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

Abstract

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.