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Note to Users NOTE TO USERS The original manuscript received by UMl contains pages with slanted print. Pages were microfilmed as received. This reproduction is the best copy available 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 Our file Notre rëldrence The author has granted a non- L'auteur a accordé une licence non exclusive licence dowing the exclusive permettant à la National Library of Canada to Bibliothèque nationale du Canada de reproduce, loan, distribute or sel1 reproduire, prêter, distribuer ou copies of this thesis in rnicrofom, vendre des copies de cette thèse sous paper or electronic fomats. la forme de microfiche/film, de reproduction sur papier ou sur format électronique. 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.
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