Registered dietitian LIZ BEAGLEHOLE of Canterbury Dietitians says facilities need to plan ahead to ensure they get the texture of the food right for each resident, while also meeting their nutritional needs.
Texture-modified diets are required at almost every site I visit. Residents are given a texture-modified diet due to problems with chewing and/or swallowing, known clinically as dysphagia. Modifying the texture of the food is a practical way to make chewing easier and to allow a safer swallow. In some cases, liquids are thickened too. The aim is to allow residents to continue to meet their nutritional needs with an oral diet, while managing the risk of choking and developing aspiration pneumonia. A speech language therapist will determine the texture modification required. A dietitian can then assist in developing a menu of suitable foods to provide.
The New Zealand Speech-Language Therapists’ Association and Dietitians New Zealand have adopted and follow the Standards for Texture-modified Foods and Fluids developed by the Dietitians Australia Association and Speech Pathology Australia. The three modified textures are soft, minced/moist, and smooth puree and the thickened fluids range from mildly, moderately or extremely thick.
Foods that can be mashed gently with a fork are as regarded as soft. Many of the foods on the regular menu of an aged care facility would be regarded as ‘soft’. The food is well cooked; the meats should be tender and the vegetables soft. Usually meats are served with a gravy or sauce. Sometimes the soft terminology gets confused and a person who requires a soft diet is given a puree. It is important that all staff understand the correct terms to use, and what they mean in texture.
Being consistent with textures served to a resident is important too. If a resident requires a puree diet, this means suitable in-between options should be provided too. Scones, muffins and soft sandwiches are not suitable for residents requiring a minced/moist or puree diet.
To create a minced/moist or a smooth puree meal, a blender or food processor is needed. Often the regular option is able to be modified. However, there are foods on the menu that are not suitable for pureeing. In these circumstances a different option is needed. I recommend that sites plan these options on the menu. The risk of poor nutrition and unwanted weight loss is higher for residents who require a texture-modified diet.
The secondary meal i.e. lunch or tea, is often more difficult to cater for texture-modified diets. When all residents are having toasted sandwiches, or eggs on toast with bacon, what can we provide for puree diets? In many cases, the option provided for puree diets is scrambled eggs. Technically, scrambled eggs are not a puree texture as they are not smooth and lump-free. My other concern is that while most residents are provided with eggs, toast and bacon, the residents on puree are only provided with eggs. Nutritionally, their meal is not the same as everyone else. Using leftovers and pureeing these is also not providing a nutritionally equivalent option.
The best way to cater for puree diets is to plan these on the menu in advance. To assist with swallowing, texture-modified diets must also be served with sauce or gravy as this helps to moisten the meal; for example, pureeing savoury mince and serving with brown gravy, or pureeing macaroni cheese and serving with extra cheese sauce. To boost the nutritional intake, a puree pudding served with the lighter meal is also a good idea. A simple mousse, instant pudding or custard, perhaps with puree fruit, is sufficient.
Sometimes hot and cold drinks will need to be thickened using a food thickener. It is important to note that not all residents on a texture-modified diet require thickened fluids. Staff should be trained in the preparation of thickened fluids to ensure the right consistency is made. Often I observe fluids that are too thick being served. These are unpalatable and do not offer hydration. Mildly thick fluids will still drip off the spoon and can be sucked up a thick straw. Moderately thick fluids will ‘blob’ off a spoon, but will still be pourable. Thicker textures than this are usually not used by speech language therapists. Check the thickness of the fluids at your site and compare these with the recommended standards.
In-between meal snacks
The in-between snacks need to be planned too. When the residents are served a scone for morning tea, what are the residents on a soft, minced or puree diet offered? When sandwiches and slices are served for supper, do the residents on puree get an alternative? Try serving milkshakes, smoothies, puree fruit and cream, dairy foods or smooth yoghurts between meals. Jelly and ice cream may not be appropriate if the resident requires thickened fluids, as these foods melt in the mouth.
One of the biggest challenges with providing texture-modified meals is how to present them well. Thankfully, gone are the days where all the food was blended together! Using different colours on the plate is important. Sometimes serving the puree meal in a small dish may improve the look. Layering colours in a clear dish looks good too. Some sites are working with food moulds that shape the puree into the whole food. For example, pureed carrots can be shaped to look like a serving of baby carrots. These look good, but require some changes in the kitchen production process.
Providing quality texture-modified diets requires time, planning, equipment and money. But without this, residents requiring a texture-modified diet are at a real risk of malnutrition caused by inadequate food intake.
Talk to your local dietitian to help you plan texture-modified diets on your menu.
Resources are available on the New Zealand Speech-Language Therapists’ Association website. Choice Catering Equipment also have coloured posters on texture-modified diets available. Contact Steve Preston at firstname.lastname@example.org to order a poster.