (64 residents; 25 care staff/home management) within a single LTC home in Ontario. Mealtime Scan (MTS), which measures mealtime experience at the level of the dining room, was used to evaluate the effectiveness of CHOICE implementation at four time points. Change in physical, social, RCC dining environment ratings and overall quality of the mealtime experience over time was determined with linear mixed-effects analyses (i.e., repeated measures). Semi-structured interviews (n = 9) were conducted with home staff to identify what components of the intervention worked well and what improvements could be made. Results Physical and overall mealtime environment ratings showed improvement over time in both areas; one home area also improved social ratings (p < 0.05). Interviews revealed in-depth insights into the program and implementation process: i) Knowing the context and culture to meet staff and resident needs; ii) Getting everyone on board, including management; iii) Keeping communication lines open throughout the process; iv) Sharing responsibility and accountability for mealtime goals and challenges; v) Empowering and supporting staff’s creative mealtime initiatives. Conclusions This developmental evaluation demonstrated the potential value of CHOICE. Findings suggest a need to: extend the time to tailor program components; empower home staff in change management; and provide increased coaching

Nutritional quality of regular and pureed menus in Canadian long term care homes: an analysis of the Making the Most of Mealtimes (M3) project

BACKGROUND: Long term care (LTC) menus need to contain sufficient nutrients for health and pureed menus may have lower nutritional quality than regular texture menus due to processes (e.g., recipe alterations) required to modify textures. The aims of this study were to: determine adequacy of planned menus when compared to the Dietary Reference Intake (DRI); compare the energy, macronutrients, micronutrients and fibre of pureed texture and regular texture menus across LTC homes to determine any texture, home or regional level differences; and identify home characteristics associated with energy and protein differences in pureed and regular menus. METHODS: Making the Most of Mealtimes (M3) is a cross-sectional multi-site study that collected data from 32 LTC homes in four Canadian provinces. This secondary analysis focused on nutrient analysis of pureed and regular texture menus for the first week of the menu cycle. A site survey captured characteristics and services of each facility, and key aspects of menu planning and food production. Bivariate analyses were used to compare menus, within a home and among and within provinces, as well as to determine if home characteristics were associated with energy and protein provision for both menus. Each menu was qualitatively compared to the DRI standards for individuals 70+ years to determine nutritional quality. RESULTS: There were significant provincial and menu texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed (p &lt; 0.01). Alberta and New Brunswick had lower nutrient contents for both menu textures as compared to Manitoba and Ontario. Within each province some homes had significantly lower nutrient content for pureed menus (p &lt; 0.01), while others did not. Fibre and nine micronutrients were below DRI recommendations for both menu textures within all four provinces; variation in nutritional quality existed among homes within each province. Several home characteristics (e.g., for-profit status) were significantly associated with higher energy and protein content of menus (p &lt; 0.01). CONCLUSIONS: There was variability in nutritional quality of menus from LTC homes in the M3 sample. Pureed menus tended to contain lower amounts of nutrients than regular texture menus and both menus did not meet DRI recommendations for select nutrients. This study demonstrates the need for improved menu planning protocols to ensure planned diets meet nutrient requirements regardless of texture. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016