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THE NUTRITIONAL IMPACT OF FLUID THICKENERS ON THE DYSPHAGIC ELDERLY
Kathleen E. A. Philip
A thesis submitted in conformity with the requirements for the degree of Master of Science Graduate Department of Nutritional Sciences University of Toronto
O Copyright by Kathleen E. A. Philip 1997 395 Wellington Street 395. rue Wellington Ottawa ON KIA ON4 Ottawa ON KIA ON4 Canada Canada Your file Votre relérence
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The author retains ownership of the L'auteur conserve la propriété du copyright in this thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts fkom it Ni la thèse ni des extraits substantiels may be printed or otherwise de celle-ci ne doivent être imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. Master of Science, 1997 Kathleen E. A. Philip Graduate Department of Nutritional Sciences University of Toronto
ABSTRACT
This study examined pablum's significance in contributing to overall
nutrient delivery and intake in the institutionalized dysphagic elderly. Fluid thickeners, including pablum, are used to increase fiuid intake. It was
hypothesized that the kilocalorie displacement from the diet by an unfortified thickener would lead to nutrient inadequacy, whereas pablum would replace displaced nutrients, thus preventing nutrient inadequacy. Seven days of food
delivery in 23 patients requiring regular fluids were used to assess the impact of
both pablum and unfortified fluid thickeners. Substitution of unfortified thickener with pablum would prevent predicted inadequacies Save fotate. While fluid
delivery was diminished in patients requiring thickened fluids, fluid and nutrient
recommendations were satisfied. Seven days of food intake in 22 patients
requiring thickened fluids revealed nutrient adequacy but folate and fluid
inadequacies. Recommendations include greater use of foods containing higher folate and water contents to increase folate and fiuid intakes instead of thickened
beverages. This thesis is dedicated to my father Joseph Abraham, who believed in me and lovingly supported me throughout this project. His encouragement to always pursue the best was the main motivation in the undertaking and completion of this Master of Science degree.
iii I am very thankful to have had the opportunity to work with Dr. Carol Greenwood and for her willingness to take me on as a graduate student. Without her advice, time and cornmitment to see this project to completion, this research would not have been possible. I would also like to express my gratitude to advisory cornmittee members Dr. Vaterie Tarasuk, for her constructive advice and insight throughout this project, and Dr. Tom Wolever, for generously allowing me to use his cornputer programs. A special thanks to Debbie Fletcher, Carol Robertson, Jaan Homits, dietitians, kitchen staff and Nutrition and Food Services administrative staff at the Baycrest Centre for Geriatric Care for darifying and making available the information which formed the basis of this research. Many thanks to all the office staff, especially Brenda Rak and Marg Hardy, for their assistance.
I am most grateful to my husband Joe who, from beginning to end, provided me with the support, motivation, and assistance I needed, especially during the most difficult times. I sincerely thank my family and Joe's farnily for their continued support throughout this project.
I also thank God for giving me the strength and perseverance as well as the wisdom and knowledge to complete this project. I believe that with God al1 things are possible and this graduate degree is a testament of that belief.
Personal financial support from Dr. Carol Greenwood and the University of Toronto in the forrn of the Life Sciences award is gratefully acknowledged. TABLE OF CONTENTS
1. Introduction
1.1 Introduction
2. Literature Review
2.1 Literature Review: Organization
2.2 Prevalence of Malnutrition in 'Healthy' lnstitutionalized lndividuals
2.2.1 Causes of Energy Malnutrition
2.2.1.1 Age-Related Causes of Malnutrition
2.2.1.2 Disease-Related Causes of Malnutrition
2.2.1.3 Social-Psychological-Ewnomic Causes of Malnutrition
2.2.2 The Consequences of Malnutrition
2.2.3 Summary of Malnutrition
2.3 Dysphagia
2.3.1 The Swallowing Process
2.3.2 Causes of Dysphagia
2.3.3 Types of Dysphagia
2.4 Prevalence and Therapeutic Approaches to Dysphagia in the lnstitutionalized Elderly
2.4.1 Prevalence 2.4.2 Physical Aspects of Dysphagia in the lnstitutionalized Elderly
2.4.3 Approaches to Dealing with Dysphagia
2.4.3.7 Pureed Foods
2.4.3.2 Thickened Fluids
2.5. Choice of Fluid Thickening Agents
2.5.1 Unfortified Fluid Thickening Agents
2.5.2 Fortified Fluid Thickening Agents
2.6 Various Techniques of Data Analysis
2.6.1 Requirements and the RN1
2.6.2 Data Analysis: Prescriptive versus Diagnostic
2.6.3 Prescriptive Mode of Data Analysis
2.6.4 Diagnostic Mode of Data Analysis
3. Hypothesis and Objectives
4. Methods
4.1 Research Methodology
4.1.1 Subjects
4.1 -2 Data Collection from RF Patients
4.1.3 Data Collection from TF Patients
4.1.4 Recommendations 4.2 Food Delivery and Practices
Nutrient Delivery to RF Clients on Regular Fluids and the Theoretical Impact of Fluid Thickening
Su bject C haracteristics
Nutrient Delivery to TF Clients on Thickened Fluids
Subject Characteristics
Measurement of Food and Nutrient Delivery
Nutrient Composition of Individual Recipes
Measurement of Daily Nutrient Delivery
Power Analysis for Days of Data Collection
Data Analysis - Prevalence of Nutrient lnadequacy
4.3 Actual lntake
4.3.1 Actual Nutrient lntakes in TF Clients on the Thickened Fluid and Pureed Food Diet
4.3.2 Su bject Characteristics
4.3.3 Food and Nutrient lntake
4.3.4 Power Analysis for Days of Data Collection
4.3.5 Data Analysis - Prevalence of Nutrient lnadequacy and Assessrnent of Energy lnta kes
vii 4.4 Prognostic Recommendations
4.4.1 Recommendations for the Future
5. Results and Discussion
5.1 Food Delivery and Practices
5.1.1 Nutrient Delivery to Clients on Regular Fluids and the Theoretical Impact of Fluid Thickening
5.1.2 Nutrient Delivery to Clients on Thickened Fluids
5.1.3 Discussion of Results of the Food Delivery and Practices
5.2 Actual fntake
5.2.1 Actual Nutrient lntakes in Clients on the Thickened Fluid and Pureed Food Diet
5.2.2 Discussion of the Actual lntake Data
5.3 Prognostic Recommendations
5.3.1 Prescriptive Data Analysis
5.3.2 Discussion of Prescriptive Data Analysis
6 General Discussion
6.1 Discussion
viii 6.2 Food Delivery and Practices
6.3 Actual lntakes
6.3.1 Implications of Actual Intake Data
6.3.1.1 Energy lntake
6.3.1.2 Fluid lntake
6.3.1.3 Folate lniake
6.3.1.4 Thiamin, Riboflavin and Niacin
6.3.1.5 Excess Cholesterol
6.4 Prognostic Recommendations
6.4.1 Prescriptive Data Analysis
6.4.2 Recommendations
6.4.2.1 Nutrient Recommendations
6.4.2.2 Fluid Recommendations
6.4.2.3 Energy Recommendations
6.5 Summary and Conclusions
6.5.1 Summary
6.5.2 Conclusions
7 References
8 Appendix A LIST OF FIGURES AND TABLES
FIGURES:
2.1 A) Establishment of the recomrnended nutrient intake (RNI) of a nutrient and 6)the concept of risk of inadequacy applied to recommended nutrient intake (RNI)
2.2 Application of the probability approach, using intervals of nutrient intake, to nutrient intakes of a population in the assessrnent of population groups
4.1 Flow chart illustrating the research methodology conducted in the study
TABLES:
Recommended Nutrient lntakes (RNI) and Requirement Estimates for men and wornen aged 75+ years
Average age and BMI of the RF patients on pureed foods and regular fluids
Average age and BMI of the TF clients on pureed foods and thickened fluids
Mean energy, fluid and nutrient deliverv to RF clients (n=23) consuming the normal pureed food and regular fluid diet as compared to the RN1
Projected mean energy, fluici and nutrient deliverv to RF patients (n=23) assuming al1 fluids are thickened with an unfortified fluid thickener or fortified fluid thickener as compared to the RN1
Nutritive values of rice flakes (pablum) per 100 gram
Mean energy, fluid and nutrient deiivew to TF patients (n=22) as corn~aredto the RN! - - r-.-.-- ---,. . --, consurning normal pureed food and fluids thickened with pablum as compared to the RN1
Mean energy intake and basal metabolic rates of TF patients (n=22) consuming the pureed food and pablum thickened fluid diet
Relationships amongst nutrient and energy intakes of TF clients (n=22)
The average caloric intake for TF subjects required to meet the RNI for a given nutrient based on the relationship between nutrient and energy consumption of the diet fortified with pablum
Nutrient density of the diet delivered to TF clients (n=22) as compared to the RN1
5.10 The nutrient densities (necessary group intakes) required to meet/surpass the persona1 requirements of the female TF clients (n=20) as compared to the actual intakes observed Chapter One
INTRODUCTION I . I IIY I nuuuu I IUIY
The senior population of North America is growing at the highest rate ever seen in history, due in part to the longer life spans provided by better health care. As a result, health care providers are faced with caring for more elderly and frail individuals. Many have survived to the age that severe impairment, associated with neurodegenerative disorders, has developed. Amongst the needs required by these seniors is the assurance of safe and adequate food and nutrient intakes.
Several reports indicate suboptimal food intake in the elderly, whether they are living independently or in an institution (Abbasi and Rudman, 1994; Keller, 1993;
Ryan et al, 1992; Payette et al, 1995). The institutionalized are problematic since disease status, along with an increase in fragility, impacts on several aspects of food intake. The concern for the institutionalized increases as the disease process impairs the ability to eat and swallow, especially since the development of a swallowing disability is superimposeci on either the normal or disease processes that are associated with aging.
The source of suboptimal food intake, which can lead to undemutrition, is not a simple problem (Payette et al., 1995). For example, food accessibifity is not an obstacle in a home for the aged as it may be for the free living. On the other hand, a number of conditions (monotony and restrictiveness of diet, loss of control over food selection, inappropriateness of food timing and temperature, inadequateness of staff for those who are unable to feed thernselves) are common in nursing homes
(Florencio, 1987; Welch et al., 1986; Eaton et al., 1986) and may possibly be affiliated with an unbalanced or reduced level of food intake (Frisoni et al., 1995). I I ~r:~ZÏS~U~: UI UIIU~I I tu11 ILIUI I uewrries increasingiy more cornpiex wnen rne ropic OT swallowing disorders is introduced. Furthemore, reductions in fluid intake are often observed in tandem with reduced food intake.
Dehydration is a serious dilemma that the institutionalized elderly face.
Providing adequate quantities of fluids to those seniors with swallowing problems is especially difficult. One method of safely delivering fluids is to thicken fluids with a fluid thickening agent to a consistency that is easily tolerable. However, fluid thickeners rnay displace either food or nutrients from the diet which can potentially lead to nutrient inadequacy. At Baycrest Centre for Geriatric Care, the fluid thickening agent of choice is rice flakes1 pablum; a fluid thickener fortified with rninerals and vitamins that may be able to replace those nutrients displaceci from the diet. If so, the risk of nutrient inadequacy as well as the threat of dehydration would be reduced. However, this 'theory' concerning the capabilities of pablum as a fluid thickening agent has not kenexamined. This study will test the hypothesis that the use of rice fiakes as a fluid thickening agent replaces nutrients tost due to calorie displacernent of fluid thickening agents and prevents inadequate nutrient intake. Chapter Two r.I LI I LWI unrz ncvirzvv. V~U~IYILN I IUIY
The literature review is organized into five major sections. The first portion of
the review will discuss malnutrition. Specifically, the prevalence of malnutrition in
seniors as well as its causes and consequences witl be discussed. The second section will review dysphagia and its vanous components. Dysphagia, a disorder
involving difficulty in swallowing, is a progressive disorder with no cure. There are different methods to help facilitate swailowing in an individual with dysphagia.
The prevalence as well as the therapeutic approaches to treating dysphagia
in the institutionalized elderiy constitute the third main division of the chapter. One of the methods to help the dysphagic patient's struggle with food consumption has been the modification of the diet from regular textureci foods to pureed food textures.
The advantages and disadvantages of using pureed food textures witl be discussed.
Another method to be reviewed is the use of thickened fluids. Fluid consumption is
necessary to prevent dehydration but the consistency of regular fluids such as coffee, tea and juice is not easily tolerated by the dysphagic client. Fluids can be thickened to a consistency best tolerated by the client. As it will become evident in the fourth section of the literature review, there are two types of thickening fluid agents; those that are not fortified with vitamins and minerals and those that are fortified. The literature review wilf outline the reasons as to why it is more advantageous and in the best interests of the dysphagic client to choose a fortified fluid thickening agent in place of an unfortified fluid thickener. Finally, the various techniques of data analysis will be outlined in detail. This section will review how nutrient requirements as well as the recommended nutrient intakes (RNls) were derived for each of the nutrients of interest to the study.
2.2 Prevalence of Malnutrition in 'Healthv' Institutionalized lndividuals
For the purpose of this thesis, the tenn 'healthy' refers to those elderly individuals who are still capable of swallowing fluids safely, but may include seniors at earlier stages of dysphagia who require texture-modified foods as well as those with physical impairments which limit or interfere with the ability to bring food to the mouth.
The definition of 'malnutrition' includes the following: A) undemourishment resulting from insufficient food intake, 2) specific nutrient deficiencies and 3) imbal- ances due to disproportionate dietary intake (Keller, 1993). The primary cause of malnutrition is decreased food intake. A high prevalence of malnutrition is reported as both protein and calorie malnutrition, as indicated by a majority of reports where malnutrition is presented as being quivalent to energy and protein undernutrition.
Specific nutnent deficiencies and imbalances due to disproportionate food intake often occur secondary to reduced food intake. As stated by Ahmed (1992) the progressive reduction in energy intake with increasing age suggests that nutrient intake contained in the energy sources will also be reduced. Malnourishment among the institutionalized elderly is not as uncornmon as
the average person may believe. Sliver et al. (1988) and Shaver et al. (1980) have
reported that the prevalence of protein energy malnutrition in nursing home residents
ranges from 23 to 85%. Studies have shown that 90% of institutionalized elderly
residents in nursing homes are at a significantly higher risk for malnutrition than those living at home (Kerstetter et al., 1992). For example, less than 5 % of
independent individuals living in a community suffer from below normal adipose
reserves and body weight whereas the incidence is ten to fifieen-fold greater in the
institutionalized. These authors also found that the incidence of malnutrition can
Vary greatly arnong the institutionalized elderly, from as low as 10% to as high as
85% in different nursing homes and hospitals. The elevated prevalence of
malnutrition found in nursing homes may in part be due to malnourished patients
being transferred from acute care hospitals to long-term care facilities after a serious
illness. On the other hand, the fact that the elderly were no longer able to care for
themselves at the time they made the transition from the free- living to
institutionalized setting should also be considered as an altemate possible
explanation. This inability to care for oneself can affect the number of individuals
entering an institution undemourished but the possibility that individuals are well
nourished upon entering an institution and then decline must also be considered. As
cited earlier, there are a nurnber of factors that can lead to decreased intake in the
institutionalized elderly.
A diet limited in energy rnay not be adequately nutrient dense to provide
sufficient amounts of micronutrients. This is especially important since there is vvvii Gviucr IUZ ru ~uyycaiLI iai LI IG iequiictiiieiiis Ur Ifle eiuerIy Tor some OT rne
nutrients may be higher than the levels currently recommended (Blumberg, 1992;
Russell, 1993). Prevalence estimates for vitamini mineral malnutrition are not as
well defined. Nevertheless, reports of inadequate intakes are available in literature
(Matthews, 1995; Payette, 1993; Ortega, 1996; Dawson, 1994). This can lead to a
deterioration in nutritional status for the elderly.
2.2.1 Causes of Enerqv Malnutrition
The sources of undernutrition due to insufficient fdintake are several in
number. Among the factors that have been suggested as influencing malnutrition
include general health status, diminished cognitive status, degree of immobility,
anorectic medications, the ability to chew or swallow and the method of feeding
(Morley et al, 1986; Abbasi and Rudman, 1994; Chemoff, 1994). They cm be grouped into different categories including the following; 1) those that occur as a
result of the aging proceçs, 2) disease-related causes and 3) social-psychological-
economic causes of malnutrition.
2.2.1.1 Aqe-relâted Causes of Malnutrition
Reduced food intake may be due to an impaired intake regulation that often
results with aging. Even though it has been dernonstrateci that seniors sttuggle to
maintain their interna1 state, only of late has it been shown that this struggle wuld be
due to alterations in the fundamental regulatory systems (Rolls et al., 1995). In fact w- VVuI RCI 3 \ t 553) IUUI IU LI lai ayii iy was iri iau associarea wirn airerarions
in food intake regulation in healthy elderly men. The reasons for these changes are
not apparent although there are changes in the gastrointestinal tract that have been shown to be associated with aging. Furtherrnore, the emptying of both solids and
liquids from the stomach is significantly slower in seniors. This in and of itself can lead to changes in satiety signals emanating from the gut. Further, alterations in concentration and sensitivity to gut peptides, such as cholecystokinin (CCK), change with age and may impair satiety signals. These investigators found that energy regulation was impaired in the elderly. In their study, they showed that if a meal was preceded by a high energy supplement, the total intake of the meal was increased.
Hence dietary supplementation may be a suitable strategy for increasing energy intakes in the senior population. Altematively, structured patteming of the meals wuld be sufficient to increase intakes. The change to which these altered satiety signals can be associated with decreased intake is unknown. Nevertheless, the data indicate that gut function changes with age thereby disturbing regulatory mechanisms associated with its function.
As the aging process continues, many seniors require assistance during meal time in order to promote intake. The required aid varies, from verbal prompting to
physical feeding assistance. Thomas et al (1991) noted in their prospective study of outcome from protein-energy malnutrition in nursing home residents that the degree
of assistance required in eating was correlated with the presence of malnutrition;
residents who remained malnourished needed more assistance in eating. In fact,
there are those among the institutionalized elderly who are no longer able to move LI IGII IUUU IIUI I I II IG plat= LU LI ICII IIIUULI 1. I I IC3t; )IFU~IC: -1 i 3Llil 3WdIIVW 1lltN IUUU, they just require assistance in bringing their food to their mouth. Because they rely on others to facilitate the feeding process, the assurance of adequate nourishment for these clients is dependent on their 'feeders' more so than on themselves.
Several reports have indicated that the inability to feed oneself (i.e. eating dependency) is a significant risk factor for undemutrition in the nursing home (Abbasi and Rudman, 1994). In these cases, the concem of inadequate intakes can be addressed and prevented by ensuring that the patient's particular meal time need has been met.
An added age-related risk component for decreased food intake by nursing home residents arises from a lowered energy need. This is a consequence of graduai reductions in the basal metabolic rate (BMR) and a low level of physical activity. Since energy balance is the main factor in determining hunger, the hypometabolic client may want and consume less food. In other words, decreased energy expenditure in the elderly leads to a reduced energy need and hence a lowered food intake. Although caloric needs rnay be satisfied, the consumption of other essential nutrients may be less than optimal, unless nutnent density is raised
(Abbasi and Rudman, 1994).
Other age-related causes of malnutrition include decreased taste acuity, loss of dentition, inadequate orat healthl hygiene, poor eyesight and reduced salivary flow. The causes of reduced consumption rnay be as minor as the iack of proper dentition. Decreased ability to chew can lead to reduced wnsumption of meats, Il II "IW C*I IU VYYYCUWIWY WWI IIVI I UUI I I =QUIL II I II IauGquaLF II ILQ~FQ VI GI ~~ayy,Irui I QI IU vitamins especially vitamins C, folate and beta-carotene (Mahan and Escott-Stump,
1996), not to mention the increased hkelihood of choking if the patient cannot chew hislher food into small enough pieces. One potential method of overcoming such a problem is through the use of food texture modification.
Neveriheless, the argument of reduced food intake as a result of aging is against the context of diminished energy requirements. The basal metabolic rates
(BMR) and levels of physical activity (especially in the institutionalized elderly) are reduced and as such, will place an 'upper limit' on intake (Abbasi and Rudman,
1994; Kerstetter et al., 1992). As mentioned eariier, a progressive decline in energy intake with increasing age is indicative of the possibility that nutrient intake wntained in the energy sources will also be decreased (Ahmed, 1992). Moreover, age-related changes in absorption and utilization (metabolism) of nutnents (Blumberg, 1992) may further exacerbate problems associated with already inadequate intakes. This 'upper limit' will drive the nutrient density needs of the diet.
2.2.1.2 Disease-Related Causes of Malnutrition
Diseases can have a significant impact on food intake. It is well recognized that many diseases such as cancer will affect appetite. Although such diseases tend to be distributed across al1 age spans, the impact of neurodegenerative disorders is most restricted to the senior population. Consequently, the focus of this study is limited to neurodegenerative disorders and their effect on food intake. I I IG I IYIUILY VI LI IG GA~ICI 1 IILIG~ aaauuaic;u VVILI I rat ni1 iaui I a uiaeea~e,pai iiwiai iy at later stages of the disease, can interfere with the senior's ability to feed himselff herself. The rigidity also hinders the ability to control the position of the head and tnink which is necessary for eating. The sirnultaneous movements such as those necessary to handle both a knife and fork become difficult. Arrn and hand tremors make self feeding of liquids impossible without spilling (Mahan and Eswtt-Stump,
1996). Degenerative and neurological modifications can debilitate the muscles and reflexes involved in swallowing (Elliot, 1988). Diminished neuromuscular, salivary and sensory capabilities along with impaired dentition can affect chewing, resulting in reduced bite strength, slower chewing, and longer meal times (Feldman et al, 1980;
Baum et al., 1982; ldowu et al, 1986). Diseases can also affect the absorption, utilization or excretion of nutrients in a negative manner. Once again, in addition to those diseases (such as renal failure) which are more uniformly spread across al1 age ranges, neurodegenerative diseases in the elderiy can play a unique role in
nutrient metabolism. Early Alzheimer's disease is marked by modifications in peripheral glucose metabolism (Mahan and Escott-Stump, 1996). The degree to which this impacts on the metabolism of other nutrients is currently unknown.
Certain drugs us& to treat various diseases in the eldedy can impair desire or the ability to eat in addition to hindering the absorption, metabolism or excretion of nutnents. For example, medications used in the treatment of Parkinson's disease
lead to such side effeds as anorexia, nausea, dry mouth and constipation. men, the elderiy individual is on a multi-drug regimen for long periods of time. Long term
effects of medications can result in changes in appetite, maidigestion and I I lalauau~~LIW 1, I I III IGI QI QI IU vILaI I III I UC~IGLIUI I II VI I I UI II la1 y luaaca a3 WGII a3 u IG effects of dwgs on nutrient catabolism. The side effects of drugs can ultirnately diminish the nutritional status of an elderly individual (Mahan and Eswtt-Stump,
1996; Kerstetter et al., 1992).
2.2.1 .3 Social-Psychological-Economic Causes of Malnutrition
Several causes of malnutrition can be related to social, psychological and economic causes. Depression, bereavement, isolation during meals, institutionalization, dementia, food preferences, and poverty are just a few of the factors that affect nutrition (Kerstetter et al., 1992; Chernoff, 1994). A change in one of these factors can often produce a change in another factor that ultimately affects the nutritional health of an elderly individual. For example, losing a loved one can cause bereavement, depression and isolation, resulting in a reduciion in appetite and food intake. Depression often accompanies a sense of loss- whether it is a loss of loved ones, productivity, sense of worth or body image. A reduction in food intake can lead to micronutrient deficiency which cm, in turn, lead to depression so that the individual enters into a cycle that leads into a downwards spiral. (Chernoff, 1994;
Kerstetter et al., 1992; Mahan and Escott-Stump, 1996).
As mentioned previously, institutionalization is one risk factor for malnutrition in the elderly. The lack of staff to help feed patients, isolation, inappropriate or unnecessary dietary restrictions, unappetizing food, and unattractive surroundings in eventually malnutrition in the elderly (Kerstetter et al., 1992; Chemoff, 1994).
2.2.2 The Consequences of Malnutrition
Diminished energy intakes in the senior population can have dire consequences. As Gonsalez-Gross and w-workers (1991) found, the elderly population are especially susceptible to micronutrient deficiencies due to diminished energy intakes. Chandra (1992) found that modest supplementation with micronutnents can ameliorate immunity and decrease the nsk of infection that is associated with old age. In other words, declines in immune status cannot be explaineci solely on the basis of advancing age; improvements in immune status would not be observed with supplementation if this was true. Poor wound healing, cardiac and respiratory diffmlties, muscle wasting, augmented risk to infection, diminished immune function and decreases in physical activity are among the physical outcornes of malnutrition in the elderiy. Malnutrition can be expressed at many different levels; social, psychological and economic consequences of malnutrition include apathy, irritability, memory loss, confusion, and increased medical costs. (Kerstetter et al., 1992; Friedman, 1991; Lipschitz, 1982). A decline in nutritional status influences the kinctional deterioration in organ systems and the prevalence of chronic illnesses afflicting older people. Notable losses in body weight increase the risk of death in both women and men (Rolls et al., 1995). VI IG VI LI lm WI IwZyUbI 1-Q VI II IUII IUCI ICIVI I lY UYYl YUYYU wu1 Ulll UIUUtI III m.
Albumin is the primary protein to which dmgs are bound; the unbound fom of the drug can diffuse through the capillary wall and exert a pharmacologic effect.
Reduced levels of serum albumin lead to increased serurn levels of the drug, heightened pharmacologic effect and potential toxicity (Mahan and Eswtt-Stump,
1996).
2.2.3 Summary of Malnutrition
As previously illustrated, there are many sources of malnutrition. Some of the issues leading to inadequate food intake and malnutrition, such as il1 fitting dentures, can be modified to improve the food intake of the elderiy. Abbasi and Rudman
(1994) noted fifteen such modifiable causes of protein-calorie malnutrition often found in the nursing home. They also provided methods of identification and the courses of action that could be taken to correct the causes of the undemutrition.
Other issues, such as energy requirements, cannot be changed and consequently, place an 'upper limit' on the likely intake of the senior. The best case scenario involves setting the upper Iimit as the goal of intake.
Health care providers try to keep the patient's best interests in mind when they use different methods to help remedy a patient's difficulty in food consumption.
These methods, such as sitting a patient upright before feeding are not solutions to the patient's problem; these techniques are rnerely used to try and make food consumption easier. ------,..-..-. ..- ri.a... iui .bu, .a isv iw Cl lY UWYL bI IUL health care providers can do. This is the situation that most institutionalized elderly face. A majority of the elderly have no difficulty with the actual proceçs of eating and swallowing; either they need assistance in bringing the food to their mouth or availability of appealing, nutntious food in surroundings that are conducive to optimal food intake. Those seniors who have problerns swallowing their food Le. dysphagic individuals, face an entirely different set of dificulties in addition to the aforementioned problems that the former group encounter. In other words, the dysphagic elderiy are at an even greater risk for malnutrition.
2.3 Dvs~hagia
Dysphagia, the swallowing disorder, as defined by the American Speech and
Hearing Association, is the difficulty in the oral preparation for swallowing or the difficulty in moving food from the mouth to the stomach (Williams, 1992). This disorder is common among efderly neurological patients with acquired damage.
2.3.1 The Swallowinci Process
Swallowing is a sequentially programmed all-or-none reflex. The motility of swallowing or deglutition is associated with the pharynx and the esophagus. The entire process involves moving the food out of the mouth through the esophagus into the stomach. - - . - .- . ------. .-- -. .-. - -. - -. m.-- #"..--Y" II I VIIUIIV.. m. ,y CI IUC UI Y
co-ordinated by the nervous system; 1) oral preparatory or buccopharyngeal or
voluntary, 2) pharyngeal, and 3) esophageal. During the oral preparatory phase the
grounded food is shaped into a bolus (ball of food) and positioned by the tongue and
palate muscles to the pharynx. The pressure of the bolus in the pharynx stimulates the pharyngeal pressure receptors, sending afferent impulses to the swallowing
center located in the brain's medulla. A normal swallow occurs when impulses from the ninth cranial (glossopharyngeal) nerve are transported to the swallowing center.
The swallowing center then reflexively activates in the appropriate sequence the
muscles involved in swallowing. Multiple responses triggered in a specific timed
sequence, i-e. a number of highly co-ordinated activities are initiated in a regular
pattern over a time period to accornplish deglutition. It is important to rewgnize that
although the process is initiated voluntarily, once it is started it cannot be stopped.
The pharyngeal phase consists of exerting pressure on the bolus as it passes
into the cricopharyngeal sphincter. This process occurs by the closure of the vocal
cords over the trachea and the closure of the nasopharynx. It is mandatory that this
phase be rapid and efficient in order to prevent aspiration and to ensure that
respiration is intemipted for only a brief moment since the respiratory passages are
sealed off temporarily. With the larynx and trachea sealed off, the pharyngeal
muscles contract to force the bolus into the esophagus. The swallowing center
organizes and triggers a host of neuromotor behaviours during the pharyngeal
phase. The four neuromotor events programmed by the swallowing refiex are; 1)
velopharyngeal closure, 2) peristaltic contraction, 3) aiway protection, (which . - - - the above four events will occur without normal triggering of the swallowing reflex.
Each of the neuromotor activities that happen during the pharyngeal phase occurs only during the interval in which the food bolus passes the relevant portion of the pharynx.
The esophageal phase includes the passage of the bolus by means of peristalsis. This peristaltic action takes place through the esophagus to the stomach upon the closure of the cricopharyngeal sphincter (Wong, 1985).
2.3.2 Causes of Dvs~ha~ia
Dysphagia may result from anatomie abnorrnalities in the oral cavity, pharynx, larynx or esophagus, or from physiological disturbances in the control of these structures. Common causes of dysphagia are strokes, cancer, multiple sclerosis,
Parkinsonisrn, and brain-spinal cord injuries. Basically the patient ioses some or al1 control of the muscles that facilitate chewing, swallowing and tongue movement.
This causes the food movement from the front of the mouth to the back and channelling of food into the esophagus very difficult. Since swallowing is controlled by the 5th, 7th, 9th and 12th cranial netves, any disruption of these nerves can affect a person's ability to chew and swallow (Matthews, 1988). Swallowing disorders are classified according to the underiying disturbance and the phases(s) of swallowing that appear to be faulty. Oropharyngeal dysphagia involves interference with the first or second stage of deglutition or both (Wong,
1985). In the oral preparatory phase swallowing disorders consist of; a) incomplete lip closure, b) reduction in tension in the cheek musculature and c) reduction in range of coordination of tongue movement. Damage to tongue function may affect only one particular direction of movement, for example, elevation of the tongue or its anteriortposterior motion (Williams, 1992).
Pharyngeal phase disorders of the swallow are several. Delayed or absent triggering of the swallowing reflex involves food falling into the pharynx without any of the four neuromotor aspects of the pharyngeal phase occurring. Reduction in velopharyngeal closure leads to the reflux of material into the nasal cavity. Damage to the pharyngeal peristalsis, unilaterally or bilaterally, results in the squeezing action of the pharyngeal constrictors failing to move the entire bolus through the pharynx.
Sometimes the larynx tucks under the base of the tongue to shift material away from the top of the airway leaving some food residue at the top of the aiway. This latter situation is an indication of damage to larynx elevation. Damage to the laryngeal adduction or airway closure is followed by food leakage through the larynx into the aiway during swallow. When there is damage to the cricopharyngeal muscle, this muscle does not open sufficiently or at the proper time, leaving food in pyriform sinuses after the swallow. Each of the above disorders can cause aspiration before, during or after the swallow (Williams, 1992). . . _ - - -. - -.,.., -. --. .- ---r* V-JVUU YJV~IIU~IU. * 4 11- would infer that there is a problem with the third stage of swallowing, namely the esophageal phase (Wong, 1985). Other types of dysphagia are; pathologie dysphagia, neurogenic dysphagia, pharyngeal phase neurogenic dysphagia, and esophageal phase neurogenic dysphagia (Wong, 1985).
2.4 Prevalence and Theramutic Approaches to Dvs~haciiain the lnstitutionalized Elderly
2.4.1 Prevalence
It has been estimateâ that 40 to 60% of the institutionalized elderly have dysphagia or swallowing difficulties (Kolodny et al., 1991; Logemann, 1983, 1990;
Tracy et al., 1989; Sheth et al., 2988; Feinberg et al., 1990). In generai, the majorii of dysphagic residents have dysphagia secondary to neurodegenerative disorders.
The presenœ of dysphagia has been stmngly linked to malnutrition (Keller, 1993).
Dysphagic patients usually have progressive disorders such as Alzheimer's disease or Huntington's chorea. Consequently, the dysphagia and feeding difficulties progress with the disease state. lndividuals suffering from such neurodegenerative diseases as Alzheimer's disease often have compounded problems, including decreased cognitive and communication skills, and motor skills etc. The eating problems of the elderly are rnultifaœted in origin and occur at a high frequency.
Steele and co-workers (1997) found that over 80 % of clients demonstrated a meal- 2.4.2 Phvsical As~ectsof Dvsphasia in the Institutionalized Elderly
As the process of aging continues, the resident with dysphagia usually moves from the stage of eating solid foods through a succession of food textures to pureed food, the last state. The patient's decreasing ability to chew and swallow regular foods are primary considerations in recommending the food texture alterations (Johnson et al., 1995). lmpaired dentition and declining neuromuscular, salivary and sensory functions can have an effect on chewing resulting in reduced bite strength, slower chewing and longer meal times (Feldman et al., 1980; Baum et al., 1982; ldowu et al., 1986). Degenerative and neurological alterations can weaken the muscles and reflexes responsible for deglutition. Depression and confusion can confound eating problems even further (Johnson et al., 1995). The pureed food diet is one method of circumventing these problems and is often fed to elderly patients who are debilitated and at risk of malnutrition if they are not already malnourished
(Rudman et al., 1989; Hotaling, 1992).
In a similar way, the client with dysphagia has moved from consuming full fluids to ingesting thickened liquids, also the last phase in the sequence of liquid textures. The challenge of ensuring that the institutionalized dysphagic person is well hydrated as well as adequately nounshed becomes even more demanding for the health care provider. , . ------. -- .----..- a. - I (Mahan and Escott-Stump, 1996). There are the institutionalized elderly who are able to 'self feed' but suffer from dysphagia or swallowing dificulties. Even if these patients receive the aid of others during feeding, the threat of insufficient nourishment may still linger since these clients struggle to conduct their food through the swallowing process. Furthermore, there are those seniors who cannot feed themselves nor can they swallow their food without difftculty. These aged, feeding- dependent individuals with dysphagia have an extraordinarily high nsk of inadequate food intake and malnutrition. The subjects of this study corne from this last group of clients.
In light of the above problems, the question anses of how one makes sure that a patient with dysphagia receives the proper nutrition, since dysphagia can be life threatening if the patient's nutritional status is compromised (Matthews, 1988).
2.4.3 A~proachesto Dealincl with Dvsphaclia
2.4.3.1 Pureed foods
The risk of malnutrition is heightened in dysphagic patients, particularly those consuming pureed foods. As mentioned earlier, pureed foods are frequently fed to elderiy patients who are debilitated and at risk of malnutrition, if they are not already undernourished (Rudman et al., 1989; Hotaling, 1992). Due to the fact that pureed foods are prepared with water, the nutrient and caloric intakes in the dysphagic of this dilution has not yet been determined nor has the ability of the individual to increase the volume of food consumption to compensate for the dilution.
Nevertheless, given that other aspects of fod intake regulation appear to be impaired in seniors, it would not be surprising if this form of compensation was also impaired. The danger of insufficient food intakes leading to nutrient inadequacy and malnutrition is a legitimate wncem for those elderly dysphagic patients consuming the pureed food diet.
The situation is worsened in dysphagic patients who are cognitively impaired.
As the patient's mental status continues to deteriorate, the patient is rendered incapable of assisting the health Gare provider in maintaining adequate nutrient intake. For example, a cognitively impaired patient lacks the ability to express when helshe is satiated or hungry. Thus, the cognitively impaired encounter even greater obstacles as the disease process progressively worsens in cornpanson to the elderly who just consume pureed food.
2.4.3.2 Thickened Fluids
In addition to using pureed foods, health care providers thicken the fluids for some dysphagic elderly patients especially those suffering from oropharyngeal dysphagia. Thin liquids such as juices are difficult to control once they become a part of the swallowing process (Wong, 7985; Matthews, 1988) since there is no bulk to activate saliva or the action of oral muscles (Owens, 1990). ------. -- --S. -..mm- -.-J m. . .-..m... .a - --.--, .VaUIUI IlyUaUY ll IUJ WU 6. IY l l IYWC difficult to swallow and wn result in aspiration, reduced fluid intake and insufficient
hydration (Dantas et al., IWO; Tuchman, 1988, 1989; Loughlin, 1989). If, on the other hand, the liquids are thickened then bolus formation is facilitated, permitting the swallowing of the liquids. (Pureed fruit, stewed fruits such as applesauce, yogurt or puddings may be more appropriate than a liquid form of a product.) Liquids can be thickened or gelatinized with fluid thickening agents to prevent dehydration. These thickeners may be beneficial as long as they are not gum-based since gum-based thickeners tend to bind the water content (Williams, 1992).
2.5 Choice of Fluid T hickenina Aaents
2.5.1 Unfortified Fluid Thickening Aqents
Starch based fluid thickening agents can be used to thicken liquids to a consistency that aids the dysphagic patient in wnsuming liquids which would not norrnally be tolerable by them. This reduœs the risk of dehydration. However, the disadvantage with these unfortifieci agents is the fact that they may displace an equivalent amount of energy in the diet of an individual with dysphagia. The total caloric intake does not change; instead, a smaller proportion of the energy is obtained from the diet. Consequently, there is also a loss of nutrients. This loss of nutrients may result in the client not obtaining enough nutrients to meet hisl her own requirements. As a consequence, the danger of nutrient inadequacy also becomes greater in these dysphagic individuals. 2.5.2 Fortified Fluid Thickenina Arients
An alternative to using these non-fortified fluid thickening agents that is of particular interest is to thicken thin liquids to a strained crearn of wheat-like texture by adding pablumlrice flakes or instant infant cereals. The use of pablurn as a thickening agent for liquids has been previously documented (Stanek et al., 1992).
These fortified fluid thickeners are usually calorically dense and supply vitarnins and minerals that would not necessarily be supplied in the non-fortified thickening agents nor in the liquids thernselves. At the same time the rice flakes have the potential, as a thickening agent, of lowering the risk of dehydration.
The preference of using a fortified thickener over an unfortified thickener is also related to the issue of ethics. The use of any thickener, fortified or unfortified results in the displacement of food and nutrients from the diet. If there is even the remote possibility that the patient could bewme nutrient inadequate if those missing nutrients are not replaced, then there is no question that strategies to prevent nutnent inadequacy must be used. The fortified thickener offers the promise to replace those nutrients and to reduce the risk of nutrient inadequacy. An additional advantage to using pablum as a thickener is the fact that it is one of the least expensive thickening agents available (Stanek et al., 1992).
The question becornes: can the rice flakes help dysphagic individuals, especially the elderly, to consume enough liquids to prevent dehydration whife supplying enough nutrients to avoid nutrient inadequacy? 2.5.2 Fortified FIuid Thickeninçi Aaents
An alternative to using these non-fortified fluid thickening agents that is of particular interest is to thicken thin liquids to a strained cream of wheat-like texture by adding pablum/rice flakes or instant infant cereals. The use of pablum as a thickening agent for liquids has been previously docurnented (Stanek et al., 1992).
These fortified fiuid thickeners are usuaHy calorically dense and suppty vitarnins and minerais that would not necessarity be supplied in the non-fortified thickening agents nor in the liquids themselves. At the same time the rice flakes have the potential, as a thickening agent, of lowering the risk of dehydration.
The preference of using a fortified thickener over an unfortified thickener is also related to the issue of ethics. The use of any thickener, fortified or unfortified results in the displacernent of food and nutrients from the diet. If there is even the remote possibility that the patient could become nutrient inadequate if those missing nutrients are not replaced, then there is no question that strategies to prevent nutrient inadequacy must be used. The fortified thickener offers the promise to replace those nutrients and to reduœ the risk of nutrient inadequacy. An additional advantage to using pablum as a thickener is the fact that it is one of the least expensive thickening agents available (Stanek et al., 1992).
The question becomes: can the rice flakes help dysphagic individuak, especially the elderly, to consume enough Iiquids to prevent dehydration while supplying enough nutrients to avoid nutrient inadequacy? 2.6.1 Requirements and the RN1
The focus of this thesis will be to examine nutrient adequacy of the diets provided to dysphagic seniors requiring thickened fluids and to assess the adequacy of actual intake. To address these issues, it is important that the methods behind the establishment of nutritional recommendations are understood such that appropriate approaches are taken. Specific attention will be given to those nutrients addressed in the context of the thesis.
Nutritional advice provided to Canadians has been based on a wntinually updated collection of nutrient requirements presented in the forrn of Recommended
Nutrient lntakes (RNls) [Table 2.13. It should be clarified, however, that nutrient requirements are not the same as the RNls.
The term 'requirement' generally refers to the level of dietary intake of a nutrient that satisfies an individual's need. There are two types of requirernents; basal and normative. Basal requirement is defined as the level of intake required to meet al1 demonstrable functional needs. A normative requirement is the level of intake that provides for levels of storage, in addition to covering basal needs, that are deemed beneficial but that are not seen as bearing any identifiable functional advantage (Beaton, 1994). Table 2.1 Recommended Nutrient lntakes (RNI) and Requirement Estimates for Men and Women Aged 75+ years
Nutrient RNI' RN1 Average Average Average Average Basal Reqt. Basal Req. Normative Req. Normative Req.
Men Women Men Women Men Women Energy (kilocalories) 2000 1700 Protein (glkglday) 0.86 0.86 +Cholesterol (mg) 300 300 Calcium (mg) 800 800 lron (mg) 9 8 Vitamin A (RE) 1000 800 Vitamin C (mg) 40 30 *Thiamin (mg) O. 8 0.8 Thiamin (mg1 1O00 kcal) 0.4 O. 4 *Riboflavin (mg) 1.O 1.O Riboflavin (mg1 1000 kcal) 0.5 O. 5 *Niacin (mg) 14.0 14.0 Niacin (mg1 1000 kcal) 7.2 7.2 Folate (pg) 215 200 ~Fluid(mL) 1500 1500 L I J + Unlike for the nutrients, the cholesterol RN1 is a maximum value, not a minimum value. Cholesterol is not an essential nutrient, whereas the other nutrients listed in the above table are considered as essential. * Nutrition Recommendations (Health and Welfare Canada, 1990) established cut-off levels thiamin, riboflavin, and niacin. Le. levels below which intakes should not fall. The fluid recommendation is a minimum level of intake (Kerstetter et al., 1992; Chernoff, 1994.). It is not classified as RNI. a Beaton, G. H. Fortification of Foods for Refugee Feedina Technical Backamund Re~ort:Denvations and Analvses. 1995A. On the other hand, the RNls are designed to surpass the nutrient requirements, basal and normative, of al1 but a few normal individuals belonging to a given group. More than one approach was used to set up the RNls since the data available varied from nutrient to nutrient. Where adequate information was available, the following multi-phase approach was used to establish the RNls.
Firstly, the mean requirements for a given population with a specified age, gender, size and physiological state were determined. The average requirement was increased by two standard deviations to account for individual variability, assuming a normal distribution of requirements. In other words, the RNls surpass the adual requirements of most of the individuals. This technique was used for obtaining the
RNls for vitamins A and Cl protein, folate, iron, as well as for thiamin, riboflavin and niacin (when the latter three nutrients were expressed in mg/ 1000 kcal) (Health and
Welfare Canada, 1990).
There is, however, a caveat for the latter three vitamins, stating that at low energy intakes, vitamin intakes should not fall below an established cut off level (i.e.
0.8 mg, 1.0 mg and 14 mg for thiamin, riboflavin, and niacin respectively). The reasoning behind the setting up of such cut 0% has not been suffciently addressed in the recommendations, but appears to be fixed at the level of thiamin, riboflavin and niacin which would be required in an 1800 kcal diet. Since many seniors do not consume 1800 kcall day this cut off value, if appropriate, cornes into effect. Hence, it would be important to know its validity. r I C~UII lauly, LI IG aiuiGI i IFI iriui IGU uavGar I wui~~I I IUI UII uuii~kv yvui iyvi individuals on weight reduction diets. In this instance, the caloric intake is intentionally decreased but the metabolic needs do not change. Since thiamin, riboflavin and niacin are primarily involveci in interrnediary metabolism, it would make sense that these levels should not fall below a minimum level. However, in the case of seniors, the decrease in energy intake is associated, in part, with a decrease in metabolic rate. Hence a cut off approach may not be valid. Neverthefess the cut offs for thiarnin, riboflavin and niacin will be addressed in the calculations of this study.
Recommendations for other nutrients could not be developed by the aforementioned method of increasing the average requirement by two standard deviations. Examples of these nutrients examined in this thesis and the approaches used to estimate the requirements follows.
There has always been difficulty in setting a RN1 for calcium. The principal problem in determining the calcium requirement results from an ability to adapt to a range of calcium intakes. Nutrition Recommendations (Health and Welfare Canada,
1990) has suggested that the recommended level of intake be 800 mg/ day since this RN1 takes into account; 1) the diminution of calcium absorption with aging, 2) the probability of increased variance in the calcium need among the elderly, 3) the evidence for a marginal vitamin D status in some postrnenopausal women, and 4) the prospect that a generous intake of calcium may restrain bone loss in some instances. It is important to note, however, that the RN1 for calcium represents a
'suitable' group mean intake. That is, it is not based on a mean requirement + 2 -. - suitable is questionable in light of the more recent recommendations for higher calcium intake in postmenopausal women (Whitney and Rolfes, 1993; Mahan and
Escote-Stump, 1996). Furthemore, it is not unreasonable to assume the calcium requirements for inactive individuals are difFerent from those of active people
(Mahan and Escott-Stump, 1996). Consequently, the approaches used to interpret cafcium intake must take this fact into account.
The RN1 for energy is set at the mean requirement since there is no set level of energy intake that is needed by al1 individuals of the same age, gender and size.
Rather, there is a wide range of energy intakes that can be considered to be sufficient, depending on a number of factors including the level of physical activity performed by the person, hisf her (BMR) and diet induced thennogenesis (DIT).
Nutrition Recommendations (Health and Welfare Canada, 1990) take into consideration the decrease in BMR that occurs with age. Nevertheless, the recommendations also take a cut-off approach stating that intakes should not fall below t800 kcal since there are increasing risks of having insufficient intakes of nutnents such as iron and calcium when the energy intakes fall below this level.
Rather, seniors are encouraged to increase physical adivity to maintain an appropriate body weight within the context of this level of intake. Thus, to maintain this cut off level in seniors, the proportion of energy expired to support activity must increase to offset declining basal metabolic rates. However, the RN1 for energy is applicable to healthy elderly people. The clients involved in this study are institutionalized, inactive individuals suffering from multiple disorders. In this case, CI ICI yy II Iianca LI IQL alluvv au1 VVGIWI I& 31CIUIIILJ GU IV IUII VWILI III i LD IW I ~i.1IYW VI II ILUI\~G predicted for these individuals based on the Hams-Benedict equation estimating
BMR will be deemed suitable to meet the energy needs of the client population, assuming that these levels allow for adequate nutrient intake (Whitney and Rolfes,
1993).
Numerous approaches to estimate the fluid needs of an individual have been developed. Fundamentally, fluid levels should be set at a level which exceeds obligatory fluid losses and allows for facultative adjustments in unne output.
Estimates of water requirements have been based on either body size (30 mU kg body weight) or caloric intake (1 mU kcal to allow for sufficient fluids to support metabolic pathways). Additionally, a cut off approach has been used. The recommendation of 1500 mU day of fluid is a minimum level of intake (Kerstetter et al., 1992; Chernoff, 1994). (There is no set RN1 for fluid intake except that water input should balance water output. In the interest of safety for the patients at the
Baycrest Centre for Geriatric Care, the 1500 mL recommendation has been adapted for this study.) That is to Say, the clients should be ingesting at least that amount each day in order to evade the threat of dehydration.
There is no set recommended level of cholesterol intake; rather, the current recommendation is that the cholesterol intake of the Canadian population be reduced (Health and Welfare Canada, 1990). For the purpose of this thesis, a recommended 300 mg/ day of cholesterol will be set as the standard level of intake; the cholesterol intakes of the clients will be compared to this standard. One reason for this set level of intake is that there has been no evidence of a detrimental effect u1 a iwvv UI iwiboruivi u~ur1.". ..O iui rn ri iyuvbivv mv --1- ~WJSw-, ,. .--..m. -..- - -y..-.-
Canada, 1990). A dietary intake of 300 mg/ day or less has become the aim for the general American population as well as 17 European counties as a part of an agreed effort to decrease coronary artery disease rnortality (Consensus Conference 1985;
European Atherosclerosis Society 1987); however, the applicability of such a recommendation to the geriatric population in this study is unknown. Nevertheless, the levels of cholesterol intake in the clients involved in this study are not of great concern since, due to their advanced age, these individuais have already passed the stage where a decrease in cholesterol intake wuld lead to a reduction in mortality in heart disease.
2.6.2 Data Analysis: Prescriptive versus Diagnostic
It is always imperative to decide how data should be examined since the data analysis should be able to answer the question that led to the research. The data analysis can also play a role in how the information will be interpreted and used in the future. Firstly, we can assess the data with the intention of resolving whether or not the diet is adequate to meet the nutrient needs of the individual1 population. In other words, in this study we will use the prescriptive mode of data analysis to determine whether the current diet is capable of meeting the nutrient requirements of the population and if not what changes must be made to the diet. Secondly, the data can be investigated with the objective of measuring the probability of nutrient inadequacy for an individual or population. In this study, the diagnostic mode of data analysis will be used to assess the probability of nutrient inadequacy occurring in the I m- - I I I Y from the work of Beaton (1994) and were used to aid in the organization of the data analysis in this study.
2.6.3 Prescriptive Mode of Data Analysis:
One approach to the data analysis is based on using the prescriptive mode as described by Beaton (1994). The prescriptive mode can be defined as the development of rewmmendations for suitable levels of intake which will minimize the prevalence of inadequate intake within a group. This level of application is used to estimate the acceptable mean intake of a population. Such an estimate is useful when trying to plan a group diet or arrange for food supplies for a population. At the group level, the aim is to ensure that virtually al1 the individuals will have intakes sufficient to satisfy their own needs.
These analyses are consistent with the establishment of acceptable group mean intakes for the population using the prognostic approach. The derived group mean intakes are designed to meet the needs of 95 % of the population.
That is, if every individual in the group has an intake equivalent to the group mean intake, (i.e. zero variance in intake), about 5 5% of the population will not meet their individual requirements. The necessary group mean intakes take into consideration the variability of individual intake. Nutrient intakel delivery data collected can be used to provide estimates of the variability in intakel delivery for this defined population group. If the levels of nutrients in the existing diet fall 311-1 L VI LI IF IuczaI, LI 1~1I I G~UI I II I IQI IuaLIuI13 MI I um LUI Y~LGUUL IIIUUII JII 13 &I ~b present diet so that those nutrients which may be problematic can be increased to safe levels. The desirable mean intake can be derived as follows:
Desirable Mean lntake = Average Requirement x (1- (2 x ~~i-ke)-'
(Equation 2.7)
{Beaton, 1995A)
where Z = ratio of the separation between average intake and average requirementl standard deviation of intakes i.e. 1.655 for a 5 % prevalence of inadequate intakes CVintake= coefficient of variation (which is standard deviation of intake divided by the average intake)
However, one of the major difficulties in designing an appropriate diet for the institutionalized elderiy is their low energy intake due to reductions in both BMR and activity. As a consequence, nutrient density probably plays a more important role in designing an adequate diet for seniors relative to other segments of the population.
Thus the next objective will be to describe an appropriate nutrient density for the diet based upon acceptable group mean nutrient intakes and actual energy consumption observed. The primary aim will be to identify those nutrients which are inadequate in the present diet and to make recommendations for future change.
The nutrient density of the diet refers to the amount of nutrient in the diet required to ensure that sufficient levels of the nutrient are available to meet the lGi lGGU3 VI LI IG II lulvluual VI LI IG pupu~ë~i~uii wr ieri rney nave sarisriea rneir energy requirements. The basic idea behind this premise of nutrient density is that people consume food in order to satisfy their energy needs rather to meet their nutrient needs. It follows that the 'adequate' diet would contain the amount of nutrients such that when the person or group of individuals eat to meet their energy needs, their nutrient needs are also met at the same time (Beaton, 1994; 19958).
This, in tum, depends on the concentration of nutrients in the diet. Nutnent density is calculateci using the following equation:
Necessary Group Mean = Necessary Group x 1000 Nutrient Density Mean Nutrient lntake kcal (Eqn 2.2) Actual Mean Energy lntake
2.6.4 Diagnostic Mode of Data Analysis:
A second approach to analyzing the data is based on using the diagnostic mode as describeci by Beaton (1994). The diagnostic mode is interpreted as the assessment of the probable adequacy of observed intakes. Albeit one can never truly evaluate the state of health (nutritional status) solely fiom dietary data, the assessment of the likely adequacy of intakes is a significant portion of the more general evaluation. Nutrient intakes can be compared to the RN1 (Health and
Welfare Canada, 1990) to help determine whether or not a person had nutrient intakes below their own requirements i.e. inadequate intakes. Nevertheless,
RNls at the individual tevel are not known and hence a true evaluation of the auaquac;y UI ai i II iuiviuuai s iriraKe ro rneer nisf ner personal requirement CannOt
be made. It stands to reason, however, that the lower a client's observed intake is as compared to the RN1 , the greater is the risk that the client has not met hidher own need. Statistical approaches can be used to establish the probability of inadequacy. Figure 2.1 demonstrates this concept in more detail.
As cited earlier the RN1 is set at the average requirement + 2 standard deviations. Figure 2.1 A shows the a normal distribution of individual requirements for a given nutrient about the mean with the RN1 set at 2 standard deviations above the mean. The probability or risk of inadequate intake of a person ingesting the RN1 would be 0.025. In other words, 2.5 % of the population would be expected to have a need above the RNI. The term 'risk' refers to the chance that a given level of intake is insufficient to meet the actual need of a person. That is to say, this is a probability statement and not a measure of the seriousness of any inadequacy that may be present. As illustrated in Figure 2.1 8,the RN1 is a requirement that is linked with a low risk of inadequacy to any individual in a specified class of people.
The determination of the adequacy of nutrient intakes in a population requires the application of probability cuwes to the estimated intakes of individuals in the group (Figure 2.2). Population (%)
-2SD -1 SD MEAN +lSD +2SD Requirement
1 .O
Risk to person that observed intake is below requ irement
O I
Obsewed level of intake of nutrient
Figure 2.1 A) Establishment of the recommended nutrient intake (RNI) of a nutrient and B) the concept of risk of inadequacy applied to recommended nutrient intake (RNI) (Health and Welfare Canada, 1983) 1.0 Risk x Observed Probability lntakes Frequency X (%)
O O
I I Nutrient lntake I
Figure 2.2 Application of the probability approach, using intewals of nutrient intake, to nutrient intakes of a population in the assessrnent of population groups (Beaton, 1994) The population assessment is expressed as the number of persons with intakes below their own needs, (specific persons not being identified), which is a summation of individual probabilities. The distribution of nutrient intakes below the average requirement can be ascertained and combined with probability statistics to calculate the number of clients likely to have intakes below their own individual needs. The following steps can be taken to determine the number of individuals within the population expected to have intakes below their own requirements for a given nutrient. Nutrient intakes are arranged into small intervals and a probability of inadequacy is designated to each interval. The anticipated number of individuais with insufficient intake is then the summation of the probability x frequency across al! of the intervals; when divided by the total number of individuals being investigated, this becomes an estimate of the expected prevalence of inadequate intakes.
In this study, the predicted prevalence of intakes insufficient to satisfy the requirements of the clients can be estimated from the following process of summation:
PROBINAD = 1 - PROBNORM (Intk- Mean Req/ SD Req)
PROC MEANS N MEAN; VAR PROBINAD (Beaton, 1994) ~GDU~LQIILavclaytz VI I-ITVDIIYHU IS a11 esriniare or me inciaence OT insufficient intakes among the individuals investigated. When multiplied by 100, the percentage of clients with inadequate deliveries is yielded.
The aforementioned procedure for analyzing group data in the diagnostic mode will be used for vitamins A and C, protein, folate, iron, as well as for thiamin, ribofiavin and niacin (when the latter three nutrients were expressed in mg/ 1000 kcal); this approach is only appropriate when the RN1 is based on the average requirement + 2 standard deviations. This technique is not valid for calcium, water, and for thiamin, riboflavin and niacin when the cut off level (measured in milligrams) is used to establish adequacy. The nurnber of individuals whose average intake of these nutrients fell below the established cut off levels for each respective nutrient can be calculateci. This number can then be divided by the total number of individuals being investigated to estimate the expected prevalence of inadequate intakes in the population for a given nutrient. This was an appropriate approach to be used for the cut offs for thiamin, riboflavin and niacin where intakes should not fall below a certain level. The approach was also suitable for fluid since the recommended level is the desired level of intake in this population; levels of fiuid intake should not fall below this level. This approach was not appropriate for calcium where the desirable population mean intake and not cut off level is being described.
In summary, there are techniques avaitable to assess the data, whether it be to determine the proportion of the population at risk for nutrient inadequacy or to aid in the recommendations of suitable levels of intake. These procedures of data analysis will also aid in assessing whether or not the minerals and vitamins in pablum can - -.- , - - -- . - --. -.-- --.- "-W.. --.-- .--- 7- .-.. -- .- -.- p.---. . --." " .--- ..,-. occurs when a fluid thickening agent is incorporateci into the diet. In other words, the data analysis cm help judge pablum's capabilities as a fluid thickening agent. Chapter Three HYPOTHESIS AND OBJECTIVES 3.1 HYPOTHESIS:
The use of various fluid thickening agents for the elderly with dysphagia is a common place practice to promote sufficient fluid intake and hydration.
Nevertheless, the impact of incorporating a fluid thickener into the diet on potential displacement of other foods and hence nutrients has not been satisfactorily addressed. Without this information, the design and implementation of appropriate meal delivery practices cannot be adequately developed.
The hypothesis of this study is that the displacement of kilocalories from the pureed food diet by an unfortified thickener will lead to nutrient inadequacy.
The rice flakelpablum thickener will replace the minerals and vitamins lost by
kilocalorie displacement, thus preventing nutrient inadequacy.
3.2 OBJECTIVES:
To address this hypothesis, three objectives were developed to; 1)
evaluate current dietary practices, 2) assess consumption profiles of individuals
and 3) develop recornmendations for future diets. These objectives are detailed
below. Food Delivery and Practices:
1. To determine the average daily nutrient, fluid and caloric delivery in an elderly
population whose food intake was confined solely to pureed textures. The
information collected will provide information on baseline nutrient delivery of
pureed diets prior to the implementation of fluid thickening strategies.
2. To ascertain the theoretical impacts of using non-fortified and fortified fluid
thickening agents on overall nutrient delivery assuming no change in total fluid
or caloric delivery. Such data will ascertain the maximal impact of thickening
agents upon displacement of kilocalories and hence nutrients from foods.
3) To evaluate the nutrient delivery to the clients actually receiving the thickened
fluid and pureed food diet. The information garnered will provide information
on both the average delivery of nutrients as well as overall changes to the
balance between food and fiuid delivery once fluid thickening strategies have
been implemented. Actual lntake:
4) To measure the actual nutrient intake in clients on the thickened fluid and
pureed food diet. The actual impact of the fortified thickener (pablum) on the
elderly diet with respect to nutrient inadequacy will be determined.
Prognostic Recommendations:
5) To develop future recommendations for the pureed food and thickened fluid
diet based upon the delivery and intake profiles observed. Chapter Four METHODS 4.0 METHODS:
4.1 RESEARCH METHODOLOGY
This observational study analyzed delivery and intake data collected by the
investigator on residents of the Baycrest Centre for Geriatric Care.
4.1.1 Subjects:
Two groups of patients requiring dietary texture modification were used in the study. The first group of patients were able to tolerate pureed foods and regular fluids and were terrned as regular fluid (RF) patients. The second group of patients were unable to tolerate regular fluids and so were placed on a diet of thickened fluids and pureed foods. This latter group of patients were termed thickened fluid (TF) patients. Exclusion criteria for both groups of patients consisted of the following; 1) patients on mixed food textures or on energy controlled diets, 2) clients on diabetic diets, and 3) patients not consuming at
least two pureed entrees per day. These criteria allowed for a more
representative sample of the delivery andlor intakes in clients without other underlying complications. There were four men and nineteen women included in the RF patient group and two men and twenty wornen in the TF patient group.
The research methodotogy as conducted in the study is illustrated in Figure 4.1. Food Deliverv and Practices to Patients
A. Food Delivew to RF Patients
Measurement of nutrient, caloric, and fluid delivery to patients on the regular fluid (RF) diet using computerized records of food delivery for the patients.
-- - B. Theoretical Impact of an Unfortified C. Theoretical Impact of a Fluid Thickener on Food Deliverv Fortified Fluid Thickener on to RF Patients Food Deliverv to RF patients
Delivery data from the RF patient Delivery data from the RF group manipulated to incorporate patient group manipulated an unfortified fluid thickener into ta included a fortified fluid the diet. thickener into the diet.
D. Food Deliverv to TF Patients
Measurement of nutrient, caloric, and fiuid delivery to patients on the thickened fluid (TF) diet using computerized records of food delivery for the patients.
Adual lntakes of Clients on Thickened Fluids 1 E. Food lntake in TF Patients I The food intake of TF patients weighed to measure actual intake...... Procinostic Recommendations
F. Recommendations
Data from the TF patient group (both delivery and intake) used ta make future rewmmendations
Figure 4.1 Flow chart illustrating the research methodology conducted in the study. Food delivery data based on seven days of cornputerized food records were randomly collected for each patient in the RF group. The information collected included al1 foods, snacks and supplements. In order to estimate total potential intake, it was assumed that al1 food delivered was consumed. The diagnostic mode of analysis was performed to determine the population of persons within the population with deliveries below their own needs for a given nutrient. These delivery collection data were then manipulated to incorporate unfortified and fortified fluid thickeners into the diet so that the theoretical impacts of using unfortified and fortified fluid thickeners, respectively, could be assessed.
4.1-3 Data Collection from TF patients:
Similarly, seven days of food delivery were randomly collected for each patient in the TF group with analysis deterrnining the percentage of individuals with insumcient delivery to meet needs. Nutrient delivery to the TF patients was compared to nutrient delivery to the RF patients to determine if overall changes to the diet were made when the transition from regular fluids to thickened fluids occu rred.
Next, seven days of weighed food intake for each TF patient were measured to determine actual intake. Data analysis determined the proportion of individuals at risk for insufficient intake for a given nutrient. Using both the delivery and intake data collected from the TF group, prescriptive data analysis was used to determine suitable nutrient densities for the diet and to make future recommendations regarding the thickener. 4.2.1 Nutrient Deliverv to RF Clients on Reciular Fluids and the Theoretical Impact of Fluid Thickening
The first aim of this section was to determine the average daily nutrient, fluid and caloric delivery in an elderly population whose food intake was confined solely to pureed textures and regular fluids as explained in Figure 4.1 A. (These
RF patients were at the last stage before the implementation of thickened fluids was necessary. Information regarding baseline nutrient and fluid delivery in this patient group would aid in determining if these patients were already at risk of nutrient or fluid inadequacy before the transition to thickened fluids was to be made.) Next the theoretical impacts of using each a non-fortified and fortified thickening agent on this senior population were ascertained as stated in Figure
4.1 B and C, respectively.
Fluid deliveries were used to determine the amount of fluid thickener required to thicken al1 fluids for each patient. The fluids included beverages and fluid supplements such as Ensure. The recommended fluid to thickener ratio as obtained from hospital practice for pablumlrice flakes was utilized. i.e. 100 mL of fluid was thickened with 75 mL (i.e. 20 g) of thickening agent. The caloric values of the total amount of thickening agent required were then calculated for each patient.
In order to determine the thickener's impact on the diet, a number of assumptions were made. The first assumption was that the total fluid delivery would not change if a fluid thickener was incorporated into the diet. In this way, total fluid delivery. Sewndly, it was assumed that total daily caloric intake would not change upon the theoretical inclusion of the thickener into the diet. That is, the equivalent catoric value of pureed foods was displaced. Furthermore, it was assumed that this displacement of food would occur equally across al1 foods delivered. The caloric value of the thickening agent was divided by the total caloric delivery for each patient on the pureed food and regular fluid diet so as to obtain the percentage of kilocalories that came from the thickening agent. In the case of the unfortified fluid thickening agent, this percentage was used as a conversion factor by which each of the nutrient totals based on the nutrient delivery to the clients on the pureed food and regular fluid diet were then subsequently reduced. (Recall: This reduction in nutrients occurs since the unfortified fluid thickener does not contain any nutrients beyond carbohydrate.)
In the case of the fortified fluid thickener, the total amount of each nutrient from the rice flakes was calculated based on the amount of rice flakes required to thicken al1 the fluids for each patient. (The amount of pablum was the same as the amount of unfortified thickener used to thicken al1 fluids.) The nutrients from the pablum were added to the nutrient deliveries calculated when the unfortified fluid thickener was theoretically incorporated into the diet. This study has confined the use of pablum to that of a fiuid thickener and has not included the use of pablum as a thickener for pureed foods. The entire population at the Baycrest Center for Geriatric Care who were on a diet of pureed foods and regular fluids were considered. Exclusion criteria is described in section 4.1. There were four men and nineteen women included in the study. The average age for the men was 88.5 years and for the women,
89.7 years (Table 4.1). The average BMI (body mass index) for the men was
20.9 and for the women, 19.4. The desirable body rnass index range in relation to age is 24-29 for persons over the age of 65 (Whitney and Rolfes, 1993;
Mahan and Escott-Stump, 1996; Bray, 1987). Alternatively, the range of 20-25 has been considered as the acceptable limits of BM1 for adults (Health and
Welfare Canada, 1990; Harrison and Waterlow, 1990). The controversy as to which range of BMI values should be used as the standard of comparison will be discussed at a Iôter point.
Table 4.1 Average age and BMI of the RF clients on pureed foods and regular fiuids at Baycrest Centre for Geriatric Care
Men Women n 4 19 Age (years) 88.5 f 1.7' (87-90) 89.7 + 5.8 (78-102) BodyMasslndex(BMI) 20.9f3.1(17.8-24.8) 19.4 + 2.2 (14.5-29.9)
1 Data are expressed as mean i STDS. Values in brackets are actual ranges. Nutrient delivery to TF patients was measured as stated in Figure 4.1 D both including and excluding the nutrients of pablum in order to measure the impact of the thickener on diet delivery. In addition, nutrient delivery to TF patients was compared to nutrient delivery to RF patients to determine if overall changes were made to the diet once a thickener was included.
4.2.4 Subject Characteristics
The entire population at the Baycrest Centre for Geriatric Care who were on a diet of pureed foods and thickened fluids were considered. Once exclusion criteria were considered, two men and twenty women who were still eligible for the study were included. The average age for the men was 89.0 years and for the women, 81.9 years. (The average age for the women included one individual aged 42 years old. Excluding this individual, the average age of the women in years was 84.0 5 9.2.) The average BMI (body rnass index) for the men was
23.9 and for the women, 22.3.
Table 4.2 Average age and BMI of the TF clients on pureed foods and thickened fluids at Baycrest Centre for Geriatric Care
Men Women n 2 20 Age (years) 89.0 f 1.4' (88, 90) 81.9 k 12.7 (42-109) Body Mass Index (BMI) 23.9 + 4.7 (20.6-27.2) 22.3 + 4.7 (15.0-32.8)
1 Data are expressed as mean + STDS. Values in brackets are actual ranges. 4.2.5 Measurement of Food and Nutrient Delivery
The information that was used was based on food delivery rather than consumption to estimate total potential intake. Potential intakes of clients were deterrnined by examining average food and nutrient delivery to individual subjects. Daily delivery of al1 foods, snacks and supplements was obtained from computerized patient files and converted to estimates of nutrient intake using actual recipes and ingredients of foods delivered. The foods that were missing
using this approach were the foods kept at the nursing station and fed to the clients, such as juice, soda pop, etc. This information was expected to be
minimal.
Seven days of food delivery were collected (based on power analysis described in section 4.2.8). These days were randomly selected from a 28 day food cycle independent of day of week. Food delivery practices do not Vary
between week days and weekends. Care was taken to avoid religious holidays where specialized meals were prepared. Data were collected from February to
March of 1995.
4.2.6 Nutrient Composition of lndividual Recipes
The recipes for the foods were kept in Foodman, (Quichelena products)
the computer program containing the recipes for the foods sewed at Baycrest.
For foods prepared within the Baycrest facility, the nutrient content of single
portions of each recipe was calculated. by Foodman based upon individual Canada, 1988).
One shortcoming with the Foodman program was its apparent inability to calculate the water content of the recipes. Water content of individual foods was estimated by subtracting the sum of the carbohydrate (including fibre), protein and total fat weights from the cooked portion size weight for each recipe.
This method of calculation is based on the assumption that once the carbohydrate, protein, and total fat weights are subtracted from the total weight of the cooked portion, most of the remaining weight can be attributed to the weight of water. (Ash was omitted from the water calculation because it was assumed that its contribution (i.e. 1 %) to the calculation was rninor.) In other words, the weight of the vitamins and minerals in the cooked food can be considered to be negligible when compared to the total weight of the food. This estimation of moisture weight was used for al1 the recipes except for two categories, namely the sauces and gravies as well as the strained soups. For strained soups and broths, the portion size was 175 mL. Assuming that the soups and broths had a density similar to water (i.e. t g = 1 mL), then the weight of the water content was estimated to be 175 g. For cream soups, the weight of the water content was estimated by subtracting the surn of the carbohydrate (including fibre), protein and total fat weights from the cooked portion size weight. For the sauces and gravies, it was assumed that the moisture content weight was equivalent to 80 % of the cooked portion size weight. [This presumption was based on the water \ru1 ILGI 113 VI 3111 ~IIQI ~ypcaVI YI avIC;a allu aaubca II UI I I ri ic clvi iuci iacu baiiauiai i
Nutrient File (Health and Welfare Canada, 1988)l.
A second problem encountered in the Foodman prograrn was the lack of nutrient analysis for the strained soups. Because these soups are without the actual vegetables and meats (due to their solid texture), it is difficult to ascribe nutrient values. In order to estimate nutrient values for these strained soups, the total nutrient values of the non-strained version of these soups were divided in half. An underlying assumption was that there is leeching of nutrients from the meats/ vegetables into the broth during the cooking process. These resulting nutrient values were then applied to the strained soups since it was felt that these numbers were conservative yet reflective of the change in nutrient values.
4.2.7 Measurement of Daily Nutrient Delivery
The nutrient content of each recipe was transferred to a Lotus program,
Diet Calc., developed by Dr. T. Wolever (Dept. of Nutrition, University of
Toronto). The Lotus program accesses the nutrient file for other commonly consumeci food (e-g. canned fruits). Any other pre-purchased foods not found in the Lotus program, e.g. gefilte fish, were added to the Lotus prograrn according to the nutrient specifications iisted in Foodman. The Diet Calc. program allowed for the calculation of energy and nutrients delivered to each client ai every meal based on the portion sizes of the foods provided at Baycrest. The nutrients used for this analysis were protein, calcium, iron, thiamin, riboflavin, niacin, vitarnins A - - - . - complete information only for these nutrients. (The calculations of nutrients in the recipes included carbohydrate and fat although the latter two nutrients were not included in the analysis.)
4.2.8 Power Analysis for Days of Data Collection
The number of days of food records required to estimate the true average nutrient delivery for this group of individuals at a probability of 0.05 was seven
(Appendix A). Since the size of the group was fixed, the only variable which could be altered was the nurnber of days of collection. To develop this estimate, values for intakes and their variability were obtained from other studies (Owen,
1989) since no published estimates were available for this group of individuals.
The data described in the Owen study (1989) were for female elderly recipients of home delivered meals. An underlying assumption was that the variability in delivery and intake would be similar. The data was generalized to the men in this study also since the male population was small. This number of seven was based on the following equation (Basiotis et al., 1987):
X = ( Z ) (Total Variabilitv) * 1 (Eqn. 4.7) ( A ) (True Ave. Intake) (No. lndividuals in group)
X = no. of days required to estimate true average intake for a group of individuals with a defined level of confidence Z = value from the Normal Statistical Tables at the 0.05 % level of significance i.e., 1-96 A = accuracy desired i.e. 0.1 or ?O % This estimate of seven days was not appropriate for estimating the true average intake of al1 the nutrients (Le. protein, cholesterol, calcium, vitarnins A and C, thiamin, riboflavin, niacin and folate) included in the analysis of the study.
In particular, Basiotis and CO-worken(1 987) found that the required number of days to estimate the true average intake for vitamin A and cholesterol was greater than seven. lncreasing the number of days of intake to provide a better estimate for vitamin A and cholesterol was not deemed a priority for this study.
4.2.9 Data Analysis - Prevalence of Nutrient lnadequacy
The diagnostic mode application for the data analysis was used in this section. That is to Say, the aim was to detemine the number of persons within the population with deliveries below their own needs for a given nutrient.
Analysis were conducted using the SAS for Windows (Version 6.1). In particular, the predicted prevalence of potential intakes insufficient to satisfy the client's requirement was estimated via a process of summation:
PROBINAD = 1 - PROBNORM (Intk- Mean Req.1 SD Req.)
PROC MEANS N MEAN; VAR PROBINAD (Beaton, 1994) al1 nutrients. Specifically, calcium, water, as well as thiamin, riboflavin and niacin
(when the latter three nutrients are expressed in milligrams since there have been cut off levels established below which intakes should not fall) underwent a different analysis. The number of individuals whose average delivery of these nutrients fell below the established cut off levels for each respective nutrient was calculated and then divided by the total number of individuals being investigated to estimate the expected prevalence of inadequate intakes. Excess exposure to cholesterol was also descnbed as the percentage of individuals receiving cholesterol in exœss of 300 mg/ day. 4.3 Actual lntake
4.3.1 Actual Nutrient lntakes in TF Clients on the Thickened Fluid and Pureed Food Diet
In contrast to the previous section where food delivery was measured, the actual impact of a fortified thickener (i.e. rice flakes/ pablum) on the TF patient group was ascertained by measuring the weighed food intakes of this client group as stated in Figure 4.1 E. These intakes were then compared to nutrient deliveries to the same group.
4.3.2 Subject Characteristics
The same clients on the pureed food and thickened fluid diet (Le. TF patients) whose nutrient deliveries were measured were also employed in this section. Nevertheless the days of food intake collection were different from the days used to collect the food delivery data. The clients selected for the siudy were located on different floors of both the hospital and the nursing home.
Because al1 the clients were not situated in one location, it was impossible to collect food consumption data from more than one location at a time. Instead, the same days for food consumption were collected for al1 the clients who were located on the same floor to allow for collection on multiple clients. This procedure was repeated for each floor of the hospital and the nursing home where the clients participating in the study were located. 4.3.3 Food and Nufrient lnfake
Actual nutrient consumption was determined by measuring seven days of food intakes for each of the 22 individuals. Total daily food consumption was determined by weighing al1 foods delivered to and consumed by the clients. Food consurnption was converted to nutrient intake by the use of the Diet Calc. program (Dr. Tom Wolever, University of Toronto). In most instances, actual consumed weights of individual foods were obtained. Nevertheless, in some cases, foods were mixed together before being fed to the client. When this occurred, the proportion of each food consumed was estirnated. Uneaten food, which was left on the tray, was also weighed.
4.3.4 Power Analysis for Days of Data Collection
The number of days of food consumption records required to estimate the true average nutrient intake for this group of individuals at a probability of 0.05 was seven. This part of the study was performed during the rnonths of December,
1995 and January, 1996. Again, religious holidays during this period were avoided. 4.3.5 Data Analysis - Prevalence of Nutrient lnadequacy and Assessrnent of Energy lntakes
The data was analyzed using the diagnostic mode application to estimate the predicted prevalence of inadequate nutrient intakes in this client population.
In order to further evafuate energy intakes in this population, energy intake relative to basal metabolic rate (BMR) was determined. The BMR in the men and the women was estimated using the Hanïs-Benedict equations (Whitney and
Rolfes, 1993):
For men: BMR = 66 + (13.7 x wt. in kg) + (5 x ht. in cm) - (6.8 x age in years)
For women: BMR = 655 + (9.6 x wt. in kg) + (1-8 x ht. in cm) - (4.7 x age in years) -
4.4.1 Recommendations for the Future
The airn of this section was to make future recommendations for the clients on the pureed food and thickened fluid diet using the prescriptive mode application as explained in Figure 4.1 F.
The focus of this part of the study was to determine whether or not the diet at the Baycrest Centre for Geriatric Care was adequate to meet the needs of the clients. In order to answer this question a nurnber of assessments were performed. The first approach was to determine the average caloric intake an individual would need to consume in order to meet the RN1 for each nutrient.
This was accomplished through the use of regression analysis using nutrient intake as the independent variable and energy intake as the dependent variable.
Data from a total of 154 days (22 clients * 7 days) was used. Once the line of best fit was generated, the caloric intake (and its 95 % confidence intervals) necessary to achieve the RN1 was determined. The RN1 values used for thiamin, riboflavin, and niacin were the cut-off values rather than those expressed relative to energy intake.
The SAS statement used for this analysis is as follows:
MODEL ENERGY=NUTRIENT/ R CLM;
PLOT NUTRIENT*ENERGY;
PLOT P.*NUTRIENT='*' U95M. *NUTRIENT='-'
L95M.*NUTRIENT='-'/OVERLAY; The second approach focused on the evaluation of the nutrient density of the diet. The nutrient density of the pureed food and thickened fluid diet delivered was compared including the nutrients from pablum and excluding the nutrients from pablum. The average minimum caloric delivery required to meet the RN1 for the nutrients based on the delivery of the pureed food and thickened fluid diet was also calculated. In this way, the extent of pablum's protective effect on nutrient intake could be measured. The equation used to calculate the average minimum caloric delivery required was the following:
x = (nutrient den si^)^' x RN1 (Eqn 4.2)
where x = average minimum caloric delivery required to achieve RN1
(The RN1 values for thiamin, riboflavin and niacin were those stated in relation to energy and not the cut off levels found in Nutrition Recommendations (Health and
Welfare Canada, 1990).)
Finally, the group mean intakes of nutrients required to meet the nutrient needs of al1 but a very small proportion of the population were calculated for the female clients consuming the pureed food and thickened fluid. These 'necessary group mean intakes' were then compared to the actual group intakes. (The male clients consuming the pureed food and thickened fluid diet were not included in inadequate information on the variability of intake.) The equation used to calculate the necessary group intake for a given nutrient was the following:
Group Mean lntake = Average Requirement * (1- (~*~~int,ke)-'
[Eqn. 4-31
(Beaton, 1995A)
where Z = 1.655 (for 95 % coverage of the population) CV = coefficient of variation, (taken from the intake data)
When the group mean intake was expressed in relation to energy for a given nutrient, the resulting value was nutrient density:
Necessary Group Mean = Necessary Group x 1000 Nutrient Density Mean Nutrient lntake kcal (Eqn 4.4) Actual Mean Energy lntake
The necessary group mean densities were then cornpared to the group mean densities actually being consumed by the female population on the pureed food and thickened fluid diet. Chapter Five RESULTS AND DISCUSSION 5.0 RESULTS:
5.1 Food Delivery and Practices
5.1.1 Nutrient Deliverv to Clients on Rerrular Fluids and the Theoretical Impact of Fluid Thickeninq
The three objectives of this section were to; 1) determine the average daily nutrient, fiuid and caloric delivery in the RF patient population, and to ascertain the theoretical impacts of inwrporating 2) an unfortified fiuid thickener and 3) fortified fluid thickener into their diet as stated in Figure 4.1 A, B and C, respectively.
The estimates of total potential intakes for nutrients, fluids and energy were compared to the RN1 for each patient to ascertain nutrient inadequacy, using probability analyses. The probability of inadequacy was based on gender specific RNls where appropriate for the elderly aged 75 years and older (Table
2.1). For presentation purposes, the delivery data were collapsed over gender but gender specific RNls are provided. The most appropriate use of these data is to determine whether the diet, as currently delivered, meets the needs of the individual recipients. The degree to which clients were actually able to consume sufficient quantities of food to attain their RNls is addressed in later sections of this thesis.
The rnean nutrient deliveries to RF patients were generally above the RN1 suggesting that the quantities of nutrients delivered to the clients were sufficient
(Table 5.1). The average drinking fluid delivery was below the recommended
1500 mL at 1132 + 343 mL. Table 5.1 Mean Energy, Fluid and Nutrient Delivew to RF Clients (n=23) Consuming the Normal Pureed Food and Regular Fluid Diet as Compared to the RN1
% of pop. with Nutrient inadea. deliverv Energy (kcal) Protein (glkg) Cholesterol (mg) Calcium (mg) lron (mg) Vitamin A (RE) Vitarnin C (mg) Thiamin (mg/ 1000 kcal) *Thiamin (mg) Riboflavin (mg/ 1000 kcal) *Ribufiavin (mg) Niacin (mg1 1000 kcal) *Niacin (mg) Folate (pg) Total Water (mL)
Fluids (mL) drunk
* according to Nutrition Recommendations (Heaith and Welfare Canada, 1990), cut-off levels have been established for these nutrients i.e. a level below which intake should not fall. this percentage results if the average normative requirements for folate are used as the standard. a Data are mean 4 SD for a total of 23 clients. Mean nutrient delivery to each client is based upon 7 days of food delivery. This is not a requirement; rather, a level which should not be exceeded " This recommendation is not classified as a RNI. less than the recornmendation for fluid, five of those individuals had deliveries which were at least 80 % of the recommendation. On the other hand, the average total water delivery of 2372 2 578 mL, which includes the water content of foods, was well above the 1500 mL recommendation, suggesting that the patients' overall fluid delivery was adequate. When protein delivery was measured in relation to body weight i.e. g protein deliveredf kg body weight, the risk of
inadequacy was 0.2 %. The female population had a 1.3 % risk of inadequacy for folate when the average normative requirement of 154 pg for folate was used as the standard. (If average basal requirement of 43 pg for folate was used as the
standard, then none of the female population was at risk.) In other words, this
Iow level of risk would be well within acceptable ranges.
One observation that was of interest was the number of clients with a
cholesterol delivery above the recommended maximum value of 300 mg (Table
5.1). Indeed, none of the patients had a cholesterol delivery below 300 mg. The
atypically high levels of cholesterol may be the result of two factors. The
Baycrest Centre for Geriatric Care is a kosher facility where one half of the meals
are dairy in nature and a heavy reliance on eggs is observed in al1 clients.
Secondly, the consistency of a soft boiied egg is ideal for the dysphagic patient,
making it a regular item in the diet of individuals with dysphagia.
The calculations required to determine the theoretical impact of thickening
al1 fiuids in the diet of RF patients employed three underlying assumptions. The
first was that total caloric delivery to clients would not change. That is, it was 1992). The second assumption was that total (drinking) fluid delivery would remain constant. Thus, the amount of thickener required for each patient was calculated based on hisl her usual fluid delivery. Finally, it was assumed that the thickenerl fluid ratio necessary to achieve a desirable consistency was the same as that currently used for rice flakes (pablum) (i.e. 20 g thickener for every 75 ml fluid).
One remarkable finding was the impact of the thickener on the caloric delivery to the individuals. The average caloric delivery of thickener required by these clients to consume fluids was 906 + 274 kilocalories. That is to Say, 34% or one third of the total caloric delivery to these individuals would have corne from the thickener itself.
Clearly. the theoretical incorporation of an unfortified fluid thickener into the diet would have a dramatically different impact on the risk of nutrient
inadequacy as compared to the inclusion of a fortified fluid thickener (Table 5.2).
The.displacement of one third of calories by an unfortified thickener would have
profound effects on the mean delivery of nutrients. Several of the nutrients for which RF patients did not illustrate a risk of inadequacy based on the standard
regular fluid and pureed food diet were now the very nutrients for which the
patients did show such a risk. ble 5.2 Projected Mean Energy, Fluid and Nutrient Deliveiy to RF Patients (n=23) Assuming All Fluids are Thickened with an Unfortified Fluid Thickener or Fortified Fluid Thickener as Compared to the RNfa
Unfortified Fluid Thickener Fortied Fluid Thickener
Nutrient Delivery % of pop. with Delivery % of pop. with inadeq. delivery Energy (kcal) Protein (glkg) C holesterot (mg) Calcium (mg) lron (mg) Vitamin A (RE) Vitamin C (mg) Thiamin (mg/ 1000 kcal) 14 *Thiamin (mg) 26 Riboflavin (mg/ 1000 kcal) 1 *Riboflavin (mg) 4 Niacin (mg1 1000 kcal) 28 *NiacÎn (mg) 35 Foiate (pg) 19 (F) Total Water (mL)
Fluids (mL) dnink 1 according to Nutrition Recornmendations (Health and Welfare Canada, 1 go), cut-off levels I ive been established for these nutrients i.e. a level below which intake should not fall. this percentage results if the average normative requirement for folate are used as the standard. a data are expressed as mean k SD for 23 clients. Baseline nutrient delivery to al1 clients was obtained from data summarized in Table 5.1. Projected nutrient deliveries were based on the assumptions that al1 fluids would be thickened and that the caloric contribution of the thickening agent would displace foods uniformly. This is not a requirement; rather, a level which should not be exceeded "This recommendation is not classified as a RNI. 10 out of 23 patients Le. 43 % calcium intakes that fell below the 800 mg level. - - of body weight, then 9 % of the female population and 11 % of the total population would have been at risk. When thiamin, riboflavin, and niacin were expressed in relation to energy, i.e. mg/ 1000 kcal, then 14 %, 1 %, and 28 % would have been at risk for inadequate deliveries respectively. A higher prevalence of inadequacy was observed. When the absolute amounts of thiamin, riboflavin and niacin delivered to the patients were compared to the established cut-offs. That is, 6 of the 23 patients (26 %) would not have met the cut-off for thiamin, 1 person (4 %) would have fallen short of the cut-off for riboflavin and 8 clients (35 %) would not have met the cut-off for niacin. About 20 % of the female population would have been at risk for folate inadequacy if the average normative requirement was used as the standard. (If the average basal requirement is used as the standard, then none of the female population would have been at risk.). No risk of folate inadequacy was seen for the male population relative to the average normative requirement. Ten clients or 43 % of the population would have had calcium deliveries below the recommended 800 mg - An interesting observation was the increase in the number of clients whose chotesterol deliveries were below the maximum recommended value of 300 mg.
The average delivery of cholesterol to the clients on the pureed food and regular fluid diet was 700 I 245 mg. The mean delivery of cholesterol dropped to 465 +
221 mg, associated with the overall displacement of food. The number of 26 % of the population (Table 5.2).
When nutrient delivery to clients on the pureed food and regular fluid diet was measured, the RF clients showed the possibility of insufficient deliveries for only two nutrients, namely protein and folate (Table 5.1) at extremely low levels of risk. If an unfortified fluid thickener was used, the number of nutrients for which clients have less than adequate deliveries increased from two to six (Table 5.2).
The degree of inadequacy for protein and folate also increased. In other words, the patients' general risk for nutrient inadequacy would have increased dramatically if an unfortified fiuid thickener had been introduced into the diet.
ln contrast to the data measuring the impact of an unfortified fiuid thickener, pablum, as the fortified fluid thickener, appeared to have a protective effect on nutrient delivery. The only nutrients for which a risk of inadequacy was demonstrated was protein and folate (i.e. 2 % and 19 % respectively) (Table 5.2).
The calcium delivery levels for the patients would have dramatically increased; the lowest calcium delivery would have been 2441 mg which is 3 times greater than the calcium RN1 (Table 2.1).
The rice flakes contain protein, carbohydrate, fat and dietary fibre and are fortified with 7 vitamins and minerals (Tabte 5.3). It appears as though these nutrients in the rice flakes would have replaced the nutrients lost with the pureed food displacement. The one exception is folate of which there is only a minimal amount in the rice flakes ( See Table 5.2). Table 5.3 Nutritive values of rice flakes (pabium) per 100 grams
Nutrient Nutritive Value of Rice Flakes Per 100 grams *
Energy (kcal) Protein (g) Fat (g) Carbohydrate (g) Dietary Fibre (g) Thiamin (mg) Riboflavin (mg) Niacin (mg) Sodium (mg) Potassium (mg) Calcium (mg) iron (mg) Folate (pg) 1
* data obtained from Heinz Co.
folate reading cornes from the amount found in white rice flour (Canadian Nutrient File, 1988) The previous calculations were based on the assumption that fluid delivery to clients would not change once the transition from regular fluids to thickened fluids was made and that as a wnsequence, foods would be displaced from the diet to compensate for the caloric content of the rice flakes. In contrast, the aim of this section was to examine the actual diet delivered to TF clients as stated in
Figure 4.1 D. The calculations allowed for the determination of both maintenance of fluid delivery in these clients as well as the impact of nutrients from rice flakes if fluid delivery changes.
Data are provided both including and excluding the nutrients in rice flakes along with their associated risks of inadequacy. This form of presentation allowed for the direct determination of the contribution of rice flakes. Information from nutrient deliveries excluding rice flakes would be representative of those achieved were an unfortified fluid thickener used.
Table 5.4 lists the mean caloric, fluid and nutrient deliveries as well as the percentages of the population that would be at risk for nutrient inadequacy for the various nutrients. Total caloric delivery to clients was comparable to that observed in RF clients (t= 1.02, p > 0.3). Thus, it would appear at the level of pureed food and thickened fluid delivery that the projected displacement of calories to compensate for the caloric content of the thickener was occurring.
When examining the nutrient adequacy of the diet excluding the contribution of rice flakes, a number of nutrient inadequacies were observed.
When thiamin and niacin deliveries were calculated in relation to energy (Le. mg/ If thiamin and riboflavin deliveries were wmpared to their cut off levels (0.8 mg and 1.O mg respectively), 2 of the 22 patients would not have met the cut-off for thiamin and 1 person would have fallen short of the cut-off for riboflavin. Two percent and 23 % of the female and male population respectively would have had inadequate deliveries of folate if the average normative requirements of folate were used as the standard. (If the average basal requirement for folate was used, then none of the client population would have been at risk.) Four percent of the population had insufficient protein deliveries. Seven patients or 32 % of the clients had calcium deliveries below the rewmmended 800 mg. able 5.4 Mean Energy, Fluid and Nutrient Delivew to TF Patients (n=22) as Compared to the RN1
lncluding Nutrients from Pablum Excluding Nutrients from Pablum
% of pop. with % of pop. with utrient inadeq. delivery Delivenr inadeq. detivery nergy (kcal) rotein (glkg) 1 holesterol (mg) alcium (mg) 3-l(mg) itamin A (RE) itamin C (mg) hiamin (mg1 1000 kcal) rhiamin (mg) iboflavin (mg/ 1000 kcal) iiboflavin (mg) iacin (mg1 1000 kcal) rliacin (mg) olate (pg) otal Water (mL) luids (mL) drunk according to Nutrition Recornmendations (Healfh and Welfare Canada, 1990), cut-off fevels have been established for these nutrients Le. a level below which intake should not fâll. lhese percentages resuit if the average normative requirement for folate are used as the standard. data are mean + SD for a total of 22 clients. Mean nutrient delivery for each client is based upon 7 days of food delivery. this is not a requirement; rather, a level which should not be exceeded 7 clients out of 22 patients i.e. 32 % of the population had calcium intakes that fell below the 800 mg level. This recommendation is not classified as a RNI. of protein in the female client population dropped from 4 % to less than 1 %. The risks of calcium, thiamin and niacin inadequacies were removed. Indeed, the rice flake thickener appeared to replace al1 the missing nutrients with the exception of folate whose risk of inadequacy remained the same. Since there was no cholesterol in the pablum, it was interesting to note that only one patient out of the group of twenty two, i.e. 5 %, had a cholesterol delivery below 300 mg.
One striking finding was the caloric impact of the pablurn on the pureed food and thickened fluid diet. Approximately 34 % or one third of the total caloric delivery to the patients was projected if alt fluids were provided to the client in the thickened form. In this section the thickener (pablum) was responsible for only 16
% of the total calories. In other words, the calories corning from the thickener was substantially less than that originally projected. As will be discussed later, this relates to a lower fluid delivery to these clients.
The lower reliance on pablurn as a thickening agent than originally projected implied that fluid delivery to TF clients would be lower than that provided to individuals on regular fluids. This indeed was the case (t=6.5; pc0.001). The average fluid delivery to RF clients consurning the pureed food and regular fluid diet of 1132 $ 343 mL (Table 5.2) was approximately twice that provided to TF clients on thickened fluids at 585 f 208 mL (Table 5.5). One expianation for the decreased fluid delivery can be found upon examination of the general pureed food and thickened fluid diet. Items such as coffee, tea, and soda are generally removed from the diet when the patient makes the transition from Y clients, the overall level of water delivery continued to surpass the 1500 ml recommendation. This, in part, relates to the fact that the food is prepared with water. Thus the high waterl caloric density of the diet becomes the more important contributor of water.
5.1.3 Discussion of Results of the Food Delivery and Practices
The main objectives of this series of analyses were; 1) to examine the adequacy of the diet delivered to TF clients and 2) to determine whether the nutrient content of rice flakes significantiy contributed to nutrient adequacy when it was utilized as a Ruid thickening agent. A two step process was ernployed.
The first was to determine the theoretical impact of using a nutrient fortified
(pablum) versus an unfortified thickening agent assuming al1 drinking fluids provided to RF clients were delivered in a thickened format. The second step was to examine the existing diet provided to TF clients and to examine the impact of nutrients contained in rice flakes in allowing the diet to achieve nutrient adequacy.
The results showed that the RF clients were being provided sufficient quantities of nutrients and fluids. The theoretical incorporation of an unfortified fluid thickener into the diet would have resulted in several nutrient inadequacies where none had existed before. Based on this observation, it appears that the approach of using an unfortified fluid thickener in the diet to increase fluid delivery employed. Alternatively, the theoretical introduction of a fortified fiuid thickener
such as pablum would have removed several nutrient inadequacies and reduced the severity of others. This level of inadequacy would be well within acceptable
ranges (Le. < 5 %). The only exception was folate which is not available to any
large extent in pablum. Although, the fiuid delivery was below the 1500 mL recommendation, the overall water delivery (including the water from foods) was welf above the recommended level. The caloric input of the thickener would have amounted to one third of the total caloric delivery which was substantial.
From these calculations, it would appear that the use of pablum as a fluid thickening agent is a good approach since, based on delivery, the pablum would have been able to aid in evading the threat of dehydration while minimizing nutrient inadequacy.
The client base for these projections was made up of patients to whorn the pureed food and regular fiuid diet was being delivered. The underlying assumption was that fluid delivery would not change once clients made the transition from regular fluids to thickened Ruids. To determine whether this was an appropriate assumption, the actual diet delivered to TF clients was examined.
One remarkable finding was the dramatic drop in fluid delivery from 1132 + 343 rnL to 585 f 208 mL, almost one half the amount. As a result, the caloric delivery of the thickener similarly dropped from 34 % to 16 % of the total caloric delivery.
In other words, the TF clients would have been receiving more of their nutrients from the pureed food diet itself. Nevertheless, when the nutrients in the pablum WW~:SUUL~~CI~U nom me oier, a numoer OT nurrienr inaaequacies inciuaing
protein, calcium, thiamin, niacin and folate were projected. These data continue
to support the hypothesis that pablum replaces nutrients lost from the diet even
though the actual amount of pablum delivered was less than that originally
projected.
An additional observation was the high caloric delivery to both RF and TF clients on pureed foods. That is, the caloric delivery to the RF patients was
2670 + 768 kcaf and to the TF patients was 2492 + 334 kcal. These caloric
quantities are very high in cornparison to the quantities actually consumed by the
elderly as indicated by past research. For example, in their work with the frail
elderly, Frisoni and CO-workers(1995) found that the average caloric intake was
1SI 5 I 405 kcal. Similarly, Johnson (1995) found that the average caloric intake
of the regular diet among nursing home residents was 1380 t- 207 kcal while the
average caloric intake of the pureed food diet was even Iower at 1291 k 140 kcal.
Thus, it appears as if 2500 kcal is too high a caloric quantity for the elderly to
consume and it is unlikely that clients would actually consume al1 nutrients and fluids delivered.
Thus from these series of calculations it would appear that nutrient delivery
is adequate, especially in the context of utilizing rice flakes (pablum) as a fluid
thickening agent. Nevertheless, this would appear to be accomplished within the
context of unrealistic total caloric delivery. Thus the focus of the next component
of this thesis was to examine actual nutrient and fluid intakes in the TF clientele
to determine if they could actually achieve desirable nutrient intakes. 5.2 Actual lntake
5.2.1 Actual Nutrient lntakes in Clients on the Thickened Fluid and Pureed Food Diet
ln contrast to the previous work, the objective of this section was to
ascertain overall nutrient adequacy and the actual impact of a fortified fluid thickener (rice flakeslpablum) on the TF patient population by means of weighed food intakes (Figure 4.1 E).
The mean caloric intake of the clients was 1568 f 342 kcal (Table 5.5);
much lower than the 2492 IT 334 kcal delivered (Table 5.4) and more in line with
other estimates of caloric intake for this population (Frisoni et al., 1995; Johnson,
1995). Water intake decreased in parallel with the reduced caloric consumption.
The total delivery of water coming from the foods and fluids to these clients was
approximately 2500 mL. Nevertheless, the total water intake was 1078 ir: 296 mL with only 301 k 100 ml actually coming from fluid consumption. Only one client
out of the population of 22 had a water intake above the recommended 1500 mL.
This low level of consumption of thickened fluids was associated with a
lower reliance on rice flakes as a thickening agent, with only 228 -t 23 kcal per
day being consumed. Nevertheless, rice flakes continued to contribute 14.5 % of
overall caloric consumption.
When total nutrient intake, including nutrients in pablum were considered,
eight percent of the population was at risk for protein inadequacy when protein
was expressed in relation to body weight i.e. gl kg (Table 5.5). When the average , lUCl .YI Y~UIWVI I IW IL IWI Iulavz waa U~GUaa LI IG aiai lual u lui LUI 1 Ipdi l3VI 1, 44 70 of the female population and 97 % of the male population were at risk for insufficient folate intakes. (If the average basal requirement for folate was used as the standard for cornparison, then none of the fernale nor the male populations were at risk for folate inadequacy.) Nine percent of the clients did not have calcium levels above the recomrnended 800 mg. While niacin exposure was adequate when expressed relative to caloric intake, 5 % of the client population did not meet the niacin cut-off level as recommended by Nutrition
Recommendations (Health and Welfare Canada, 1990).
The intakes of the clients were considered after removing the nutrients and
kilocalories that would be present as a result of pablum to determine the actual
impact of the pablum in the diet. Not surprisingly, the level of risk was higher when these nutrients were elirninated. Fifteen percent of the population had
inadequate intakes of protein (Table 5.5). Less than 1 % of the population had
inadequate thiamin and niacin intakes, respectively, when thiamin and niacin
intakes were expressed in relation to energy i.e. mg/ 1000 kcal. If thiamin,
riboflavin and niacin intakes were compared to the cut-off levels, 55 % of the
population did not meet the thiamin cut off level, 27 % did not meet the riboflavin
cut-off and 59 % did not meet the niacin cut off. None of the population had
calcium levels above the recommended 800 mg. At risk for folate inadequacy were 52 % of the female population and 97 % of the male population. (This last finding was based on using the average normative requirements of folate.) ible 5.5 Mean Energy, Fluid and Nutrient lntakes of TF Patients (n=22) Consuming Normal Pureed Food and Fluids Thickened with Pablurn as Compared to the RN1
lncluding Nutrients from Pablum Excluding Nutrients from Pablum
% of pop. with % of pop. with trient nadeq. intake lntake inadeq. intake iergy (kcal) 1340 4 319 otein (glkg) 8 0.96 + 0.27 15 iolesterol (mg) 474 4 185 ~lciurn(mg) gb 518 k 128 in (mg) 16-i-4 :amin A (RE) 1804 k 772 :amin C (mg) 121 +42 iiamin (mg/ 1000 kcal) 0.62 1 0.1 5 hiamin (mg) 0.81 f 0.21 boflavin (mg/ 1000 kcal) 0.92-i- 0.12 iboflavin (mg) 1.23 f 0.31 acin (mg/ 1000 kcal) 10.36 1.61 iacin (mg) 5 13.72 k 3.47 'late (pg) *97 (M),44 (F) 164 154 97 (M), 52 (F) ta1 Water (mL) 1078 t 296 iids (mL) drunk iccording to Nutrition Recommendations (Health and Welfare Canada, 1990), cut-off levels have been established or these nutrients i.e. a level below which intake should not fall. hese percentages result if the average normative requirement for folate are used as the standard. lata are mean f SD for a total of 22 clients. Mean nutrient intake of each client is based upon 7 days of weighed food intake. clients out of 22 patients i.e. 9 % of the population had calcium intakes that fell below the 800 mg level. !2clients out of 22 patients i.e. 100 % of the population had calcium intakes that fell below the 800 mg level. 'his is not a requirement; rather, a level which should not be exceeded his recommendation is not classified as a RNI. II ~f IG avei aye vaaai ieyuii eiiiei ILS ui iuiaie were useo as me sranaaras, men neirner the female nor male populations were at risk.)
Pablum reduced the severity of some of the nutrient inadequacies. The risk of
insufficient calcium intakes was reduced from 100 % to 9 % (Table 5.5). The
percentages of the population not meeting the thiamin and riboflavin cut off levels were eliminated and reduced from 59 to 5 % in the case of niacin. That is to Say, the threat of the population not meeting the thiamin and riboflavin cut-offs was eliminated once pablum was incorporated into the diet. The risk of insufficient protein intakes was reduced in half with the aid of pablurn. On the other hand, inadequate folate intakes remained the same even when pablum was included in the diet. This finding was expected since there is only a minimal amount of folate in rice flakes (Table 5.3).
As previously noted, the caloric intake actually achieved was substantially lower than the mean delivery. While this intake level is more consistent with published
estimates of intake in frail (Frisoni et al., 1995) and/ or institutionalized seniors
(Johnson, 1995), an attempt was made to determine whether the clients would likely be
in energy balance. To address energy balance, intake relative to basal metabolic rate was examined.
The average BMR of this population based on the Harris-Benedict equation was
estimated to be 1074 f 169 kcal (Whitney and Rolfes, 1993) (Table 5.6). Energy
intakes expressed relative to the BMR were on average 1.38 (male) and 1.47 (female) times BMR. Since this population was bedridden and would have had only minimal energy expenditure from activity, it appears as though the clients' intakes were greater than their caloric needs. On the other hand, the caloric consurnption of the men and -----.--.-rr--. '- -- ...--. . """ " .-. . " .- .---....m. ..,.UV- ,V.V.Y -1 III.UI.Y ,Y. ,,,Y,l Ul lu women (Table 5.6). Were these individuals to consume energy at the level of the RNI, then the RN11 BMR ratios for the men and women would be 1.56 and 1.64, respectively, suggesting that high activity levels would be necessary to remain in energy balance. 'able 5.6 Mean Energy lntake and Basal Metabolic Rates of TF Patients (n=22) Consuming the Pureed Food and Pablum Thickened Fluid Deta
Energy Basal Energy lntake Metabolic Rate lntake -RN! BMR BMR
Male
Female
a Data are mean + SD for 22 individuals. estimates of BMR based on the Harris-Benedict equation (Whitney and Rolfes, 1993) ------. - -. ------7 ------
The analysis of the actual food consumption of the TF clients provides evidence that the nutrients from pablum replace those nutrients lost with the displacement of food that occurs when a fluid thickening agent is incorporated into the diet. For nutrients such as thiamin, riboflavin, and niacin, the risk of nutrient inadequacy is eliminated once the nutrients from pablum are included in the diet. The risk for nutrient insufficiency for nutrients such as protein and calcium is dramatically reduced. The risk of calcium inadequacy was 100 % if pablum was not included in the diet; this risk was reduced to 9 % once pablum was included in the diet. This finding was very different from that based on the theoretical inclusion of pabtum into the diet of RF patients which projected that the lowest calcium delivery would be three times the RNI. This observation may be explained in part by the fact that the level of pablum, which contains a considerable amount of calcium (Table 5.3), consumed in the diet was much lower than that originally projected based on delivery. A reduction in the arnount of pablum in the diet would be paralleled by a reduction in calcium levels.
Nevertheless, the threat of folate inadequacy is the same, regardless of the presencel absence of pablum due to the minimal amount of folate in pablum.
These results point out the benefit of using a fortified fluid thickener, but suggest that the formulation of pablum is not ideal for this client population.
One astounding observation was the caloric intakes of these clients. Their intakes well surpassed the caloric levels that would have been predicted based on their basal metabolic rates (BMR). An appropriate estimate of energy needs . - . - - - - r-r-.-'---. - .- -" .--- "------. -----7------" -, .. -.-.. - .- .- -.-.. - --.-.- diet induced thermogenesis and an extra 10 % BMR is added to be consistent with minimal activity levels (Mahan and Escott-Sturnp, 1996; Whitney and Rolfes,
1993). The caloric intake achieved was actually greater than would have been predicted based on this calculation at 1.38 and 1.47 times the BMR for the male and female populations, respectively. If indeed the 1.2 BMR estimate was correct, then weight gain would have predicted. However, based on chart reviews, this population was weight stable over the six rnonth period prior to the collection of the intake data.
The apparent anomaly of the population eating in excess of their energy needs without any evidence of weight gain suggests that other issues rnay be playing a role. The first issue is whether the Harris-Benedict equation is a reliable estimate of BMR. Roberts and CO-workers(1992) found in their study of energy requirements of elderly men that measured energy expenditure on average differed only slightly from values predicted from body weight by standard equations. Changes in BMR with age are consistent with changes in age and weight.
The second issue to be considered is the possibility that the advanced disease status of these patients may actually play a role in increasing the rnetabolic rate or in interfering with energy utilization. As mentioned earlier, a number of studies have raised the possibility that increases in energy expenditure rnay result from the tremor that occurs in Parkinson's disease (PD) (Abbott et al.,
1992; Davies et al., 1994). Nevertheless, the patients with PD involved in this PLUUY ai c ai ai i auvai I~GUqbayc III LI IG UI~GQ~Gplu~~aa, IIIU~CIIG ~I~IUIL~IQLI ICI than tremor was observed. Based on the results of their study of energy expenditure in patients with PD, Markus and CO-workers (1992) postulated that the muscle rigidity was responsible for the increase in energy expenditure observed in the patients. Energy expenditure was measured by means of indirect calorimetry. However, they also found that when the muscle rigidity was markedly decreased in treated patients or in those patients in whorn minimal rigidity was present, resting energy expenditure was still raised in cornparison with control subjects. In other words, raised energy expenditure plays an integral although unexplained role in Parkinson's disease in many patients. Another prospect is that diet induced thermogenesis may play an important part in the energy metabolism of aged individuals, however, little research has been done in this area.
On the other hand, the average caloric intakes for the men and the women are lower than what would be prescribed to them based on the RNls. The caloric intakes of these clients surpasses their requirements; to demand that the patients ingest even more is impractical and would be arduous to carry out.
One important issue is whether the client population is able to maintain desirable body weights given their energy intakes. As mentioned earlier, a number of sources have indicated that a BMI range of 24 to 29 is desirable for those aged over 65 years (Whitney and Rolfes, 1993; Mahan and Escott-Stump,
1996; Bray, 1987). The range has been associated with minimum mortality.
Utilizing life insurance data (Society of Actuaris, 1979)' Andres and CO-workers women at each decade of Iife. The data for both men and women rose with age and with no sex difference. This led to a new set of age-related ranges for BMI including the range previously mentioned for individuals over the age of 65 years.
The average BMls of the men and women in this study were 23.9 and 22.3 respectively. According to the aforementioned BMI range the women in the group were, on average, underweight. However, this age-related BMI range is based on the weight-for-height tables that are designed for healthy individuals whereas the seniors in this study were not healthy and suffer from a number of disorders.
Furthermore, weight gain would be required in order for the BMI of these clients to fit into the BMI range of 24- 29. This in turn, would necessitate greater csrloric intakes; an arduous goal at best since, as already mentioned, caloric intakes are much greater than that based on BMR. According to Andre and colleagues
(1985), individuals with specific illnesses should have their weight goals set in accordance with established medical information. Moreover, they indicated that more studies are required especially in persons over the age of 70 since the data was too sparse to make any recommendations with confidence to aged individuals.
In contrast, other sources (Health and Welfare Canada, 1990; Harrison and Waterlow, 1990) have indicated that the healthy range of BMls for al1 adults is 20 to 25. In this case, the men and women involved in this study had BMls that fell within this ideal range. Although similar arguments can also made against Y W. - - proportion to height for these clients.
One interesting observation was the decreased intake of nourishments or snacks among this client group. The bulk of these nourishments were fluid supplements such as Ensure and Boost. One reason behind the implementation of nourishments between meals was to ensure adequate nutrient and energy intakes in the client population. Actual nourishment intake was measured in TF clients; in general consumption of the nourishments was low. This suggests that the use of nourishments as optimal between-meal snacks is not an effective strategy to increase either fluid or nutrient intake in this population.
The entire reasoning behind using pablum as a fluid thickening agent was multifaceted in origin. Firstly, pablum demonstrates the ability to thicken fluids to a consistency that is easily tolerable by patients with dysphagia. Secondly, it was predicted that the nutrients in pablum could potentially replace those nutrients that are lost with the displacement of food that tends to take place when a fiuid thickening agent is introduced into the diet. Thirdly, it was believed that the use of pablum as a fluid thickener would increase Ruid intakes to what would be considered a 'safe' tevel, and consequently, help in preventing the risk of dehydration. From the data regarding the actual intakes of TF clients, it appears as though the first two objectives were fulfilied but the third aim of pablum was not. The fluid levels were severely decreased in the clients ai 301 f 100 mL; even when the total water intake (which included both the water in foods and fluid levels) was examined, it too was well below the 1500 mL recommendation at -. concern for health care givers. As mentioned previously, the airn of introducing any fluid thickener into the diet of a client with dysphagia is to ensure adequate hydration since dehydration is a real problem among patients with dysphagia. The fluid thickener is supposed to aid such clients in consuming regular fluids by thickening the fluid to a consistency that is easy to swallow. At this point, it seems as though the use of pablum has not promoted fluid intakes of the patients to the point where the risk of dehydration is not a problem. However, there is no conclusive evidence of dehydration in this group. It is possible that the recommended level of fiuid intake may not be suitable for this population.
Nevertheless, the low level of fluid intake remains a concern.
Hence, it would appear that the intent of pablum was correct. Pablurn did eliminate the risk of inadequacy for thiamin and riboflavin (when the cut off recomrnendations were used as the standard of comparison) and reduced the severity of nutrient inadequacy for protein, calcium and niacin (when the cut off recommendations for niacin were used as the standard of comparison).
Nevertheless, while nutrient inadequacy was not a serious concern, by in large, the overall diet needs to be addressed, since the problem associated with fluid intake was not corrected. The data collected to date could provide important information necessary to develop guidelines for future changes as will be seen in the next section of this thesis. V
5.3.1 Prescriptive Data Analysis
The aim of this section was to make recommendations based on the collected intake data which could provide the fundamental basis for the reformulation of diets provided to TF clients (Figure 4.1 F). Since it would appear that one of the major limitations to providing adequate levels of nutrients to these seniors is their low energy intake, an attempt was made to define appropriate nutrient densities which would reduce nutrient inadequacies to acceptable levels
(i.e. p < 0.05).
The relationship between nutrient intakes and energy intakes was first determined using nutrient levels including those provided by the pablum. The nutrient intake relative to the day's caloric intake for al1 7 days for each of the 22 patients, i.e. 154 days, was examined by rneans of regression analysis. The ? values for each of the nutrients were calculated and the significance of the
Pearson's r values were assessed using the 2 tailed test method. (Table 5.7).
Nutrient intakes were significantly positively related to energy intake. That is, nutrient intakes increased as energy intakes increased with 25 to 44 % of the variance in nutrient intake being explained on the basis of total caloric consumption. Table 5.7 Relationships Amongst Nutrient and Energy lntakes of TF Clientsa
Nutrient F value Level of Significance for ~eakon'çr Protein (glkg) 0.001 Calcium (mg) Vitamin A (RE) Vitamin C (mg) Thiamin (mg) Riboflavin (mg) Niacin (mg)
' values are the results of regression analysis based on a total of 154 days of intake data. Since nutrient intakes were related to energy intakes, the minimum average daily caloric intake required to achieve each nutrient RNI was determined using the line of best fit obtained from linear regression analysis
(Table 5.8). Caloric intakes required varied greatly depending on the nutrient.
When the nutrients from pablum were considered, an intake of 1500 kcal/ day of the diet would contain sufficient calcium, iron, thiamin, riboflavin, niacin, vitamins
A and C, and protein to meet the RNls. That is, the diet, as consumed on average by the clients, contains adequate amounts of these nutrients. On the other hand, over 1730 kcal would be necessary in order that the recommended levels of water and folate be met.
Pabtum's protective effect on the nutrient density of the diet was obsewed when measuring nutrient delivery including and excluding the nutrients from pablurn (Table 5.9). Pablum increased the nutrient density for most nutrients.
The densities of calcium, iron, thiamin, riboflavin, and niacin in the diet containing pablum were approximately twice as high as the nutrient densities of the diet not including pablum. Vitamins A and C and folate did not follow these trends since pablum does not contain vitamins A or C, and only a minimal amount of folate.
Nevertheless, the minimum caloric delivery required to meet the RNI was less than 1500 kcal for iron, vitamins A and C, Table 5.8 The Average Galoric lntake for TF Subjects (n=22) Required to Meet the RN1 for a Given Nutrient Based on the Relationship Between Nutrient and Energy Consumption of the Diet Fortified with Pablurn
Nutrient RN1 Caloric lntake (km for the Energy the Energy lntake lntake , Protein (glkg)
' Calcium (mg) 1 lron (mg) 'vitamin A (RE) Vitamin C (mg) *Thiamin (mg) *Riboflavin (mg) *Niacin (mg) 1Folate (pg) Total Water (mL)
* according to Nutrition Recommendations (Health and Welfare Canada, 1990), cut-off levels have been established for these nutrients Le. a level below which intake should not fall. a values are mean f SE based on results from regression analysis. b This recommendation is not classified as a RNI. ' The caloric intake required to meet the RN1 for males was deterrnined since it was the higher of the two RN1 values. 'able 5.9 Nutrient Density of the Oiet Delivered to TF Clients (n=22) as Compared to the RN1
Nutrient Density Caloric Delivet-y Nutrient Density Caloric Delivery ~ Nutrient Delivered Required to Meet Delivered Required To (per 1000 kca~)~ RNI~ (per 1000 kcal)' Meet RNI~
With Pablum With Pablum Without Pablum Without Pablum lron (mg) 22-4 409 10+2 900 Calcium (mg) 940 + 186 428 -1 92 1869 Vitamin A (RE) 1274 + 272 1535 + 311 651 Vitarnin C (mg) 78 + 15 94 +21 426 Thiamin (mg1 1000 kcal) 1.60 + 0.37 0.58+ 0.18 690 Thiamin (mg) 1379 Riboflavin (mg1 1000 kcal) 549 Riboflavin (mg) 1099 Niacin (mg1 1000 kcal) 770 Niacin (mg) 1497 Folate (pg) 1604 Total Water (mL)
8 the caloric delivery of the diet with pablum was 2492 f 334 kcal; without pablum, 2092 f 329 kcal a values are mean + SD based on 22 observations. values were obtained using equation 4.2 this recommendation is not classified as a RNI. thiamin, riboflavin and niacin, regardless of whether the nutrients from pablum were included or excluded (Table 5.10). The minimum caloric delivery required to meet the folate RN1 was greater than 1500 kcal regardless of whether the nutrients from pablum were included or exciuded. Only in the case of calcium did pablum's ability to increase nutrient density appear to make a difference; greater than 1800 kcal were required to meet the calcium RNI if the calcium from pablum was excluded whereas less than 900 kcal were required if the calcium from pablum was included. One assumption made in these calculations of the nutrient delivery was that al1 foods would be uniformly consumed.
The data derived from estimating the food delivery to TF clients implied that if al1 thickened fluids were ingested, the existing nutrient density of the diet containing pablum was adequate to meet nutrients needs (Table 5.9). However, it was observed that the actual fluid consumption of 301 & 100 mL was only 51 % of fluid delivery (585 5 208 mL). Thus, the protective role of pablum can only be observed if ail thickened fluids are consumed by the clients.
The previous data was also based on the assumption that the goal was to provide al1 the clients with the RNIs for the nutrients. Nevertheless, it is possible to design a diet based on the appropriate group mean intakes which will lower the risk of inadequacy to less than 5 % with lower energy densities. The necessary group mean nutrient intakes required to meetlsurpass the personal requirements of the female TF clients was calculated using equation 4.3 (Table 5.1 0). 101
ble 5.10 The Nutrient Densities (Necessary Group Intakes) Required To MeetlSurpass the Personal Requirements of the Female TF Clients (n=20) as Compared to the Actual lntakes Obsewed
Nutrient Average Necessary Group Mean Necessary Nutrient Nutrient Density of the Requirement lntake' Density Diet as Consurned
(Unrelated to energy) (per 1000 kcal) (per 1000 kcal) I 0.69 Protein (glkg) 1.21 0.82 Calcium 800" 533 874 lron (mg) IO 6.4 23 Vitamin A (RE) 625 417 Il68 Vitamin C (mg) 59 40 78 Thiamin (mg) 0.35 1.55 1 Riboflavin (mg) 0.40 1.98 Niacin (mg) 5.28 18.11 Folate (pg) 216 1O9 1 'Fluid (ml) 1O00 675
1The necessary group intake obtained from the following equation:
Group Mean lntake = Average Requirement * (1- (~'~~i.bd"(Beaton, 1995A) where Z = 1.655 (for 95 % coverage of the population) CV = coefficient of variation, (taken frorn the intake data)
* The necessary group mean intake was derived from the recommendation and not from the equation. The necessary nutrient density was based on the necessary group mean intake. a This recommendation is not classified as a RNI. b~hevalues given are expressed relative to energy i.e. mg1 1000 kcal. the calcium RN1 is a desired group mean intake and is not based on the average requirement + 2 SD. average requirement, the cut off values for the three vitamins were used. These values were then used to develop the necessary group mean densities using equation 4.4 based on the assumption that mean caloric intake is 1500 kcal in this population. Hence if the density is adjusted for 1500 kcal, then a group mean intake at that level cm be obtained. These recomrnended densities were wmpared to the actual nutrient densities of the diet consumed. The derivation of the necessary group mean intake for fluid was based on the recommended level of intake rather on equation 4.3. The recommended 1500 rnL of fluid is considered to be the necessary intake for every individual in order to avert the risk of dehydration. The necessary nutrient density for fluid was then based on the necessary group mean intake. Consistent with the estimates of nutrient inadequacies, the densities of iron, vitamins A and C, thiamin, riboflavin and niacin related to energy actually consumed are approximately twice the amount deerned as necessary to meet/ exceed the personal requirements of these female clients. Not surprisingly, the recommended nutrient densities for protein, folate, and fluid are beiow the levels provided in the diet. ~3.3.~UISC;USSIUII VIrresC;r I~ZIV~uaza nriaiysis
Unlike the previous work which examined nutrient and fluid adequacy within the population, the aim of this section of the study was to provide recommendations for suitable nutrient densities of a diet planned for this client population.
The underlying hypothesis was that caloric intakes could not be increased beyond the level currently observed. Three series of estimates were developed.
The first was to determine the minimum caloric intake necessary to satisfy nutrient needs based on the current diet provided. Second, suitable group mean intakes for each nutrient to achieve an acceptably low level of inadequacy was calculated using variance estimates of intake based on the client population.
Finally, the desirable group mean intakes were converted to nutrient densities assuming that a mean energy intake of 1500 kcall day was representative of achievable intakes in this population. The data suggest that the current diet, including nutrients from pablum, has an inappropriately low density of protein, calcium, folate, and fluid. That is, while the pablurn contributes nutrients in a positive fashion, its formulation is unable to overcome problems with protein, calcium, folate and fluid consumption.
As mentioned earlier, the first series of estimates determined were the minimum caloric intakes required to achieve the RNI. A minimum caloric intake of
1425 kcal was required for al1 the nutrients except folate and fluid (Table 5.8).
For the latter two nutrients, over 1730 kcal was required to achieve the recomrnendations. The estimates of minimum caloric intake required to delivery (Table 5.9). This is due to the issue of fluid intakes being lower than fluid delivery leading to less reliance on the thickener as discussed previously.
Nevertheless, the caloric needs are below actual caloric intake for al1 nutrients with the exception of folate and fluid for both delivery and intake. These two sets of reaults (i.e. Tables 5.8 and 5.9) are consistent with the estimates of nutrient inadequacy found within the client population.
The second series of estimates derived were the necessary group mean intakes using the estimate of actual intakes and their variance based on the client population. These estimates were calculated in order to determine appropriate group mean nutrient densities necessary to meet requirements based on a reasonably achievable intake of energy. The necessary group nutrient intakes required to meet or surpass the persona1 requirements of the female population were higher than the RN1 for al1 nutrients except vitamin A (Table 5.10). This finding was to be expected since the higher estimates reflect the large variances of intake observed in the TF population. The variances observed in this study were larger than those found in past research. Johnson and CO-workers(1995) exarnined seven days of food intake and nutrient supplement use in 20 female nursing home residents consuming a pureed food diet. The variances of energy and nutrient intakes observed in their study were much smaller than the variance of intakes noted in this study.
The final series of estimates determined necessary nutrient densities required to meet requirements based on a 1500 kcall day diet, assuming that this cl IGiyy il ILanG VVa3 1 Fyi~~~iirurivG WI uui iiuvruiu ID iruitwu ri, .,VU- W.,,, ,. r-r,.,..,. ..
The necessary nutrient densities were lower than the nutrient densities actually consumed for al1 nutrients except protein, folate and fluid (Table 5.10). These results were consistent with findings of nutrient inadequacy arnong the clients on the thickened fluid diet. These data suggest that the diet is safe for certain nutrients but inadequate for others. Since it is unlikely that overalt caloric intake cari be increased, overalt adjustments to nutrient density are necessary.
The role of pablum was found to be valuable in increasing calcium levels.
Based on delivery, a dietary intake of approximately 1900 kcall day would be required to achieve the recommendation if pablum was not in the diet. If pablum was included in the diet, only 850 kcall day would be required. That is, inadequate calcium levels would be evident without pablum but the insufficiency is covered by using pablum. Reinforcing this finding is the fact that the risk of inadequate calcium intakes dropped from 100 to 9 % when pablum was included in the diet (Table 5.5).
Vitamins A and C as well as folate levels were diluted or decreased due to the presence of pablum in the diet. This observation was a result of the absence of vitamins A and C and the marginal amount of folate in pablum. However, this nutrient dilution did not pose a problem for vitamins A or C since the diet with pablum could stiil meet the nutrient needs of the client population.
As demonstrated by the data, the protein intake of TF clients falls short of the recommended. Although the protein in pablurn does reduce the risk of somewhat low level.
A focus on fluid and folate levels in the diet is necessary. As demonstrated earlier, both the delivery and intakes of the TF clients were well below recornrnendations for folate and fluid. Hence, the necessary nutrient densities for folate and fluid must be achieved by means other than pablum. Chapter Six GENERAL DISCUSSION 6.1 DISCUSSION:
The use of a fiuid thickening agent in the diet of an individual with dysphagia is one of the non-invasive methods to ensure that the patient with dysphagia receives sufficient fluids to avert dehydration. Nevertheless, the use of fluid thickening agents is not without its own inherent cost. That is, the thickener displaces food intake thus making it more difficult to achieve nutrient adequacy in this population. The hypothesis under investigation in this study is that the displacement of kilocalories from the pureed food diet by an unfortified fluid thickener will lead to nutrient inadequacy. The rice flakel pablum thickener will replace the minerals and vitamins lost by kilocalorie displacement, thus preventing nutrient inadequacy. The data provided in this thesis support the hypothesis for certain nutrients such as thiamin, riboflavin and niacin but not for others including folate, protein and calcium, although in the case of the latter two nutrients the risk of nutrient inadequacy was lowered considerably.
Several steps were taken to address this hypothesis. The first was to determine the theoretical impact of thickening al1 fluids delivered to clients when they made the transition from regular to thickened fluids. Based on these theoretical calculations, the data suggested that pablurn protected against projected inadequacies for protein, calcium, thiamin, riboflavin, and niacin.
However, folate was a problem since it is not present in the pablum.
Nevertheless, when the actual delivery of the TF diet was examined, the importance of pablum was much less pronounced. This predominantly related to the fact that fluid delivery was reduced by approximately 50 %. Thus, the less than originally projected. The risk for folate inadequacy remained a concern.
Since total caloric delivery to the clients was in excess of predicted consumption, the second step was to evaluate the nutrient and fluid adequacy of the TF diet as consumed by the clients. The actual intake data revealed Iower than predicted fluid consumption. Even when overall water intake (including water found in foods) was considered, the fluid intake of this client population was still below the 1500 mlrecommendation. Folate intakes were well below the
RNI, indicating a cause for concern in the population. The hypothesis was proved to be true for some nutrients; that is, pablum did have protective effect on protein, thiamin, riboflavin, niacin and calcium intakes. Nevertheless, in the case of other nutrients such as folate, the hypothesis was found to be not true.
Finally, as a result of these data, recommendations were developed as pertaining to the existing diet using a number of estimates. One recommendation was that pablum, as a fluid thickening agent, be reformulated to better meet the nutrient needs of the geriatric population. lncreasing the folate and fluid concentrations in the diet were among the other recommendations.
The details of these observations have been discussed following the results for each individual section and hence will not be repeated here. Rather, the discussion will focus on the implications of the observations. In order to evaluate food delivery and practices, two assumptions made in this study were that: 1) Ruid and 2) caloric deliveries would not change. However, it was observed that fluid delivery decreases when the transition from regular fluids to thickened fluids is made. The average quantity of drinking fluids being delivered to the RF clients was 1132 + 343 mL (Table 5.4). This amount decreased by over one haff so that TF patients were receiving on average 585 +
208 mL (Table 5.5). As mentioned previously, part of this decrease may be explained by the general removal of items such as coffee, tea and soda when the transition to thickened fluids from regular fluids takes place. The preparation of the pureed food with water ensured an adequate fluid supply in the diet, thus reducing the risk of dehydration.
Because of this reduction in fluid delivery, less thickener was required to thicken the fluids. This finding was confirmed when one examined the potential impact of the thickener on the total caloric delivery to RF patients. The thickening agent, fortified or unfortified, would be responsible for approximately one third of the total average caloric delivery. At this level, it was projected that protein, calcium, folate as well as thiamin, riboflavin and niacin deliveries would be at high risk for inadequacy if an unfortified thickening agent was used (Table 5.2). For the most part, pablum would protect these deliveries with the exception of folate
(Table 5.2). When nutrient delivery to the TF clients measured, the thickener's caloric input accounted for only 16 % of energy; less than half than that originally predicted. Less pureed food was displaced from the diet. The delivery of the pUl WSU lVUU QI IU LI IIbnCI ICU llUlU UlCl LI lai II IC~IUUGUpauiui II II I~UIpu8 arczu auiiibirci Ir quantities of the various nutrients. The only exception was folate. However, if the diet was devoid of pablurn, then the nurnber of nutrients, including protein, calcium, thiamin and niacin, as well as the severity of inadequacy would have increased. The incorporation of the pablum into the diet does make a difference.
The assumption that caloric delivery would not change was correct. The caloric delivery to those patients on regular fluids was 2670 + 768 kcal which was not significantly frorn the delivery of 2492 + 334 kcal to those patients receiving thickened fluids (t=1.O2 , p > 0.3).
However, the research performed up to this point was al1 theoretical in nature; the actual consumption levels of the clients on the pureed food and thickened fluid diet had not yet been investigated. One problem with tray delivery is that one does not know nor can one predict with reasonable accuracy which meats will be well consumed and which will not. This issue is particularly problematic in the cognitively impaired where periods of alertness may Vary throughout the day. It is unlikely, given the large quantities of food delivered, that al1 food would be consumed; hence the need to examine actual intakes. The aim of this section was to measure the actual intakes of TF clients. It was believed, based on the research performed up until this point, that the hypothesis would be proven to be true. Namely, pablum would replace those nutrients lost with the displacement of food that occurs with the introduction of a fluid thickening agent into the diet, thus preventing nutrient inadequacy.
Pablurn removed the risk of nutrient inadequacy for thiamin and riboflavin such that the cut off levels for the vitamins were met and it reduced the risk of niacin inadequacy to within acceptable ranges (Le.p = 0.05). The presence of pablum reduced the threat of insufficient protein and calcium intake by one half and 90 % respectively, although the risk of inadequacy for both nutrients was about 10 % suggesting a concern. Only the risk of folate inadequacy remained virtually the same whether the pablum was present in the diet or not; that is, the
risk of folate inadequacy was outside acceptable ranges in both cases. As stated earlier, this was to be expected since there is only a marginal amount of folate in pablum (Table 5.3).
As mentioned earlier, there was one female patient aged 42 years who was included in the study. In retrospect, this patient should have been excluded from the study. Her age, BMR and the RNls appropriate for her age group
restrict her from being classified as a senior even though her lifestyle is comparable to that of other institutionalized elderly. Nevertheless, she was
included in the study in order to prevent the population size from diminishing. ------..r.----.--.- -. ------. ...--m.- --.-
6.3.1.1 Energy
Actual intake of energy was 1568 + 342 kcal, only 62 % of the overall energy delivered to each TF client. This level of caloric intake is consistent with other studies dernonstrating average caloric intakes of 1515 I405 kcal and
1380 + 207 kcal for the regular diet while the average caloric intake of the pureed food diet was even lower at 1291 + 140 kcal (Frisoni et al., 1995;
Johnson 1995). The actual caloric intakes, while in the range of other studies, are below the recommended intakes of 2000 kcal and 1700 kcal for males and females, respectively (Table 2.1). To determine whether these clients would be in negative energy balance, a number of parameters were examined including weight stability and intakes relative to BMR, al1 of which indicated energy balance in this population.
The first parameter indicating energy balance in this population was weight stability. Weight stability of the clients had been ensured by examining the previous six months' weight records for each individuat. The average BMI (body mass index) values were 23.9 f 4.7 and 22.3 4 4.7 for males and females respectively, which is within the BMI range of 20 to 25, the healthy range of weights (Health and Welfare Canada, 1990; Harrison and Waterlow, 1990). On the basis of body weight, it would appear that energy needs were being met for al1 the individuals in this client population. Nevertheless, body weight is not necessarily a sensitive predictor of energy requirements. This may be particularly true in the elderly population where declining renal function is account for weight stabitity despite losses in lean body weight.
Adequacy of energy intakes was also assessed by examining intakes relative to BMR. As cited earlier, a ratio of 1.2 times 8MR was considered reasonable for this population since BMR + 10 % BMR would cover diet induced thermogenesis and an additional IO % BMR would cover minimal activity levels.
The observed intake to BMR ratios were much greater than 1.2 times BMR, namely ? .38 and 1.47 for males and female respectively (Table 5.6). Clearly, the population is consuming more than sufFicient energy to meet needs for BMR,diet induced thermogenesis, and minimal activity levels. An explanation for this unusual finding may possibiy be found upon examination of the various components that make up energy requirernents.
When estimating the energy needs of an individual, there are three aspects to consider, narnely, resting energy expenditure, diet induced thermogenesis, and energy expenditure for activity. Roberts and CO-workers
(1992) estimated the energy needs of healthy elderly men by rneasuring total energy expenditure (TEE), body composition, and resting energy expenditure
(REE) using 2~2180techniques and indirect calorimetry. They found that the measured resting energy expenditures were slightly lower on average than values predicted from body weight by standard equations. Consequently, this contributed slightly to the difference between measured TEE/ REE ratios and the suggested requirements. Their work suggest that BMR estimates based on weight for age are reasonably close to that measured by more sophisticated - - unknown as to whether neurodegenerative diseases influence BMR. In advanced disease states, such as those observed in the patients of this study, such an influence is possible. Decreased efferent signals from the brain could impact on the hormonal state of the individual and hence metabolism.
Additionally, while not a cornponent of BMR, altered efferent signals could impact on gut motility and contractility which could impair absorption.
That diet induced thermogenesis changes with aging and hence could affect the energy requirements of the senior population also remains a possibility.
Diet induced thermogenesis is the estimation of the energy required to process food, Le. to digest, absorb, transport, metabolize and store ingested n utrients
(Whitney and Rolfes, 1993). As mentioned earlier, this thermic effect of food is proportional to energy intake and is estimated at about 10 % of the energy taken in. It is unknown whether diet induced thermogenesis changes with age, nevertheless, its contribution to total energy expenditure is smaller than the probable errors entailed in estimating overall energy input and expenditure
(Whitney and Rolfes, 1993).
The TF patients, for the most part, were bedridden and required assistance for the most basic activities such as bathing and feeding. In other words, these clients would be considered highly inactive, with a low energy expenditure. On the other hand, the energy required for activity may actually be increased, especially in disease states such as Parkinson's disease. Many of these aged people have diseases such as Parkinsonism which entails a great UGQI VI II IVVIUI t~aly a11an11JY VI LIGIIIVIIIly. l I 113 SII~KH ly lllay el ttu ar 1 augmentation in caloric output. These individuals appear to require an increased caloric intake just to maintain body weight; a caloric input that is greater than what would be considered typical for an elderly person. Levi and CO-workers,
(1990) found that the resting energy expenditure in patients with Parkinson's disease (PD) was remarkably higher than in healthy subjects. They have postulated that some patients with PD may have greatly augmented energy needs because of their atypical neuromuscular state. Energy output may differ considerably from day to day and with medication (Levi, et al., 1990; Markus et al., 1992). Markus and co-workers (1992) found that resting energy expenditure was increased in PD patients before and afier treatment with apomorphine.
Patients developing dyskinetic movements in the treated state showed a further augmentation in energy output. However, the validity of this measure of 'resting expenditure' is questionable since true resting in the patients cannot be measured without some involuntary movement due to tremor occurring. Abbott and co- workers (1992) have suggested that the weight loss that is often observed in PD patients is a result of an augmented energy output which was not satisfied by a corresponding increase in food intake. In fact, Davies et al., (1994) observed in their study that PD patients lost weight in spite of increased caloric intake. They have postulated this may be a reflection of a raised metabolic rate or a change in muscle metabolism. Nevertheless, most of the TF clients did not have active tremors; in fact, upon patient observation, most of the clients with PD appeared to be rigid. Hence, a change in energy requirements resulting from tremors does intôkes were much greater than their apparent energy needs.
On the other hand, there are potential errors associated with intake measurements. One possibility would be that some of the food was not being consumed by the TF patients. Food intake was actually weighed and not estimated, nevertheless, there were: 1) problems with mixing foods and so estimates of the proportion of each food item consumed were required, and 2) losses due to drooling and spilling were not measured although patient observation suggested that such losses were minimal. Finally, energy content of the food items were based on average nutrient composition data which always presents a problem since errors representing both over- and underestimation of the caloric content of foods can be expected.
6.3.1.2Fluid
The whole issue of introducing fluid thickeners into the diet of the client with dysphagia was brought forth because of the inability to tolerate regular fluids and the need to maintain hydration. Dehydration is a serious concern in the patient with dysphagia. Insuficient water intake by the aged can lead to dehydration, high blood pressure, increased body temperature, constipation, nausea and vomiting, dryness of the mucosa, diminished urine output, and mental confusion (Ahmed, 1992). Dehydration is the one factor considered to most contribute to mental confusion in the institutionalized senior. The elderly body fluids. As a consequence, they are more susceptible to suffer from hypothermia or hyperthermia in response to immoderate heat or cold (Kerstetter et al., 1992).
The intent of providing thickened fluids was to maintain hydration in patients unable to tolerate regular fluids. However, fluid intake was problem since only about 300 mL of fluid was consumed on average by the TF client population. A fluid intake of 1500 mU day is considered to be desirable in this client population. The prediction of the adequate fluid intake that would result by using the pablum was incorrect. The total water intake (including water from food) was only 1078 f 296 mL; markedly less than the 1500 mt recommendation.
Only one patient out of tvventy two had a total water intake above 1500 mL. This low intake of fiuids is a concern.
Presumably, the overall target is to provide a diet containing 1 mU kcal such that, at 1500 kcal, the recommended 1500 mL of fluid intake is met.
Currently, the pureed food diet offers a water density of approximately 0.75 mU kcal. That is, the water density of the pureed food at present is much lower than the water density required to ensure adequate hydration. Interestingly, thickened fluid supplements have an even lower water to energy ratio in comparison to the general pureed food diet. Thickened fluid supplements such as Boost or Ensure have water densities of only 0.49 and 0.41 mU kcal respectively. The water density of the pureed food diet is approximately the same as that of the thickened juices and thickened milk. Juices such as orange or apple that are thickened with Similarly, thickened milk has a water density of 0.72 mU kcal. These findings argue that pablum-thickened fluids are not an effective strategy for increasing fluid intake in the context of low energy requirements.
In light of the results, the question now becomes; can other thickeners provide a suitable product using less thickener and hence less energy? Stanek and CO-workers(1992) found that, of al1 the thickeners examined in their study, the thickener Nutra-Thik (Menu Magic, Indianapolis, Ind.) added the least energy to the liquids thickened. A smaller quantity of the thickener was required to thicken the liquid base to a high viscosity level in cornparison to pablum.
However, the cost of using Nutra-Thik to thicken liquids was double the cost of using pablum. Clearly, there are other thickeners available which can provide an appropriate product using less thickener and less energy than pablum but at a higher cost.
As mentioned earlier, the average pureed food diet provided a higher water to energy ratio than thickened fluid supplements and approximately the same ratio as those of thickened juices and milk. However, there are foods and food types within the diet which have water to energy ratios equivalent to or greater than the desired 1.0 mU kcal. Desserts such as pureed mixed fruit, applesauce, pureed pears and pureed peaches al1 have water to energy ratios that are approximately 1.0 mU kcal. The water densities of the pureed vegetables are slightly higher at about 1.15 mU kcal. By increasing the delivery and intake of such items at mealtimes, fluid intake could be improved. For ~A~~IIPIG,wawl UC~131iy CIUUIU uc II ILI CQDCU uy ~GIVII IY ~UIGGUII UIL VI puleeu apple sauce at breakfast, not just at lunch and dinnertime.
6.3.1.3 Folate
Both the delivery and actual intake data of this study suggest that the levels of folate are inadequate to meet recommendations. This issue was further investigated by looking at the folate intakes relative to the basal requirement
(Table 2.1). Without exception, each client had a folate intake that was above the basal requirement. The question is: what is the implication of these observations for the clients?
As defined earlier, the basal requirement is the level of intake required to satisfy al1 demonstrable functional needs (Beaton, 1994). Since the basal needs for folate were being met, the probability of megaloblastic anemia being present in the patients would be low if not absent. On the other hand, the normative requirements for folate were not being met which would indicate that clients are at risk for reduced body stores of folate. This issue of inadequate body stores of folate is not isolated to the institutionalized etderly. Millions of people, for a host of cultural, religious and socio-ewnomic reasons, consume less than the daily quantities necessary to maintain body stores (Dawson and Waters, 1994).
The primary coenzyme form of folate is tetrahydrofolate (THF) which is part of the enzyme complex that aids in converting vitamin Bq2 to one of its coenzyme fons and aids in the synthesis of DNA needed for al1 rapidly growing protein synthesis which are crucial processes in growing tissues. Hence, cell proliferation of lymphocytes, the cells which fight infection, will be hindered if folate levels are depressed in the body. Folate intakes above basal requirements but below normative requirements wuld leave patients susceptible to infection in tirnes of depressed food intake since there are no avaitabie folate stores from which the body could draw. Other syrnptoms of folate deficiency are fatigue, dyspnea, sore tongue, diarrhea, irritability, forgetfulness, anorexia. glossitis and weight loss (Mahan and Escott-Stump, 1996).
Further implications of folate deficiency include deterioration of functional and mental capacity (Ortega et al., 1996). In their study, Ortega and CO-workers found that greater independence and capacity were demonstrated in the elderly when folate intake and serum or ewhrocyte folate concentrations were sufficient.
The TF client population of this study were cognitively impaired but it is unlikely that the sole cause of this deterioration in cognition was due to inadequate folate intakes. However, it is possible that insufficient folate levels could be causing this deterioration to progress at a faster rate than would be seen as a result of aging and the disease process alone.
Malnutrition of folate may be worsened by reasons secondary to inadequate intake. Upwards of 90 % of folate is destroyed due to the cooking process. Furthermore, as Meas 50 % of folate is estimated as being absorbed from the mixed diet (Dawson and Waters, 1994). Not surprisingly, the need for supplementation is common with folate. 6.3.1.4 Thiamin, Riboflavin, and Niacin
As mentioned throughout, two standards were used when determining whether the deliveryi intake of thiamin, riboflavin and niacin were adequate to meet the nutrient needs of the clients, namely the established cut offs and average requirements in relation to energy. Depending on which standard was used, very different results were obtained. The question becomes which of the two criterion values is more suitable for this population.
Each of the three vitamins play an important role in energy metabolism.
Thiamin pyrophosphate is a coenzyme involved in both the oxidative decarboxylation of a-keto acids as well as in the formation and degradation of ketols by transketolase. Ribofiavin is a constituent of the coenzymes flavin adenine dinucleotide and riboflavin-5'-phosphate. The flavoproteins function as enzymes in the direct oxidation of substrates by oxygen. Niacin is the generic term for nicotinic acid and its biologic derivatives. Nicotinamide, in its active forrn, functions in two coenzymes, namely nicotinamide adenine dinucleotide (NAD) and its phosphate (NADP), which rernove hydrogen from substrates during glycolysis and respiration. Indeed, the role that these vitamins play in energy metabolisrn is vital; thiamin is necessary for the utilkation of energy, even when no food is eaten and niacin is used during fasting (Health and Welfare Canada,
1990). For safety reasons, cut offs levels for each of the three nutrients were set up in the Nutrition Recommendations (Health and Welfare Canada, 1990) as the level of consumption per day below which the mean daily intake for adults SI IVUIU i IVL iati, evai i II GIieiyy II liane 31iuuiu iaii ueiuw ruuu nuia. I I ICI C: I 143 been no clear evidence indicating that there is a corresponding reduction in the requirement for thiamin when energy intakes falls to levels of 1800-2000 kcall day and below. It is acknowledged that a reduction in food intake, as in weight reduction programs, does not similarly affect the requirement for thiamin because of its relation to energy expenditure (Health and Welfare Canada, 1990). Since the average intake of the TF client population was lower than 2000 kcals (Le. approximately 1500 kcal), it would appear appropriate that the cut off levels be used as the criterion value for assessing adequacy. When the actual vitamin intakes were compared to the cut off levels, large proportions of the population were considered to be at risk for inadequate intakes (Table 5.5). Nevertheless, further research is required to determine if such cut off teveb are appropriate for elderly individuals, especially those who are institutionalized.
The average requirement for these vitamins also recognizes that vitamin intake is related to energy intake and consequently is measured in relation to energy (Beaton, 1994). When vitamin intake was measured against this standard, it was found that sufficient levels were being provided in the diet (Table
5.5). The average requirement, although lower than the established cut-off for each vitamin, has been designed to cover the needs of the adult population in the context of their energy intakes. Despite the possibility that the requirements of older adults may be higher than younger adults, there is inadequate data to form the basis for a different recornmendation. The average requirement for these vitamins are similar to intakes recommended by other countries around the world (Truswell, AS. et al., 1983) and as such appears to be a more suitar>ie stanaara of intake for this population.
6.3.1-5 Excess Cholesterol
Another interesting observation made in this study was the high levels of cholesterol intakes. The question concerning this observation is: should the elevated cholesterol intakes be an issue of concern with respect to the health of the client population? Clearly the concern relates to the fact that high levels of cholesterol are associated with atherosclerosis or cardiovascular disease (CVD) which causes heart attacks and strokes (Whitney and Rolfes, 1993). The degree to which the concern should drive changes to intake, however, must be evaluated in the context of this specific population. First the average age of the clients was
89.0 and 81.9 yeats for men and women respectively, indicating the Iikelihood that they are not genetically susceptible to cardiovascular disease since they have survived to this late stage in their life. Second, it would appear that the important contributor to cholesterol is eggs, an important component of the pureed food diet. Eggs contain just over 200 mg of cholesterol, ail of it in the yolks (Whitney and Rolfes, 1993). Hence, the concern is that high cholesterol foods such as eggs may be increasing the clients' risk for cardiovascular disease.
Thus, the most effective means to decreasing cholesterol would be to decrease the intake of eggs. Given the inherent complexities of feeding the pureed food diet to these clients, restricting the intake of eggs may limit the ability of the client to meet their nutnent (especially protein) intake via oral means. The alternative case, it is assumed that oral intake is more pleasurable for these patients as well as being associated with greater dignity. The final question is; how does one weigh al1 these attributes in order to make the best decision? In light of the above arguments of the advanced age of this population, the difficulty in meeting nutrient needs, and the maintenance of oral feeding, it appears as though the inclusion of eggs in the pureed food diet provides a greater contribution to the best interests of the client in comparison to its exclusion. u.9 ~IU~IIU~LIC.~~C.UIIIIII~IIU~LIU~I~
6.4.1 Prescriptive Data Anatysis
One of the objectives in this study was to make future recommendations for TF clients based on the prescriptive mode of data analysis. As observed, nutrient intakes were positively related to energy intakes. The correlation between nutrient intake and energy intake was significant for al1 nutrients. This relationship allowed for the estimation of the minimum energy intake needed to satisfy the recomrnended nutrient intakes for the various nutrients based on the pureed food and thickened fluid diet. The average caloric intake of the clients consuming the pureed food and thickened fluid diet was 1568 I 342 kcal. At this level of consumption, the diet contained sufficient quantities of protein, calcium, iron, vitamins A and C, thiamin, riboflavin and niacin to meet the RNls respectively (The cut off values for the latter three nutrients were used as the standard of comparison). The only nutrients requiring higher consumption levels in order to satisfy the recommendations were folate and fluid. In particular, both folate and fluid required that over 1730 kcal be consumed in order to meet the recommended levels. This would imply that the folate and fluid densities in the diet were inappropriately low and that methods to increase their density were required. As mentioned earlier, although pablum does have a protective effect on protein and calcium intakes, the intakes are not raised sufficiently such that risk of inadequacy is within an acceptable range (Le. 5 % or less). The results from this study's measures of food intake, in combination with other studies
(Frisoni et al., 1995; Johnson, 1995), suggest that it unlikely to exceed mean - - . . designed to provide suitable nutrient densities to achieve adequate intake at this caloric intake.
The nutrient density of the diet was inappropriately low for folate and water which implied that the diet needs to be altered for these nutrients. As observed, pablurn played an important role in improving intakes for protein, calcium, thiamin, riboflavin and niacin. Thus it appears to be an important contributor to the intake of these nutrients. From a nutrient perspective, it would seem wise to continue using pablum. Nevertheless, from a fluid perspective the use of pablum did not achieve a suitable fluid:energy ratio.
6.4.2 Recommendations
One of the aims of this study was to make useful and helpful recommendations. With this in mind, the recommendations can be divided into three categories; 1) those pertaining to nutrient levels and intakes 2) those relating to fiuid levels and intakes and finally 3) those associated with energy intakes.
6.4.2.1 Nutrient Recommendations
From the results of this study, it is apparent that folate intakes should be increased. Generally, there are three methods of achieving such an increase, namely, through the use of supplements, multivitamin pills and foods. Of these LI et: ~U~~~SLIUI13, LI uar: VI IUUU~LU II ILI GQ~CIUIQLC II ~iancaappcai a LU uc LI rc most practical and least expensive.
All of the clients on the pureed food and thickened fluid diet whose actual intake patterns were studied were consuming either Boost or Ensure, supplements which are supposed to help increase mineral and vitamin intake but have been unsuccessful in doing so. That is to Say, ail the patients were receiving the supplements but the consumption of these products among the patients has been poor. These two fluid supplements in their various forms al1 required thickening with the exception of Ensure pudding. Because there is minimal folate levels in pablum, the folate to energy ratio is decreased when the supplement is thickened. For example, the fo1ate:energy ratio drops from 0.43 to
0.21 pgI kcal when Ensure is thickened and a similar decrease is observed when
Boost is thickened (i.e. from 0.25 to 0.14 pg/ kcal). Thickening Ensure + reduces the folate density from 0.56 to 0.33 pg/ kcal. Similarly, the thickening of Glucerna
(another fluid supplernent) decreases the folate to energy ratio from 0.42 to 0.21 pg/ kcal. The folate density of Ensure pudding is even lower at 0.27 pg/ kcal even though it does not require thickening. Among the fluid supplements utilized in this study, Citrotein had the highest folate to energy ratio at 1.23 pg/ kcâl,
however, the ratio drops to 0.58 pg/ kcal when it is thickened with pablum. The
ideal folate to energy ratio is 0.22 pg/ kcal. Hence, al1 the fluid supplements, with the exception of Boost, appear to contain sufficient folate to meet the ideal folate to energy ratio. The replacement of meal items with these fiuid supplements consumption would be higher at meal time than between meals. The one disadvantage to the use of such enteral products is their high cost.
Another method of increasing folate intake is the use of multivitamin/ mineral tablets. Folate intake could be raised without elevating the caloric intake of the patients. Pike and Chandra (1995) found that supplementation with micronutrients can play a critical role in the maintenance of normal immune function in seniors. In their study of folate and cobalamin deficiency, Dawson and Waters (1994) found that the need for supplementation was more common with folate even though malnutrition of both nutrients occurs on a world-wide scale. Chandra (1992) concluded from his study that supplementation with a physiological âmount of micronutrients ameliorated immunity and reduced the threat of infection in old age. An added benefit to using a rnultivitamin tablet is if a patient were to have low levels of another nutrient, the tablet could also potentially bolster intakes of that nutrient to higher and 'safer' levels. However, the economic feasibility for the daily administration of a multivitamin to each client should be examined.
One last suggestion for raising folate ingestion levels would be to increase in the diet the number of foods that are folate dense. This would mostly likeiy require a rearrangement of the diet to include these foods but in the long term, this method of increasing folate is probably the least expensive and most practical of the suggestions stated. For example, the folate to energy ratio of the pureed vegetables is, on average, 0.73 pgl kcal of folate which is higher than the ratios in the diet) to increase folate intakes would most Iikely be less expensive to administer than the use of supplements or multivitamins.
6.4.2.2 Fluid Recommendations
The research in this study has indicated that the delivery of the current diet as well as the selection offered does not allow for adequate fluid intake. Hence, changes to the water:energy ratio of the diet are warranted. As mentioned earlier, food items such as pureed mixed fruit and pureed vegetables contain a higher water to energy ratio than a beverage or fluid supplement thickened with pablum.
Such food items are already present in the diet; it is proposed that the quantities of such foods be increased.
The next issue to be addressed is how the water density of the diet should be increased. Should the water density of al1 meals be increased or should one meal be targeted for increasing the availability of water dense foods? For example, it is recognized that breakfast is one meal that is well consumed. One method of increasing the water to energy ratio of the diet would be to increase the availability of water dense foods at breakfast where there is some assurance that the meal will be well consumed. Food items such as cottage cheese have a water density of 1.O mU kcal. Yet other breakfast foods such as poached and
soft boiled eggs have low water densities of 0.5 mU kcal, as do white and whole wheat bread (0.14 and 0.13 gl mL, respectively). As demonstrated, typical DreaKTaSL IUUua 1 iavt: a wiuc I ai IYG ui vvarGi UGI IGILIG~ uur ,, uvui -, uui.iuu. meal has a water to energy ratio of 0.8 mU kcal which is lower than the recommended ratio. Nevertheless, it is unknown whether the breakfast meal has a higher water to energy ratio than the lunch and dinner meals. These are issues that must be considered.
6.4.2.3 Energy Rewmmendations
One issue that has been of interest is the high levels of energy intake observed in the TF patients. These high levels of consumption are nevertheless lower than what is recommended based on the RN1 for energy. The reasoning behind the suggested high energy intakes is that the elevated energy intake will allow seniors to consume nutrients to satisfy their own requirements. In order to prevent weight gain, it is recommended that the elderly engage in physical activity rather than lower energy consumption since the risk of insufficient nutrient
intakes is augmented (Health and Welfare Canada, 1990). The RNI for energy was set with the intention of meeting the energy needs of a healthy elderly population. It can be argued that it is inappropriate to apply the energy RN1 to the client population in this study since the clients can be categorized as 'sick'.
Hence, the energy standards for this client group should be outside the RNls.
Alternatively, this study has found that the clients were eating well above their estimated energy needs although the possibility that energy needs were
underestimated exists. Furthermore, other research has indicated that this study (Frisoni et al., 1995; Johnson , 1995). As cited earlier, weight goals and energy intake should be tailored to meet the needs of the specific individual.
However, such an approach is not always pragmatic for large populations of institutionalized elderly. The recomrnendation of this study with regards to energy intake is that 1500 kcal be accepted as a reasonable target for energy intake in the diet as consumed; adjustments can be made to the diet based on this Ievel of intake. 6.5.1 Summary
The five objectives carried out in this study included the following;
1) gathering baseline data regarding the average daily nutrient, fluid and caloric delivery of pureed diets prior to the implementation of fluid thickening strategies,
2) ascertaining the theoretical impacts of using non-fortified and fortified fluid thickening agents on overall nutrient delivery assuming no change in total fluid or caloric delivery to determine the maximal impact of thickening agents on displacement of kilocalories and hence nutrients from foods, 3) evaluating nutrient delivery to the clients actually receiving the thickened fluid and pureed food diet to obtain information on both the average delivery of nutrients as well as overall changes to the balance between food and fluid delivery once fluid thickening strategies had been implernented, 4) measuring the actual nutrient intake in clients on the thickened fiuid and pureed food diet in order to determine the actuat impact of pablum with respect to nutrient inadequacy, and 5) developing recommendations for the pureed food and thickened fluid diet based upon the delivery and intake profiles observed.
The objectives were met through the analysis of delivery and intake data of RF and TF clients who were restricted to pureed food diets and resided at the
Baycrest Centre for Geriatric Care. Diagnostic data analysis was used to determine the proportion of the RF population at risk for insufficient delivery for a given nutrient. Similar analysis was performed to ascertain what percentage of the TF population was at risk for inadequate delivery as well as intake for a pal LILuIaI I IULI ICI IL. I I IG ~IGG~IiprivG uara ai IUIYQIQ rruu uvwu SV UULUI i 1118 -W nutrient densities for the pureed food diet and to make future recommendations.
The first step in the latter method of analysis involved ascertaining the average caloric intake an individual would need to consume in order to meet the RN1 for each nutrient using regression analysis. The second step focused on evaluating the nutrient density of the thickened fluid diet delivered including and excluding the nutrients from pablum. Finally, the mean group intakes of nutrients necessary to satisfy the nutrient needs of al1 but a very small proportion of the population was calculated for the female clients consuming the thickened fluid diet. The necessary mean group intakes were then expressed as nutrient densities which were then compared to group mean densities actually consumed. In summation the principal findings of this study include the following:
1) The RF clients on the pureed food and regular fluid diet are being delivered sufficient nutrient quantities.
2) If al1 fluids were to be thickened with an unfortified fluid thickener, then there would be a number of nutrient inadequacies. On the other hand, if the fluids were to be thickened with pablum, then these nutrient inadequacies would be either dramatically reduced or altogether eliminated.
3) Fluid delivery decreases when the transition from regular fluids to thickened fluids is made. Hence, reliance on the thickener to provide nutrients in the pureed food and thickened fluid diet was less than expected. This did not lead to safe if al1 the food delivered is consumed.
4) The nutrients found in the pablum had a positive impact on the actual intake of certain nutrients including protein, calcium, thiamin, riboflavin and niacin. The addition of pablum to the diet was of no relevance to the intakes of vitamins A and C since those nutrients not found in pablum, or to folate of which pablum contained a marginal amount.
5) The actual donc intakes of the TF clients are much lower than delivery levels but greatly exceed the estimated levels based on basal metaboiic rates.
6) The minimum caloric intake required to achieve the RN1 can be satisfied with the average caloric intake consumed (approximately 1500 kcal) for al1 nutrients except folate and fluid.
7) Fluid intakes are still well below the recommended levels. Pablum as a fiuid thickener does not increase fluid intakes.
6.5.2 Conclusions
The purpose of this study was to analyze the claim that pablum, as a fortified fluid thickening agent, couid prevent dehydration and remove the risk of nutrient inadequacy that accompanies the displacernent of food from the diet when a fluid thickening agent is introduced into the diet. In particular, the hypothesis of this study was that the displacement of kilocalories from the pureed food diet by an unfortified thickener would lead to nutrient inadequacy. The rice flakel pablum thickener would replace the minerais and vitamins lost by study supported the hypothesis for certain nutrients but not for others. Pablum reduced andlor eliminated the threat of nutrient inadequacy for most nutrients such as protein, calcium, thiamin, riboflavin, and niacin when it was incorporated into the diet. Pablum, however, could not raise the fluid intake of the clients to the recommended 1500 mL, nor could it reduce or eliminate the risk of folate inadequacy. The findings of this study present a challenge to the industry to develop a product with greater fluid holding capacity, higher content of folate and possibly other nutrients not examined in this research. The study showed low utilization of delivered food suggesting the need to prevent food wastage in the institution. 7.0 REFERENCES:
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Number of Davs Resuired for Accurate Assessrnent of lntake
The following equation was used to estimate the number of days required to estirnate true average intake for a group of individuals with a certain Ievel of confidence:
X = ( Z ) (Total Variabilitv) " 1 ( A ) (True Ave. Intake) (No. Individuais in group)
(Basiotis et al., 1987)
X = no. of days required to estimate true average intake for a group of individuals with a defined level of confidence Z = value from the Normal Statistical Tables at the 0.05 % levet of significance i-e.,1.96 A = accuracy desired Le. O.? or 1O %
Total variability and true average intakes for the different nutrients were obtained frorn Owen's study (1989) of elderly recipients of home delivered meals.
Nutrient No. Days Required*
Protein (g) Vitamin A (lu) Vitamin C (mg) Thiamin (mg) Riboflavin (mg) lron (mg) Calcium (mg)
* number of days required assuming that there would be approximately 24 patients in the QrouP APPLIED -1 IMAGE, lnc = 1653 East Main Street ,-.- Rochester, NY 14609 USA ------Phone: il61482-0300 ------Fax: 7161288-5989
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