The journal of nutrition, health & aging

, Volume 22, Issue 8, pp 916–922 | Cite as

Modified Texture Food Use is Associated with Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

  • V. Vucea
  • Heather H. KellerEmail author
  • J. M. Morrison
  • L. M. Duizer
  • A. M. Duncan
  • N. Carrier
  • C. O. Lengyel
  • S. E. Slaughter
  • C. M. Steele



Modified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered.


Making the Most of Mealtimes (M3) is a cross-sectional multi-site study.


32 LTC homes in four Canadian provinces.


Regular (n= 337) and modified texture food consumers (minced n= 139; pureed n= 68).


Malnutrition risk was determined using the Mini Nutritional Assessment short-form (MNA-SF) score. The use of MTFs, and resident and site characteristics were identified from health records, observations, and standardized assessments. Hierarchical linear regression analyses, accounting for clustering, were performed to determine if the prescription of MTFs is associated with malnutrition risk while controlling for important covariates, such as eating assistance.


Prescription of minced food [F(1, 382)=5.01, p=0.03], as well as pureed food [F(1, 279)=4.95, p=0.03], were both significantly associated with malnutrition risk among residents. After adjusting for age and sex, other significant covariates were: use of oral nutritional supplements, eating challenges (e.g., spitting food out of mouth), poor oral health, and cognitive impairment.


Prescription of minced or pureed foods was significantly associated with the risk of malnutrition among residents living in LTC facilities while adjusting for other covariates. Further work needs to consider improving the nutrient density and sensory appeal of MTFs and target modifiable covariates.

Key words

Malnutrition long term care older adults modified texture food pureed texture Mini Nutritional Assessment 


  1. 1.
    Niezgoda H, Miville A, Chambers LW, Keller HH. Issues and challenges of modified-texture foods in long-term care: A workshop report. Ann Long-Term Care. 2012;20:22–7.Google Scholar
  2. 2.
    Allard JP, Aghdassi E, Mcarthur M, Mcgeer A, Simor A, Abdolell M, et al. Nutrition Risk Factors for Survival in the Elderly Living in Canadian Long-Term Care Facilities. J Am Geriatr Soc. 2004;52(1):59–65.CrossRefPubMedGoogle Scholar
  3. 3.
    Furman EF. Undernutrition in older adults across the continuum of care: nutritional assessment, barriers, and interventions. J Gerontol Nurs. 2006;32(1):22–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Dyck MJ, Schumacher JR. Evidence-based practices for the prevention of weight loss in nursing home residents. J Gerontol Nurs. 2011;37(3):22-33-35.Google Scholar
  5. 5.
    Crogan NL, Pasvogel A. The influence of protein-calorie malnutrition on quality of life in nursing homes. J Gerontol Med Sci. 2003;58(2):159–64.CrossRefGoogle Scholar
  6. 6.
    Brownie S. Why are elderly individuals at risk of nutritional deficiency? Int J Nurs Pract. 2006;12:110–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Keller H, Carrier N, Duizer L, Lengyel C, Slaughter S, Steele C. Making the most of mealtimes (M3): grounding mealtime interventions with a conceptual model. J Am Med Dir Assoc. 2014;15(3):158–61.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Rice N, Normand C. The cost associated with disease-related malnutrition in Ireland. Public Health Nutrition. 2012. p. 1966–72.Google Scholar
  9. 9.
    Arvanitakis M, Beck A, Coppens P, De Man F, Elia M, Hebuterne X, et al. Nutrition in care homes and home care: How to implement adequate strategies (report of the Brussels Forum (22-23 November 2007)). Clinical Nutrition. 2008. p. 481–8.Google Scholar
  10. 10.
    Desai J, Winter A, Young KWH, Greenwood CE. Changes in type of foodservice and dining room environment preferentially benefit institutionalized seniors with low body mass indexes. J Am Diet Assoc. 2007 May;107(5):808–14.CrossRefPubMedGoogle Scholar
  11. 11.
    Wendland B. Malnutrition in Institutionalized Seniors: The Iatrogenic Component. J Am Geriatr Soc. 2003;51(1):85–90.CrossRefPubMedGoogle Scholar
  12. 12.
    Abbasi AA, Rudman D. Undernutrition in the nursing home: prevalence, consequences, causes and prevention. Nutr Rev. 1994;52(4):113–22.CrossRefPubMedGoogle Scholar
  13. 13.
    Keller HH, Carrier N, Slaughter SE, Lengyel C, Steele CM, Duizer L, et al. Prevalence and Determinants of Poor Food Intake of Residents Living in Long-Term Care. J Am Med Dir Assoc. 2017;18(11):941–7.CrossRefPubMedGoogle Scholar
  14. 14.
    Siebens H, Trupe E, Siebens A, Cook F, Anshen S, Hanauer R, et al. Correlates and consequences of eating dependency in institutionalized elderly. J Am Geriatr Soc. 1986;34(3):192–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Namasivayam AM, Steele CM. Malnutrition and Dysphagia in Long-Term Care: A Systematic Review. J Nutr Gerontol Geriatr. 2015;34(1):1–21.CrossRefPubMedGoogle Scholar
  16. 16.
    Foley NC, Martin RE, Salter KL, Teasell RW. A review of the relationship between dysphagia and malnutrition following stroke. J Rehabil Med. 2009;41:707–13.CrossRefPubMedGoogle Scholar
  17. 17.
    Verbrugghe M, Beeckman D, Van Hecke A, Vanderwee K, Van Herck K, Clays E, et al. Malnutrition and associated factors in nursing home residents: a cross-sectional, multi-centre study. Clin Nutr. 2013;32(3):438–43.CrossRefPubMedGoogle Scholar
  18. 18.
    Thomas DR, Ashmen W, Morley JE, Evans WJ. Nutritional Management in Long- Term Care: Development of a Clinical Guideline. Journals Gerontol Ser A Biol Sci Med Sci. 2000;55(12):M725–34.CrossRefGoogle Scholar
  19. 19.
    Tamura BK, Bell CL, Masaki KH, Amella EJ. Factors associated with weight loss, low BMI, and malnutrition among nursing home patients: a systematic review of the literature. J Am Med Dir Assoc. 2013;14(9):649–55.CrossRefPubMedGoogle Scholar
  20. 20.
    Sura L, Madhavan A, Carnaby G, Crary M a. Dysphagia in the elderly: Management and nutritional considerations. Clin Interv Aging. 2012;7:287–98.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Dahl WJ, Whiting SJ, Tyler RT. Protein content of pureed diets: Implications for planning. Can J Diet Pract Res. 2007;68(2):99–102.CrossRefPubMedGoogle Scholar
  22. 22.
    Beck AM, Hansen KS. Meals served in Danish nursing homes and to Mealson- Wheels clients may not offer nutritionally adequate choices. J Nutr Elder. 2010;29:100–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Durant M. A comparison of energy provision by diet order in a long-term care facility. Can J Aging. 2008;27(March):225–7.CrossRefPubMedGoogle Scholar
  24. 24.
    Lam IT, Keller HH, Duizer L, Stark K. Micronutrients on the Menu: Enhancing the Quality of Food in Long-term Care for Regular, Nontherapeutic Menus. Can J Diet Pract Res. 2015;76(2):1–7.CrossRefGoogle Scholar
  25. 25.
    Woods JL, Walker KZ, Iuliano-Burns S, Strauss BJ. Malnutrition on the menu: Nutritional status of institutionalised elderly Australians in low-level care. J Nutr Heal Aging. 2009;13(8):693–8.CrossRefGoogle Scholar
  26. 26.
    Vucea V, Keller HH, Morrison JM, Duncan AM, Duizer LM, Carrier N, et al. Nutritional quality of regular and pureed menus in Canadian long term care homes: an analysis of the Making the Most of Mealtimes (M3) project. BMC Nutr. 2017;3(80):11.Google Scholar
  27. 27.
    Hall G, Wendin K. Sensory design of foods for the elderly. Ann Nutr Metab. 2008;52(suppl 1):25–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Kendall K, Sinacori J, Tulunay-Ugur O. Challenges and Opportunities in the Management of Dysphagia. Otolaryngol - Head Neck Surg. 2010;143(2):P30–1.CrossRefGoogle Scholar
  29. 29.
    Vucea V, Keller HH, Morrison JM, Duizer LM, Duncan AM, Steele CM. Prevalence of Modified Texture Food Use in Canadian Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project Vanessa. Dysphagia (submitted Oct 2017). 2017Google Scholar
  30. 30.
    Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the “malnutrition universal screening tool” (’MUST’) for adults. Br J Nutr. 2004;92:799–808.CrossRefPubMedGoogle Scholar
  31. 31.
    Germain I, Dufresne T, Gray-Donald K. A Novel Dysphagia Diet Improves the Nutrient Intake of Institutionalized Elders. J Am Diet Assoc. 2006;106:1614–23.CrossRefPubMedGoogle Scholar
  32. 32.
    Keller H, Chambers L, Niezgoda H, Duizer L. Issues associated with the use of modified texture foods. J Nutr Health Aging. 2012;16(3):195–200.CrossRefPubMedGoogle Scholar
  33. 33.
    Carrier N, West GE, Ouellet D. Cognitively impaired residents’ risk of malnutrition is influenced by foodservice factors in long-term care. J Nutr Elder. 2006;25(3–4):73–87.PubMedGoogle Scholar
  34. 34.
    Nelson KJ, Coulston AM, Sucher KP, Tseng RY. Prevalence of malnutrition in the elderly admitted to long-term-care facilities. J Am Diet Assoc. 1993;93(4):459–61.CrossRefPubMedGoogle Scholar
  35. 35.
    Suominen M, Muurinen S, Routasalo P, Soini H, Suur-Uski I, Peiponen A, et al. Malnutrition and associated factors among aged residents in all nursing homes in Helsinki. Eur J Clin Nutr. 2005;59(4):578–83.CrossRefPubMedGoogle Scholar
  36. 36.
    Keller HH, Carrier N, Slaughter S, Lengyel C, Steele CM, Duizer L, et al. Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes. BMC Geriatr. 2017;17(1):15.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Guigoz Y, Vellas B, Garry PJ. Assessing the Nutritional Status of the Elderly: the Mini Nutritional Assessment as Part of the Geriatric Evaluation. Nutr Rev. 1996;54(January):S59–65.CrossRefPubMedGoogle Scholar
  38. 38.
    GuigozZ Y. The Mini Nutritional Assessment (MNA) review of the literature—What does it tell us? J Nutr Health Aging. 2006;10(6):466-485-487.Google Scholar
  39. 39.
    Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia. 2016;32(2):293–314.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Keller H, Hirdes JP. Using the Minimum Data Set to determine the prevalence of nutrition problems. Can J Diet Pract Res. 2000;61(4):165–71.PubMedGoogle Scholar
  41. 41.
    Namasivayam-MacDonald AM, Morrison JM, Steele CM, Keller H. How Swallow Pressures and Dysphagia Affect Malnutrition and Mealtime Outcomes in Long-Term Care. Dysphagia. 2017;1–12.Google Scholar
  42. 42.
    Statistics Canada. Canadian Health Measures Survey Cycle 1 2007 to 2009 Clinic Questionnaire [Internet]. Statistics Canada. 2009. Available from: http://www23. Scholar
  43. 43.
    Watson R, Deary IJ. Feeding difficulty in elderly patients with dementia: confirmatory factor analysis. Int J Nurs Stud. 1997;34(6):405–14.CrossRefPubMedGoogle Scholar
  44. 44.
    Vallén C, Hagell P, Westergren A. Validity and user-friendliness of the minimal eating observation and nutrition form - Version II (MEONF - II) for undernutrition risk screening. Food Nutr Res. 2011;55:1–7.CrossRefGoogle Scholar
  45. 45.
    Simmons S, Bertrand R. Enhancing the Quality of Nursing Home Dining Assistance: New Regulations and Practice Implications Creating Home in the Nursing Home II Symposium Sandra F. Simmons 1,2 PhD Rosanna M. Bertrand 3 PhD. 2013Google Scholar
  46. 46.
    Keller HH, Gibbs-Ward A, Randall-Simpson J, Bocock M-A, Dimou E. Meal rounds: an essential aspect of quality nutrition services in long-term care. J Am Med Dir Assoc. 2006;7(1):40–5.CrossRefPubMedGoogle Scholar
  47. 47.
    McGilton KS, Sidani S, Boscart VM, Guruge S, Brown M. The relationship between care providers’ relational behaviors and residents mood and behavior in long-term care settings. Aging Ment Health. 2012;16(4):507–15.CrossRefPubMedGoogle Scholar
  48. 48.
    Sloane PD, Ivey J, Helton M, Barrick AL, Cerna A. Nutritional Issues in Long-Term Care. Journal of the American Medical Directors Association. 2008. p. 476–85.Google Scholar
  49. 49.
    Keller HH, Carrier N, Slaughter SE, Lengyel C, Steele CM, Duizer L, et al. Prevalence of inadequate micronutrient intakes of Canadian long term care residents. Br J Nutr (submitted Sept 2017). 2017Google Scholar
  50. 50.
    Amunrud EA, Mitchell CO, Sun MM. Acceptability and Health Effects of Commercially Prepared Puree Foods in Nursing Home Residents. Journal of the American Dietetic Association. 1999. p. A119.Google Scholar
  51. 51.
    Cassens D, Johnson E, Keelan S. Enhancing taste, texture, appearance, and presentation of pureed food improved resident quality of life and weight status. Nutr Rev. 1996;54(1):S51–4.CrossRefPubMedGoogle Scholar
  52. 52.
    Stahlman L, Mertz Garcia J, Hakel M, Chambers IV E. Comparison ratings of pureed versus molded fruits: preliminary results. Dysphagia. 2000;15:2–5.CrossRefGoogle Scholar
  53. 53.
    Stahlman LB, Garcia JM, Chambers E, Smit AB, Hoag L, Chambers DH. Perceptual ratings for pureed and molded peaches for individuals with and without impaired swallowing. Dysphagia. 2001;16:254–62.CrossRefPubMedGoogle Scholar
  54. 54.
    Adolphe JL, Whiting SJ, Dahl WJ. Vitamin fortification of pureed foods for long-term care residents. Can J Diet Pract Res. 2009;70(3):143–50.CrossRefPubMedGoogle Scholar
  55. 55.
    Kennewell S, Kokkinakos M. Thick, cheap and easy: Fortifying texture-modified meals with infant cereal. Nutr Diet. 2007;64:112–5.CrossRefGoogle Scholar
  56. 56.
    Smoliner C, Norman K, Wagner K-H, Hartig W, Lochs H, Pirlich M. Malnutrition and depression in the institutionalised elderly. Br J Nutr. 2009;102(11):1663–7.CrossRefPubMedGoogle Scholar
  57. 57.
    Bourdel-Marchasson I. How to improve nutritional support in geriatric institutions. J Am Med Dir Assoc. Elsevier Ltd; 2010 Jan;11(1):13–20.Google Scholar
  58. 58.
    Whear R, Abbott R, Thompson-coon J, Bethel A, Rogers M, Bmedsci AH, et al. Effectiveness of Mealtime Interventions on Behavior Symptoms of People With Dementia Living in Care Homes: A Systematic Review. J Am Med Dir Assoc. 2014;15(3):185–93.CrossRefPubMedGoogle Scholar
  59. 59.
    Sloane PD, Ivey J, Helton M, Barrick AL, Cerna A. Nutritional issues in long-term care. J Am Med Dir Assoc. 2008;9(7):476–85.CrossRefPubMedGoogle Scholar
  60. 60.
    Lauque S, Arnaud-battandier ÃF, Gillette S, Plaze ÃJ, Andrieu S, Cantet C, et al. Improvement of Weight and Fat-Free Mass with Oral Nutritional Supplementation in Patients with Alzheimer’s Disease at Risk of Malnutrition: A Prospective Randomized Study. J Am Geriatr Soc. 2004;52:1702–7.CrossRefPubMedGoogle Scholar
  61. 61.
    Lauque S, Arnaud-Battandier F, Mansourian R, Guigoz Y, Paintin M, Nourhashemi F, et al. Protein-energy oral supplementation in malnourished nursing-home residents. A controlled trial. Age Ageing. 2000;29(1):51–6.CrossRefPubMedGoogle Scholar
  62. 62.
    Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM. Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake. Clin Nutr. 2010;29(2):160–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Budtz-Jørgensen E, Chung JP, Rapin CH. Nutrition and oral health. Bailliere’s Best Pract Res Clin Gastroenterol. 2001;15(6):885–96.CrossRefGoogle Scholar
  64. 64.
    Ontario Ministry of Health and Long-Term Care. Ontario Regulations 79/10: Long- Term Care Homes Act [Internet]. 2007. Available from: statute/07l08Google Scholar
  65. 65.
    Province of New Brunswick. New Brunswick Regulation 85-187: Nursing Homes Act [Internet]. 2014. Available from: Scholar
  66. 66.
    Province of Alberta. Nursing Homes Act [Internet]. 2017. Available from: http://www. Scholar
  67. 67.
    Province of Manitoba. Personal Care Homes Standards Regulation [Internet]. 2009. Available from: Scholar
  68. 68.
    Bunn DK, Abdelhamid A, Copley M, Cowap V, Dickinson A, Howe A, et al. Effectiveness of interventions to indirectly support food and drink intake in people with dementia: Eating and Drinking Well IN dementiA (EDWINA) systematic review. BMC Geriatr. 2016;16(1):89.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Abdelhamid A, Bunn D, Copley M, Cowap V, Dickinson A, Gray L, et al. Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis. BMC Geriatr. 2016;16:26.CrossRefPubMedPubMedCentralGoogle Scholar
  70. 70.
    Liu W, Cheon J, Thomas SA. Interventions on mealtime difficulties in older adults with dementia: A systematic review. Int J Nurs Stud. 2014;51(1):14–27.CrossRefPubMedGoogle Scholar
  71. 71.
    Vucea V, Keller HH, Ducak K. Interventions for Improving Mealtime Experiences in Long-Term Care. J Nutr Gerontol Geriatr. 2014;33(4):249–324.CrossRefPubMedGoogle Scholar
  72. 72.
    Lin L-C, Huang Y-J, Su S-G, Watson R, Tsai BW-J, Wu S-C. Using spaced retrieval and Montessori-based activities in improving eating ability for residents with dementia. Int J Geriatr Psychiatry. 2010;25(10):953–9.CrossRefPubMedGoogle Scholar
  73. 73.
    Lin L-C, Huang Y-J, Watson R, Wu S-C, Lee Y-C. Using a Montessori method to increase eating ability for institutionalised residents with dementia: a crossover design. J Clin Nurs. 2011;20(21–22):3092–101.CrossRefPubMedGoogle Scholar
  74. 74.
    Liu W, Cheon J, Thomas S a. Interventions on mealtime difficulties in older adults with dementia: A systematic review. Int J Nurs Stud. 2014;51(1):14–27.CrossRefPubMedGoogle Scholar
  75. 75.
    Philip KE, Greenwood CE. Nutrient contribution of infant cereals used as fluid thickening agents in diets fed to the elderly. Journal of the American Dietetic Association. 2000. p. 549–54.Google Scholar
  76. 76.
    Odlund Olina, Armyr I, Soop M, Jerstrom S, Classon I, Cederholm T, et al. Energydense meals improve energy intake in elderly residents in a nursing home. Clin Nutr. 2003;22:125–31.CrossRefGoogle Scholar
  77. 77.
    Ilhamto N, Keller HH, Duizer LM. The Effect of Varying Ingredient Composition on the Sensory and Nutritional Properties of a Pureed Meat and Vegetable. J Nutr Gerontol Geriatr [Internet]. 2014;33:229–48. Available from: http://www.tandfonline. com/doi/abs/10.1080/21551197.2014.927307CrossRefPubMedGoogle Scholar
  78. 78.
    Hotaling DL. Nutritional considerations for the pureed diet texture in dysphagic elderly. Dysphagia. 1992;7:81–5.CrossRefPubMedGoogle Scholar

Copyright information

© Serdi and Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  • V. Vucea
    • 1
  • Heather H. Keller
    • 2
    Email author
  • J. M. Morrison
    • 1
  • L. M. Duizer
    • 3
  • A. M. Duncan
    • 4
  • N. Carrier
    • 5
  • C. O. Lengyel
    • 6
  • S. E. Slaughter
    • 7
  • C. M. Steele
    • 8
    • 9
  1. 1.Department of KinesiologyUniversity of WaterlooWaterlooCanada
  2. 2.Schlegel-University of Waterloo Research Institute for AgingWaterlooCanada
  3. 3.Department of Food ScienceUniversity of GuelphGuelphCanada
  4. 4.Department of Human Health and Nutritional SciencesUniversity of GuelphGuelphCanada
  5. 5.École des sciences des aliments, de nutrition et d’études familiales, Faculté des sciences de la santé et des services communautairesUniversité de MonctonMonctonCanada
  6. 6.Department of Food and Human Nutritional SciencesUniversity of ManitobaWinnipegCanada
  7. 7.Faculty of NursingUniversity of AlbertaEdmontonCanada
  8. 8.Toronto Rehabilitation InstituteUniversity Health NetworkTorontoCanada
  9. 9.Rehabilitation Sciences Institute, Faculty of MedicineUniversity of TorontoTorontoCanada

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