Clinical Nutrition ESPEN: S.L. Okkels, M. Saxosen, S. Bügel, A. Olsen, T.W. Klausen, A.M. Beck
Clinical Nutrition ESPEN: S.L. Okkels, M. Saxosen, S. Bügel, A. Olsen, T.W. Klausen, A.M. Beck
Original article
a r t i c l e i n f o s u m m a r y
Article history: Background and aims: Old adults suffering from dysphagia have difficulties swallowing, chewing and/or
Received 18 December 2017 eating, and are therefore at high risk of undernutrition. In-between-meals that are texture modified are
Accepted 17 March 2018 of particular importance for people suffering from dysphagia. To meet their adequate daily amount of
food intake they are recommended to eat 3e5 in-between-meals daily. The aim of the current pilot study
Keywords: was to identify the most liked in-between-meals for old adults based on flavour and describe the basic
Minimal Eating Observational Form (MEOF)
sensory properties of these in-between-meals. Following, the equality between flavour and appearance-
Eating Validation Scheme (EVS)
based preferences was investigated.
Liking
Nursing home residents
Methods: From three nursing homes 30 old adults aged 70 years or older suffering from dysphagia were
Protein enriched products recruited. They were assessing 20 texture modified in-between-meals based on their flavour and
Undernutrition appearance on a 3 point hedonic scale.
Results: When participants were asked to assign liking based on flavour, the most liked in-between-
meals were frozen, cold and sweet (vanilla ice cream, strawberry parfait and panna cotta). These
meals were among the in-between-meals richest in fat and energy. Liking based on flavour and
appearance was equal in 18 out of 20 samples. Furthermore, nutritional and sensory characteristics of the
preferred meals were described.
Conclusion: Flavour and sensory-based ranking of in-between-meals opens the possibility to design new
in-between-meals to old adults with dysphagia, by choosing the most liked in-between-meals to offer
the target group.
© 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.
https://doi.org/10.1016/j.clnesp.2018.03.119
2405-4577/© 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Okkels SL, et al., Acceptance of texture-modified in-between-meals among old adults with dysphagia, Clinical
Nutrition ESPEN (2018), https://doi.org/10.1016/j.clnesp.2018.03.119
e2 S.L. Okkels et al. / Clinical Nutrition ESPEN xxx (2018) e1ee7
adults with eating problems (including people with dysphagia), difficulties and nutritional status together with a research assis-
should eat at least three high in protein and energy in-between- tant (MS) by observations and interviews of the participants with
meals a day [9]. In order to ensure safety and proper nutrition the use of Minimal Eating Observational Form (MEOFII) [12] and
for people suffering from dysphagia, texture modified food (TMF) Eating Validation Scheme (EVS) [13].
with a special consistency has been created. TMF is one among
different nutritional interventions to be used for people with 2.2.1. Minimal Eating Observational Form
dysphagia [10]. In this pilot study the texture types of the in-be- The state of eating difficulties was identified through the
tween-meals were either minced & moist or pureed. All the screening tool Minimal Eating Observational Form (MEOF) II. This is
included participants were able to eat these texture types. In order a categorical scale tested for reliability and validity in nursing home
to have puree texture the liquids were adjusted with a thickening residents with dysphagia. Besides problems with chewing and
agent (liquids should be taken with a spoon). swallowing the scale includes difficulties with ingestion and energy
Sensory evaluations of different Texture Modified Foods have in eating the meal. The scale ranges from 1 to 9, where to a higher
been done with meat products, carrot-based foods, soups, pa ^te
s number corresponds a worse disability [12].
and timbales [11,12]. Despite the fact that people with dysphagia is
one of the most vulnerable groups in regards to undernutrition [5], 2.2.2. Eating Validation Scheme
none of these studies have evaluated which TMF in-between-meals Nutritional assessments were performed using the Eating Vali-
this group prefer. Therefore, these people were the focus of this dation Scheme (EVS), which in Denmark is recommended for old
study. adults receiving home care and nursing home residents [9]. The
The aim of the current pilot study was to identify the most liked EVS assessment involves questions of eating habits, nutritional risk
in-between-meals for old adults based on flavour and describe the factors and weight loss. The evaluation can result in three different
basic sensory properties of these in-between-meals. Following, the scores: 0 for participants not at risk of being undernourished; 1
equality between flavour and appearance-based preferences was means that there is a risk of undernourishment; 2 means that the
investigated. participant will benefit from a nutritional intervention [13]. Since
chewing and swallowing problems are among the included nutri-
2. Materials and methods tional risk factors dysphagia leads to a risk of undernourishment. A
participant suffering from this condition will have an EVS score of at
2.1. Participants least 1.
To be included in the pilot study participants should be: 2.3. Study design
Please cite this article in press as: Okkels SL, et al., Acceptance of texture-modified in-between-meals among old adults with dysphagia, Clinical
Nutrition ESPEN (2018), https://doi.org/10.1016/j.clnesp.2018.03.119
S.L. Okkels et al. / Clinical Nutrition ESPEN xxx (2018) e1ee7 e3
2.3.4. Storage the nursing homes where breakfast at 8.30 AM, lunch at 12 AM and
For practical reasons, the in-between-meals were stored dinner at 18 PM. The normal assortment of in-between-meals were
frozen in plastic cups (ca. 100 g each) and thawed in refrigerator served in the afternoon or late evening and included cake, sand-
the day before serving. Before serving soups, mashed potato, rice wiches and protein drinks.
pudding and rye bread soup were warmed approximately 2 min To control for carry-over effect, participants were served the
in a microwave oven at 400 Watt until it reached a temperature samples of in-between-meals in randomized order. The program
of approximately 45 C. Strawberry parfait and vanilla ice cream “research randomizer” was used to find the exact order of the 20 in-
were served frozen after being lightly tempered at room between-meals for each participant. Two research assistants (MS
temperature. The rest of the meals were served cold at approx- and SLO) collected the data by filling in the answers on the ques-
imately 15 C. Full recipes are available from the first author upon tionnaire. As far as practically possible, the same research assistant
request. interviewed participants on all four days to make the participant
feel as comfortable as possible.
2.3.5. Sprinkles The participant was instructed to clear their mouth with a
Six of the meals were garnished to make them look more spoonful of water (thickened if needed) between every taste.
appealing: The milkshake was sprinkled with raspberry dust, the
rum mousse with buckthorn dust, the panna cotta with blueberry
dust and the mashed potato and pumpkin soup with parsley dust. 2.6. Statistical analysis
Furthermore, the rice porridge was served with cinnamon sugar.
Statistical analysis was performed using IBM SPSS Statistics
2.3.6. Layers version 22.3, and Graphpad Prism version 6.
The following seven in-between-meals were made in layers: the Data was tested for normal distribution and T-test was used as a
rye bread soup with whipped cream, the prune trifle, raspberry robust and valid tool when analysing these data [18]; [19]. A paired
jelly, strawberry porridge, apple porridge with vanilla cream and T-test was performed to investigate significant differences between
the mashed potato with bacon and onion puree. appearance and flavour ratings of the 20 in-between-meals. These
statistical tests and P-values were two-sided, with P < 0.05
2.3.7. Basic sensory characterization considered statistically significant. Characteristics of the old adults
Two people with culinary and sensory experience (MS and SLO) were presented as means ± standard deviation (SD) or numbers
evaluated each in-between-meal during a tasting session, and and percentages (%). When dividing ranked flavour liking against
selected the sensory descriptors to be used in the pilot study ac- nutritional content (protein, fat and energy respectively) the data
cording to predominant basic taste and serving temperature. The was non-parametric distributed and correlations were calculated
predominant basic tastes in the 20 in-between-meals were divided using Spearman's rank correlation coefficient. When dividing
in three: salty, sour and sweet, as well as the serving temperatures flavour liking according to sensory characteristics (predominant
warm, cold or frozen. basic taste, serving temperature, layer and sprinkles) Kruskal Walis'
test was adopted when testing the difference between these (one-
2.4. Questionnaire design way ANOVA on rank). A simple generalized estimation equation
was done to test whether the degree of appetite (independent
The questionnaire for the in-between-meal evaluation was variable) influenced the rating of flavour (dependent variable).
developed in cooperation with health care professionals and the
authors, pilot tested with different sizes of scales, and constructed
in Danish. Since appetite could be a confounder influencing the 2.7. Ethical committee
flavor preference [15], this aspect was assessed in order to be able
to make correlation analysis on how it influenced the results. The After reviewing the study protocol, the Danish Ethical Com-
questionnaire consisted of items regarding level of appetite, mittee concluded that formal approval of the pilot study was not
appearance and flavour of each sample. A 3-point Likert scale with required (ref number H-16019673).
symbols representing facial expressions and the response cate-
gories: “Bad”, “Neither good nor bad”, and “Good” were chosen to
make the questionnaire simple and understandable for the target 3. Results
group [16].
Using a simple category scale, the participant was asked at the 3.1. Participants
beginning of the interview: “how hungry do you feel right now?”.
Following, before tasting the sample, the participant was asked: Fiftyfive old adults were informed about the pilot study and
“how much do you like the appearance of the sample?”. And after screened for inclusion and exclusion criteria. Of these twelve did
tasting a teaspoon of the sample “how much do you like the flavour not wish to participate and thirteen did not meet the inclusion
of the sample?” Participants were instructed on how to differen- criteria. Subsequently, thirty old adults with dysphagia from three
tiate their answers. different nursing homes accepted to participate. The primary cau-
ses of the dysphagia in these participants were neurological dis-
2.5. Tasting session eases like stroke or Parkinson's disease. Three of the participants
only completed a partial amount of tasting sessions because of
Each participant tasted and rated 5 different in-between-meals unwillingness (N ¼ 1) or tiredness (N ¼ 2).
once per day for four consecutive days, for a total of 20 in-between- A high degree of the participants suffered from dementia (83%),
meals. The session was carried out like an interview and lasted 63% of them would benefit from a nutritional intervention (EVS
approximately 15 min per day. Since it was previously shown that score 2), and with regard to the extent of eating difficulties (MEOF
appetite for in-between-meals is higher in the morning than the II) participants fell into three almost evenly split groups. Average
afternoon, the time point of the tasting session was chosen to be age of the participants (years ±SD) was 84 ± 7.8, and average body
between 9.30 and 11.30 AM [17]. Other time points of main meals at mass indexes 23.7 ± 4.8 (BMI ±SD) (Table 1).
Please cite this article in press as: Okkels SL, et al., Acceptance of texture-modified in-between-meals among old adults with dysphagia, Clinical
Nutrition ESPEN (2018), https://doi.org/10.1016/j.clnesp.2018.03.119
e4 S.L. Okkels et al. / Clinical Nutrition ESPEN xxx (2018) e1ee7
Table 1 classified according to its protein, fat and energy content pr. 100 g.
Characteristics of the 30 old adults regarding Age, Body Mass Indexes (BMI), Nursing In order to separate the meals predominant basic taste was defined
home, Gender, Dementia, Usage of thickening agents, Level of eating difficulties
(MEOF II) and Nutritional status (EVS). Data are presented as N (%) and average
for each meal according to its salty, sour or sweet taste. Serving
(±SD). temperature was divided in warm, cold or frozen, and appearance
was defined depending on whether the food included layers and/or
Characteristics Average (±SD)
sprinkles (Table 2).
Age 84 (±7.8) Ranked means of flavour liking are seen in Fig. 1A. The in-
Body Mass Indexes (BMI) 23.7 (±4.8)
between-meals that scored highest were vanilla ice cream, straw-
Number of participants N (%)
Nursing home 1 4 (13) berry parfait and panna cotta. At the lower end of the spectrum
Nursing home 2 16 (54) were the pumpkin soup, carrot soup and clear soup. This ranking
Nursing home 3 10 (33) was used to test the correlation of mean liking of flavour against
Females 19 (63)
nutritional factors of the in-between-meals. A significant spear-
Males 11 (37)
Dementia 25 (83)
man's rank correlation coefficient was identified for fat content and
Using thickening agent in fluids 5 (17) flavour liking (r ¼ 0.5706, p-value 0.0086, Fig. 1B) as well as energy
Minimal Eating Observational Form (MEOF)II content and flavour liking (r ¼ 0.7414, p-value 0.0002, Fig. 1C), both
Number 1e3 8 (27) resulting in a higher flavour liking.
Number 4e6 10 (33)
No correlation between protein content and flavour liking could
Number 7e9 12 (40)
Eating Validation Scheme (EVS) be seen (r ¼ 0.0339, p-value not significant (0.8871), Fig. 1D).
Score 1 (at risk of undernutrition) 11 (37)
Score 2 (benefit from intervention) 19 (63)
Table 2
Classification of 20 in-between-meals including: In-between-meal name, protein, fat and energy content pr. 100 g, predominant basic taste, serving temperature, layers and
sprinkles. Ranked by mean flavour preference.
In-between-meal name Protein pr. Fat pr. Energy pr. Predominant Serving tempb Layersc Sprinklesd
100 grams (g) 100 grams (g) 100 gram. (kJ) basic tastea
Please cite this article in press as: Okkels SL, et al., Acceptance of texture-modified in-between-meals among old adults with dysphagia, Clinical
Nutrition ESPEN (2018), https://doi.org/10.1016/j.clnesp.2018.03.119
S.L. Okkels et al. / Clinical Nutrition ESPEN xxx (2018) e1ee7 e5
Fig. 1. Ranked mean flavour liking (A), Correlation of ranked in-between-meal flavour liking average and fat pr. 100 g (B), energy pr. 100 g (C), and protein pr. 100 g (D). Correlations
were operated using Spearman's rank correlation coefficient. Significant correlations indicated with asterisks ***P < 0.001, **P < 0.01.
Please cite this article in press as: Okkels SL, et al., Acceptance of texture-modified in-between-meals among old adults with dysphagia, Clinical
Nutrition ESPEN (2018), https://doi.org/10.1016/j.clnesp.2018.03.119
e6 S.L. Okkels et al. / Clinical Nutrition ESPEN xxx (2018) e1ee7
Please cite this article in press as: Okkels SL, et al., Acceptance of texture-modified in-between-meals among old adults with dysphagia, Clinical
Nutrition ESPEN (2018), https://doi.org/10.1016/j.clnesp.2018.03.119
S.L. Okkels et al. / Clinical Nutrition ESPEN xxx (2018) e1ee7 e7
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Please cite this article in press as: Okkels SL, et al., Acceptance of texture-modified in-between-meals among old adults with dysphagia, Clinical
Nutrition ESPEN (2018), https://doi.org/10.1016/j.clnesp.2018.03.119