Making the Most of Mealtimes (M3) study

Prevalence and determinants of poor food intake of residents living in long-term care

Poor food intake leads to malnutrition in long-term care homes, yet, determinants of food consumption are not well understood. Lack of research on determinants related to poor food intake affects our ability to develop interventions that can maintain residents’ nutritional status. This study measured residents’ energy and protein intake, and examined associations between resident, dining room, staff factors, and food intake. This study was conducted in 32 long-term care homes from 4 provinces, with 20 residents per home. The average age of participants was 86.3 +/- 7.8 years, and 69% of participants were female. Researchers weighed food for 3 days and reviewed health records for diagnoses, medications, and diet prescriptions. Other variables included: nutritional risk, oral health and dysphagia risk, eating challenges, mealtime interactions with staff, physical features in dining environments, mealtime experience, staff experience, features of the home, and food service.

Key findings:

Median energy and protein intake were 1571.9 +/- 411.93 kcal and 58.4 +/- 18.02 g/day, respectively. Increasing age, number of eating challenges, diet type (pureed), and rarely requiring eating assistance were associated with lower energy and protein intake. Being male, well-nourished, often requiring eating assistance, and living on a dementia unit were associated with higher energy and protein intake. Energy intake was lower in homelike dining rooms and higher in dining rooms where team members provided person-centred care. Protein intake was higher with increased in-home dietitian presence. There was a significant interaction between pureed/liquidized diets and eating challenges for energy intake. This means that pureed food was associated with lower energy intake, but eating challenges overcame this low intake, as requiring partial or total eating assistance was the most common eating challenge recorded.

Clinical relevance:

This is the first known study to assess resident, unit, staff, and home variables with food intake. Results from this study document the frequency of key issues that may influence food intake for long- term care residents. Findings from this study show that interventions targeting pureed food, restorative dining, eating assistance, and person-centred care practices might increase food intake. Future research should develop and/or evaluate education programs for staff and family to support self-feeding and overcome eating challenges. Practice implications from this research include: utilizing oral health and dysphagia assessment in long-term care, allotting sufficient dietitian time for menu planning, incorporating resident assessment and treatment, improving quality of modified texture foods, and designing dining spaces that support person-centered care.

Citation: 

HH Keller, N Carrier, SE Slaughter, C Lengyel, CM Steele, L Duizer, J Morrison, S Brown, H Chaudhury, MN Yoon, AN Duncan, V Boscart, G Heckman, L Villalon. (2017). doi: 10.1016/j.jamda.2017.05.003

Prevalence of inadequate micronutrient intakes of Canadian long-term care residents

This study, conducted in 32 long-term care homes from 4 provinces, determined the prevalence of inadequate nutrient intake in long-term care. Weighed and estimated food and beverage intake were collected over 3 days for 632 long-term care residents, and nutrient intakes were compared to Dietary Reference Intakes.

Key findings:

Average participant age was 85.2 +/- 7.6 (male) and 87.4 +/- 7.8 (female), and 33% of participants consumed modified texture foods. At least 1 nutrient pill was taken by 78.2% of males and 76.1% of females. Participants on modified texture food diets had lower intake for most nutrients, yet, consumed some nutrients in larger amounts than regular texture consumers due to ingredient enhancement (e.g., calcium). Over 50% of participants consumed inadequate amounts of folate, vitamin B6, Ca, Mg, and Zn (males only), with more than 90% consuming amounts below the Estimated Average Requirement or Adequate Intake for vitamin D, E, K, and Mg (males only). Vitamin D supplements improved intake for 50-70% of participants. For nine out of twenty examined nutrients, a high number of long-term care residents consumed less than the Estimated Average Requirement or Adequate Intake. Strategies to increase nutrient intake in long-term care are needed.

Clinical relevance and future directions:

Most older adults are not consuming micronutrients at the recommended levels. Vitamin D supplementation improved intake in this sample, but other nutrient supplementation was inadequate. Researchers should explore whether nutrient-enhanced products appeal to long-term care residents and whether these products will increase nutrient intake sufficiently, reducing the number of residents with low intakes of key nutrients. Researchers should also investigate whether adequate nutrient consumption improves health conditions. This research will help create a comprehensive understanding of the problems surrounding inadequate nutrient intake for long-term care residents.

Citation: 

HH Keller, C Lengyel, N Carrier, SE Slaughter, J Morrison, AM Duncan, CM Steele, L Duizer, KS Brown, H Chaudhury, MN Yoon, V Boscart, G Heckman L Villalon. (2018). doi:10.1017/S0007114518000107

Prevalence of malnutrition or risk in residents in long-term care: Comparison of four tools

This study compares prevalence and association with resident risk factors when malnutrition was identified by four different tools. As there was no gold standard for comparison, the four tools were compared to determine which would have the best sensitivity and specificity when any of the tools were used as the criterion. 638 residents from 32 Canadian long-term care homes participated in this study. The following 4 tools were used:

• Mini-Nutritional Assessment-Short Form

• Patient-Generated Subjective Global Assessment Global Category Rating

• Pt-Global webtool

• InterRAI Long Term Care Facility undernutrition trigger

Key findings:

Malnutrition prevalence was highest with the Mini-Nutritional Assessment-Short Form (53.7%). Prevalence was least common with InterRAI (28.9%). The Patient-Generated Subjective Global Assessment Global Category Rating (44%) was higher than the Pt-Global webtool (33.4%). Despite some exceptions, tools were constantly associated with resident factors (i.e., age, gender, number of medications, and dementia diagnosis). The Patient-Generated Subjective Global Assessment Global Category Rating showed the best sensitivity and specificity when compared to all other tools.

Clinical relevance:

Prevalence of malnutrition in long-term care varies depending on the tools used. Specifically, the Mini-Nutritional Assessment-Short Form as a risk screening tool found that >50% of residents were at risk for malnutrition or malnourished. Conversely, the InterRAI identified <30% of residents to be malnourished. Neither of these tools are comprehensive enough to provide a full picture of malnutrition in this setting. The Patient-Generated Subjective Global Assessment appears to be more useful for identifying malnutrition, as it includes more risk factors and symptoms, including a physical exam to determine body composition changes and a clinician’s judgement. Future research should investigate the predictive validity of the Patient-Generated Subjective Global Assessment Global Category Rating in long-term care residents, as it may be the preferred tool for this population.

Citation: 

HH Keller, V Vucea, SE Slaughter, H Jager-Wittenaar, C Lengyel, F Ottery, N Carrier. (2019). doi: 10.1080/21551197.2019.1640165

Inadequate fluid intake in long-term care residents: Prevalence and determinants

Half of long-term care residents experience dehydration, as many do not consume recommended levels of water and other fluids. This paper describes fluid intake for long-term care residents and explores factors associated with intake. 622 long-term care residents (average age: 86.8 +/- 7.8 years) participated in the study. Researchers estimated total fluid intake over 3 days and collected information on resident and unit-level variables (e.g., dementia status, activities of daily living, eating challenges).

Key findings:

• Fluid intake varied from 311-2390 mL (mean intake =1104.1 +/- 379.3) per day

• The majority of residents (85%) did not consume the minimum recommendation of 1500 mL of fluids per day

• Fluid intake was lower in those with increased age, cognitive impairment, eating challenges, and increased dining room staffing

• Fluid intake was higher in males and those requiring more physical assistance

• Modification of eating challenges and physical assistance (perhaps through staff training) should be the focus of future research interventions

Clinical relevance:

Unexpectedly, mobility and urinary incontinence were not associated with poor fluid intake. Key variables that predict intake may inform future strategies and targeted interventions to improve fluid intake in long-term care. Future research should involve longitudinal studies evaluating the relationships between these factors, fluid intake, and the occurrence of dehydration.

Citation: 

AM Namasivayam-MacDonald, SE Slaughter, J Morrison, CM Steele, N Carrier, C Lengyel, HH Keller. (2019). doi: 10.1016/j.gerinurse.2017.11.004

Making the Most of Mealtimes (M3): Effect of eating occasions and other covariates on energy and protein intake among Canadian older adult residents in long-term care

Food intake is variable among long-term care residents, and some residents are at risk for protein- energy malnutrition. This study sought to identify whether eating occasions and other factors (e.g., presence of family or volunteers) were associated with energy and protein intake for meals and snacks. 630 residents from 32 Canadian long-term care homes participated in the study. Residents had a median age of 88 years, and 31.3% of residents were male. Approximately 56% of residents had moderate to severe cognitive impairment.

Key findings:

• Energy and protein intake were significantly associated with eating occasions

• Residents consumed the most energy at breakfast and the evening snack, and the most protein at dinner (main meal for ~66% of residents) and the evening snack

• Higher intake at any eating occasion was linked to being male, living on a dementia care unit, and family/volunteer presence at meals (respectively: +79 kcal and +3.4 g protein, +39 kcal and +2.1 g protein, +58 kcal and +2.5 g protein)

• Intake was lowest in the oldest age group and for those occasionally needing eating assistance (respectively: -59 kcal and -3.6 g protein, -36 kcal and -2.0 g protein)

Clinical relevance:

Since energy and protein intake are associated with eating occasions, long-term care home staff can consider providing more protein- and nutrient-dense foods at times when residents eat best. This analysis suggests that breakfast and evening snacks are the best for food consumption, making these times good opportunities to improve energy and protein intake. Staff can offer meals and snacks high in protein and energy to support protein and energy intake, particularly for residents who are at risk of malnutrition. Staff can also encourage family members to visit and support food intake of their loved one. Greater staff training may be required to remind staff to provide more eating opportunities (i.e., snacks throughout the day to increase overall food intake), and eating assistance or encouragement during mealtimes.

Citation:

V Trinca, JM Morrison, SE Slaughter, HH Keller. (2020). doi: 10.1111/jhn.12686

Prevalence and characteristics associated with modified texture food use in long-term care: An analysis of Making the Most of Mealtimes (M3) Project

Researchers aimed to describe the prevalence of modified texture food consumers when applying standard diet terminology. This study was the first to use a diverse sample of long-term care residents to determine prevalence of modified texture food use and describe consumers. Researchers collected resident data from health records. The 32 long-term care homes from 4 different provinces in Canada used 67 different terms to describe modified texture food diets, so researchers recategorized diets using the International Dysphagia Diet Standardization Initiative Framework.

Key findings:

Modified texture diets were prescribed to 47% of participants (298 out of 639 participants). Prevalence was high and differed significantly among provinces (p<0.0001). Numerous resident factors, such as eating challenges or cognitive impairment, were associated with being prescribed a modified texture diet in long-term care. Factors that were significantly associated with modified texture food diets were: dysphagia and malnutrition risk, dementia diagnosis, prescription of oral nutritional supplements, lower body weight and calf circumference, greater need for physical assistance with eating, poor oral health status, and dependence in all activities of daily living.

Clinical relevance:

There is limited research on modified texture diet consumers in long-term care. The present study found that residents on modified texture food diets were more vulnerable than residents on regular texture diets. This information improves the current understanding of modified texture food consumers and establishes areas for improvement. Interventions that mitigate inadequate food intake for this group of residents is needed; this paper indicates key considerations while developing these interventions.

Citation: 

V Vucea, HH Keller, JM Morrison, LM Duizer, AM Duncan, CM Steele. (2019). doi: 10.3148/cjdpr-2018-045

Modified texture food use is associated with malnutrition in long-term care: An analysis of Making the Most of Mealtimes (M3) project

Modified texture food (particularly pureed) is linked to high prevalence of undernutrition and weight loss for people living in long-term care. This paper compared whether being prescribed modified texture diet or a regular texture diet, was associated with malnutrition risk for long-term care residents. 337 residents on a regular diet, 139 residents on a minced diet, and 68 residents on a pureed diet participated in this study. The Mini-Nutritional Assessment-Short Form was used to determine malnutrition risk. Analyses were conducted to adjust for other factors known to be associated with modified texture use, such as eating challenges and presence of dementia, to determine if the prescription of a modified texture diet itself is associated with malnutrition.

Key findings:

• Prescription of minced food was associated with malnutrition risk among long-term care residents

• Prescription of pureed food was also associated with malnutrition risk among long-term care residents

• Other significant factors associated with malnutrition risk were use of oral nutritional supplements, eating challenges (e.g., spitting out food), poor oral health, and cognitive impairment

Clinical relevance:

Prior research did not attempt to determine the independent effect of being prescribed a modified texture diet on malnutrition risk. By considering other factors, often seen with use of modified textures (e.g., dysphagia, dementia, eating assistance) and adjusting for these factors, a better understanding of the diet itself and risk were determined. Prescription of minced or pureed textures is associated with malnutrition. This suggests that the diets themselves may be promoting malnutrition. Future research should explore nutrient density and sensory appeal of modified texture foods to mitigate malnutrition. Improved quality of modified texture foods should be coupled with other interventions that can promote food intake such as good oral health, restorative dining quality eating assistance, and mealtime experience.

Citation: 

V Vucea, HH Keller, JM Morrison, LM Duizer, AM, Duncan, N Carrier, CO Lengyel, SE Slaughter, CM Steele. (2018). doi: 10.1007/s12603-018-1016-6