Dehydration is estimated to be present in half of long term care residents, as many do not consum... more Dehydration is estimated to be present in half of long term care residents, as many do not consume the recommended levels of fluid intake. This study aims to describe fluid intake in long term care residents and identify the factors associated with fluid intake. Data were collected from 622 long term care residents, with a mean age of 86.8 ± 7.8. Total fluid intake was estimated over three non-consecutive days. Potential resident and unit-level variables risk factors for low fluid intake were collected, such as dementia status, activities of daily living, and eating challenges. Average daily fluid intake ranged from 311-2390 mL (1104.1 ± 379.3). Hierarchical regression analysis revealed that fluid intake was negatively associated with increased age, cognitive impairment, eating challenges and increased dining room staffing. Being male and requiring more physical assistance were positively associated with intake. Variables identified to predict intake could help inform strategies and targeted interventions to improve fluid intake.
Change presents challenges and opportunities. How change happens determines success. Using eviden... more Change presents challenges and opportunities. How change happens determines success. Using evidence-based approaches can make quality improvement (QI) changes easier and more likely to achieve their full potential. How theoretically-grounded QI can be integrated into day-to-day CLC activities depends on the improvement project, the environment into which it is to be integrated, the mechanisms by which it is introduced, and how its implementation is facilitated. The Veterans Health Administration (VHA) is one of the largest healthcare providers in the U.S., with 135 nursing homes (called Community Living Centers-CLCs). Recent VHA QI initiatives in CLCs have been grounded in the "COM-B" model of behavior change. The COM-B model describes a cyclical process in which human behavior (B) is generated by three components-capability, motivation, and opportunity (COM)-which in turn affect behavior (B) in a cycle. We describe three specific QI projects grounded in COM-B: (a) VHA's Central office leadership implementing a national CLC rollout of a quality dashboard, (b) health services researchers implementing a CLC QI project to improve CLC resident and staff interactions as part of a larger research study, and (c) CLC management and staff implementing unit-based QI programs focused on increasing CLC resident engagement in life. Each of these stakeholders will discuss the unique perspectives, challenges, and opportunities of their implementation experience, aligning them through the lens of the COM-B model and sharing successful, practical lessons applicable to nursing home frontline staff, mid-level management, and systems-level leadership.
American Journal of Speech-language Pathology, Aug 9, 2019
The purpose of this study was to determine if older adults residing in long-term care were able t... more The purpose of this study was to determine if older adults residing in long-term care were able to accurately self-report their swallowing status by comparing subjective complaints of dysphagia and objective methods of swallowing screening. Method: Data were collected from 397 residents of longterm care (M age = 86.8 years ± 7.8; 263 female). Cognitive impairment scores were collected, and each resident was asked (a) if they thought they had a swallowing problem, (b) if they coughed/choked when they ate, and (c) if they coughed/choked when they drank. These responses were compared to results of a swallowing screening tool and mealtime observations of coughing and choking. Results: Residents who reported swallowing difficulties (10%, n = 41) were 8 times more likely to fail the swallowing screening ( p < .001); however, 80% of residents who failed the swallowing screening did not previously report that swallowing was an issue. There was no significant association between self-reports of coughing and choking at meals and observations. There was no difference in level of cognition between residents who accurately reported swallowing status and those who were inaccurate. Conclusions: Residents are largely unable to accurately self-report swallowing difficulties and also have difficulty accurately reporting incidences of coughing and choking. These findings suggest that concerted efforts are required to implement regular, formal swallowing screening protocols in long-term care to objectively identify those at risk.
Canadian Journal of Public Health-revue Canadienne De Sante Publique, Mar 22, 2023
Objectives Nutrition risk is a key component of frailty and screening, and treatment of nutrition... more Objectives Nutrition risk is a key component of frailty and screening, and treatment of nutrition risk is part of frailty management. This study identified the determinants of a 3-year decline in nutrition risk (measured by for older adults stratified by risk status at baseline. Methods Secondary data analysis of the comprehensive cohort sample of the Canadian Longitudinal Study on Aging (CLSA) (n = 5031) with complete data for covariates at baseline and 3-year follow-up. Using a conceptual model to define covariates, determinants of a change in nutrition risk score as measured by SCREEN-8 (lower score indicates greater risk) were identified for those not at risk at baseline and those at high risk at baseline using multivariable regression. Results Models stratified by baseline nutrition risk were significant. Notable factors associated with a decrease in SCREEN-8 for those not at risk at baseline were mental health diagnoses ), living alone at follow-up (-1.98; CI [-3.40, -0.56]), and lack of dental care at both timepoints (-0.91; CI [-1.62, -0.20]) and at follow-up only (-1.32; CI [-2.45, -0.19]). For those at high nutrition risk at baseline, decline in activities of daily living (-2.56; CI [-4.36, -0.77]) and low chair-rise scores (-1.98; CI [-3.33, -0.63]) were associated with lower SCREEN-8 scores at follow-up. Conclusion Determinants of change in SCREEN-8 scores are different for those with no risk and those who are already at high risk, suggesting targeted approaches are needed for screening and treatment of nutrition risk in primary care. Objectifs Le risque nutritionnel est l'un des principaux éléments de la fragilité et le dépistage, et le traitement du risque nutritionnel font partie de la prise en charge de la fragilité. Dans cette étude, nous avons cerné les déterminants du risque de déclin nutritionnel sur 3 ans chez les personnes âgées (mesuré par l'instrument SCREEN-8 -Seniors in the Community Risk Evaluation for Eating and Nutrition), stratifiés selon l'état de risque au départ. Méthode Nous avons analysé les données secondaires d'un échantillon de la cohorte globale de l'Étude longitudinale canadienne sur le vieillissement (ELCV) (n = 5 031) avec des données complètes pour les covariables au départ et au suivi après 3 ans. En utilisant un modèle théorique pour définir les covariables, nous avons cerné les déterminants d'un changement du score de risque nutritionnel tel que mesuré par l'instrument SCREEN-8 (un faible score indiquant un risque élevé) pour les personnes qui n'étaient pas à risque au départ et pour celles qui étaient à risque élevé au départ, en faisant appel à la régression multivariée. Résultats Les modèles stratifiés selon le risque nutritionnel au départ étaient significatifs. Les facteurs notables associés à la baisse du score SCREEN-8 chez les personnes qui n'étaient pas à risque au départ étaient les diagnostics de santé mentale 83;44,22]), le fait de vivre seul au suivi 98;40,56]) et l'absence de soins dentaires au départ et au
and less likely to fall from tripping (0.72; 0.54-0.96). Men were more likely to fall while seate... more and less likely to fall from tripping (0.72; 0.54-0.96). Men were more likely to fall while seated (1.42; 1.07-1.87) or while rising from sitting (1.49; 1.11-1.99), and less likely to fall while walking (0.61; 0.50-0.75). Falls in men were more likely to involve wheelchairs (1.50; 1.16-1.93), and less likely to involve walkers (0.57; 0.43-0.76). Falls from loss of support were more common among individuals who were less independent in performing activities of daily living (ADL), who used multiple medications, and who used mobility aids. Individuals with independent ADL and intact cognition were more likely to fall while walking, but less likely to fall while seated or while rising. Conclusion: Our results elucidate differences between older men and women in the scenarios that lead to falls, to inform strategies to prevent falls in the LTC setting.
Understanding the knowledge, attitudes, and practices (KAP) of hospital staff is needed to improv... more Understanding the knowledge, attitudes, and practices (KAP) of hospital staff is needed to improve care activities that support the detection/prevention/treatment of malnutrition, yet quality measures are lacking. The purpose was to develop (study 1) and assess the administration and discriminative potential (study 2) of using such a KAP measure in acute care. In study 1, a 27-question KAP questionnaire was developed, face validated (n = 5), and tested for reliability (n = 35). Kappa and Intraclass Correlation (ICC) were determined. In study 2, the questionnaire was sent to staff at five diverse hospitals (n = 189). Administration challenges were noted and analyses completed to determine differences across sites, professions, and years of practice. Study 1 results demonstrate that the knowledge/attitude (KA) and the practice (P) subscales are reliable (KA: ICC = 0.69 95% CI 0.45-0.84, F = 5.54, p < 0.0001; P: ICC = 0.84 95% CI 0.68-0.92, F = 11.12, p < 0.0001). Completion rate of individual questions in study 2 was high and suggestions to improve administration were identified. The KAP mean score was 93.6/128 (range 51-124) with higher scores indicating more knowledge, better attitudes and positive practices. Profession and years of practice were associated with KAP scores. The KAP questionnaire is a valid and reliable measure that can be used in needs assessments to inform improvements to nutrition care in hospital.
Purpose: As many as 74% of residents in long-term care (LTC) are anticipated to have swallowing d... more Purpose: As many as 74% of residents in long-term care (LTC) are anticipated to have swallowing difficulties (dysphagia). Low food intake is commonly reported in persons with swallowing problems, but food intake may also be affected by fatigue in the swallowing muscles. As fatigue sets in during mealtimes, the strength of the tongue may decline. Tongue strength is also known to decline with age but it is unclear how this functional change may influence food intake. In this pilot study, we explored the relationship between tongue strength and meal consumption in persons not previously diagnosed with dysphagia. Methods: The Iowa Oral Performance Instrument was used to collect maximum anterior isometric tongue-palate pressures from 12 LTC residents (5 male; mean age: 85, range 65e99). Residents were also screened for dysphagia with applesauce and a water swallow test. Each resident was observed at three different meals to record the length of time taken to eat the meal, amount of food consumed, and any indication of overt signs of swallowing difficulty (e.g. coughing). Results: Residents who displayed observable swallowing difficulties at mealtimes had significantly lower tongue strength than those without swallowing difficulties (p < 0.01). Those with lower tongue strength took significantly longer to complete meals (p < 0.05) and consumed less food. Tongue strength was not predictive of performance on the water screen and the water swallow test was not a good predictor of which participants were observed to display mealtime difficulties. Conclusion: Among seniors in long term care, reduced tongue strength is associated with longer meal times, reduced food consumption, and the presence of observable signs of swallowing difficulty. Further exploration of these relationships is warranted.
Canadian Journal of Dietetic Practice and Research, Sep 1, 2019
Many long-term care (LTC) residents have an increased risk for dysphagia and receive texture-modi... more Many long-term care (LTC) residents have an increased risk for dysphagia and receive texture-modified diets. Dysphagia has been shown to be associated with longer mealtime duration, and the use of texturemodified diets has been associated with reduced nutritional intake. The current study aimed to determine if the degree of diet modification affected mealtime duration and to examine the correlation between texture-modified diets and dysphagia risk. Data were collected from 639 LTC residents, aged 62-102 years. Nine meal observations per resident provided measures of meal duration, consistencies consumed, coughing and choking, and assistance provided. Dysphagia risk was determined by identifying residents who coughed/choked at meals, were prescribed thickened fluids, and/or failed a formal screening protocol. Degree of texture modification was derived using the International Dysphagia Diet Standardization Initiative Functional Diet Scale. There was a significant association between degree of diet modification and dysphagia risk (P < 0.001). However, there was no association between diet modifications and mealtime duration, even when the provision of physical assistance was considered. Some residents who presented with signs of swallowing difficulties were not prescribed a texture-modified diet. Swallowing screening should be performed routinely in LTC to monitor swallowing status and appropriateness of diet prescription. Physical assistance during meals should be increased.
Background: Many patients are admitted to hospital and are already malnourished. Gaps in practice... more Background: Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital. Methods: A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions. Results: Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team. Conclusions: Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care.
Journal of Human Nutrition and Dietetics, Jul 23, 2019
Background: Food intake varies among long-term care (LTC) residents and, as a result, some reside... more Background: Food intake varies among long-term care (LTC) residents and, as a result, some residents are at risk for protein-energy malnutrition and its consequences, such as sarcopenia. The present study aimed to determine whether eating occasions, as well as other factors that may vary with eating occasions (e.g. family/volunteer presence), were associated with energy and protein intake at meals and snacks. Methods: The present study comprised a secondary analysis of the cross-sectional Making the Most of Mealtimes study, including 630 residents (median age 88.00 years, range 62-107 years; 197 males) from 32 Canadian LTC homes. An analysis of variance compared protein and energy intake at meals and snacks. Mixed repeated measures linear regression testing for meal and relevant covariates (e.g. family/volunteer presence) was also conducted. Results: Energy and protein intake was significantly associated with eating occasions (F = 44.31, P < 0.001; F = 12.72, P < 0.001), with the greatest energy intake at breakfast, and the greatest protein intake at dinner. Regression analysis confirmed these findings when considering other factors. Covariates associated with higher intake included: being male (+79 kcal; +3.4 g protein), living on a dementia care unit (+39 kcal; +2.1 g protein) and family/volunteer presence at meals (+58 kcal; +2.5 g protein). Intake was lowest in the oldest age group (À59 kcal; À3.6 g protein) and for those sometimes requiring eating assistance (À36 kcal; À2.0 g protein). Conclusions: Energy and protein intake appears to be associated with eating occasions. Based on these exploratory findings, LTC homes may consider providing more protein-dense foods at breakfast. Protein and energy dense snacks could also be used more extensively to support intake.
Background: Nutrition care in hospitals is often haphazard, and malnourished patients are not alw... more Background: Nutrition care in hospitals is often haphazard, and malnourished patients are not always readily identified and do not receive the care they require. The Integrated Nutrition Pathway for Acute Care (INPAC) is an algorithm designed to improve the prevention, detection and treatment of malnutrition in medical and surgical patients. More-2-Eat is an evaluation of the implementation of INPAC care activities (e.g. screening) in five diverse medical units from different hospitals in Canada. The primary purpose is to understand how tailored implementation affects INPAC uptake and factors that impact this implementation. The principal outcome is a toolkit that can provide guidance to others. Methods: This participatory action research uses a before-after time series design to address several research questions focused on implementation and uptake of INPAC (e.g., Does the implementation of INPAC improve the detection of malnutrition? Do nutrition care related knowledge, attitudes and practices scores of unit staff change with the implementation of INPAC?). A six-month developmental phase where baseline data were collected is followed by a twelve-month implementation phase and a three-month sustainability phase. Qualitative and quantitative data are collected concurrently, and to address key research questions, these data are merged. Quantitative data are collected on-site by trained local dietitians and include chart audits of nutrition care practices and a more detailed assessment of recruited patients on quality of life, disability, frailty, food intake and barriers to food intake. Thirty-day post discharge follow up for these patients occurs by researchers via a telephone interview at three time points within baseline and implementation phases, to ascertain the same and other outcomes (e.g. readmission to hospital). Qualitative data include focus groups and key informant interviews completed by researchers, monthly teleconferences among the sites and site-completed forms that track implementation activities. Resource utilization of dietitian time for various care activities (e.g. assessment) and staff time to assist patients at mealtimes is also collected. Discussion: More-2-Eat provides an example of how implementation can be tailored when a care algorithm is embedded into routine practice. The project also highlights important learning points with respect to data collection and techniques to support implementation.
Proceedings of the 8th International Workshop on Multimedia Assisted Dietary Management
Figure 1: Sample scene from NV-Synth dataset with the associated multi-modal image data (e.g., RG... more Figure 1: Sample scene from NV-Synth dataset with the associated multi-modal image data (e.g., RGB and depth data) and annotation metadata (e.g., instance and semantic segmentation masks) derived using objects from the NutritionVerse-3D dataset [33]. There are 2 meatloaves, 1 chicken leg, 1 chicken wing, 1 pork rib, and 2 sushi rolls in this scene.
Background Mealtimes are an essential part of living and quality of life for everyone, including ... more Background Mealtimes are an essential part of living and quality of life for everyone, including persons living with dementia. A longitudinal qualitative study provided understanding of the meaning of mealtimes for persons with dementia and their family care partners. Strategies were specifically described by families to support meaningful mealtimes. The purpose of this manuscript is to describe the strategies devised and used by these families living with dementia. Methods A longitudinal qualitative study was undertaken to explore the meaning and experience of mealtimes for families living with dementia over a three-year period. 27 families [older person with dementia and at least one family care partner] were originally recruited from the community of South-Western Ontario. Individual and dyad interviews were conducted each year. Digitally recorded transcripts were analyzed using grounded theory methodology. Strategies were identified and categorized. Results Strategies to support quality mealtimes were devised by families as they adapted to their evolving lives. General strategies such as living in the moment, as well as strategies specific to maintaining social engagement and continuity of mealtime activities were reported. Conclusions In addition to nutritional benefit, family mealtimes provide important opportunities for persons with dementia and their family care partners to socially engage and continue meaningful roles. Strategies identified by participants provide a basis for further education and support to families living with dementia.
Slaughter S, et al. Qualitative analysis of a virtual research meeting summarises expertbased str... more Slaughter S, et al. Qualitative analysis of a virtual research meeting summarises expertbased strategies to promote hydration in residential care during COVID-19 and beyond. BMJ Open 2022;12:e055457.
The coronavirus disease-2019 (COVID-19) is an infectious disease that causes a variety of symptom... more The coronavirus disease-2019 (COVID-19) is an infectious disease that causes a variety of symptoms, including cough, fatigue, sore throat, and in some cases, impaired taste and smell (1, 2). Each of these symptoms can impact a person's desire and ability to eat, which prevents the body from acquiring the vitamins, minerals, and macronutrients needed to protect itself and recover from illness (3, 4). COVID-19 has also restricted access to healthcare appointments, community services, grocery shopping, and social visits with family and friends. Consequently, patients are at increased risk of developing malnutrition (3-5). As part of a larger survey about nutrition care practices as patients leave the hospital or are cared for in primary and community care, we investigated the challenges that Canadian dietitians have experienced while providing care to their patients during the COVID-19 pandemic. COVID-19 survey questions were available via an online platform (QualtricsXM) from April 25-May 31, 2020. Dietitians were asked two questions about COVID-19: i) their perception of nutrition-related challenges for patients returning to the community post-hospital discharge; and ii) how the pandemic had affected their practice. For these questions, the dietitians submitted their qualitative responses via an open comment box. Two hundred and fifty-five dietitians participated in this survey with 23.5% (n= 60) and 16.9% (n= 43) providing responses for COVID-19 questions one and two, respectively. These responses were analyzed using qualitative description with minimal interpretation (6). Decreased access to healthcare professionals and nutrition care services due to limited in-person contact and service cancellations was the most common challenge that dietitians reported for discharged patients. Nutrition counselling, education, and meal delivery programs have been shown to improve energy and protein intake as well as prevent rehospitalization (7-9). Hence, dietitians felt that barriers to accessing these resources could cause or exacerbate nutrition problems since patients would be unable to receive the nutritional supports that they required. Additionally, dietitians reported that many patients were experiencing food insecurity due to decreased income and increased anxiety regarding grocery shopping during the pandemic. This was most evident amongst populations that are at high risk of poor outcomes with COVID-19, such as older adults and individuals with
Background: Mealtimes are important to quality of life for residents in long-term care (LTC). CHO... more Background: Mealtimes are important to quality of life for residents in long-term care (LTC). CHOICE (which stands for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities, and Enjoyment) is a multi-component intervention to improve relationship-centred care (RCC) and overall mealtime experience for residents. The objective of this developmental evaluation was to determine: a) if the dining experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required. Methods: A mixed methods study conducted between April-November 2016 included two home areas (64 residents; 25 care staff/home management) within a single LTC home in Ontario. Mealtime Scan (MTS), which measures mealtime experience at the level of the dining room, was used to evaluate the effectiveness of CHOICE implementation at four time points. Change in physical, social, RCC dining environment ratings and overall quality of the mealtime experience over time was determined with linear mixed-effects analyses (i.e., repeated measures). Semi-structured interviews (n = 9) were conducted with home staff to identify what components of the intervention worked well and what improvements could be made. Results: Physical and overall mealtime environment ratings showed improvement over time in both areas; one home area also improved social ratings (p < 0.05). Interviews revealed in-depth insights into the program and implementation process: i) Knowing the context and culture to meet staff and resident needs; ii) Getting everyone on board, including management; iii) Keeping communication lines open throughout the process; iv) Sharing responsibility and accountability for mealtime goals and challenges; v) Empowering and supporting staff's creative mealtime initiatives. Conclusions: This developmental evaluation demonstrated the potential value of CHOICE. Findings suggest a need to: extend the time to tailor program components; empower home staff in change management; and provide increased coaching.
Background and Objectives: Poor food intake is common in long-term care (LTC). The mealtime exper... more Background and Objectives: Poor food intake is common in long-term care (LTC). The mealtime experience has been identified as influential, yet, research has been limited by lack of quality, standardized measures. The purpose of this study was to develop and test for inter-rater reliability the Mealtime Scan (MTS), an observational measure. Research Design and Methods: MTS was derived from the literature on ambiance, mealtime experience, social interactions at mealtimes, and social models of care. Three scales on person-centered care and physical and social environments are used to summarize key aspects observed with MTS. Two raters assessed MTS for reliability at 30 different meals conducted in 10 dining rooms, within three LTC residences. Intraclass correlation coefficient (ICC) was used to assess reliability. Results: MTS demonstrated good to excellent reliability on the three summative scales (physical ICC = 0.73, social ICC = 0.81, person-centered care ICC = 0.83) and other scalable items had good to excellent reliability (e.g., background noise ICC = 0.65, Mealtime Relational Care checklist: negative interactions ICC = 0.85). Discussion and Implications: MTS is reliable and face valid for assessing mealtime experience. Future work will explore construct validity of this measure. MTS can be used to support improving the mealtime experience for residents living in LTC.
Background: Long term care (LTC) menus need to contain sufficient nutrients for health and pureed... more Background: Long term care (LTC) menus need to contain sufficient nutrients for health and pureed menus may have lower nutritional quality than regular texture menus due to processes (e.g., recipe alterations) required to modify textures. The aims of this study were to: determine adequacy of planned menus when compared to the Dietary Reference Intake (DRI); compare the energy, macronutrients, micronutrients and fibre of pureed texture and regular texture menus across LTC homes to determine any texture, home or regional level differences; and identify home characteristics associated with energy and protein differences in pureed and regular menus. Methods: Making the Most of Mealtimes (M3) is a cross-sectional multi-site study that collected data from 32 LTC homes in four Canadian provinces. This secondary analysis focused on nutrient analysis of pureed and regular texture menus for the first week of the menu cycle. A site survey captured characteristics and services of each facility, and key aspects of menu planning and food production. Bivariate analyses were used to compare menus, within a home and among and within provinces, as well as to determine if home characteristics were associated with energy and protein provision for both menus. Each menu was qualitatively compared to the DRI standards for individuals 70+ years to determine nutritional quality. Results: There were significant provincial and menu texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed (p < 0.01). Alberta and New Brunswick had lower nutrient contents for both menu textures as compared to Manitoba and Ontario. Within each province some homes had significantly lower nutrient content for pureed menus (p < 0.01), while others did not. Fibre and nine micronutrients were below DRI recommendations for both menu textures within all four provinces; variation in nutritional quality existed among homes within each province. Several home characteristics (e.g., for-profit status) were significantly associated with higher energy and protein content of menus (p < 0.01). Conclusions: There was variability in nutritional quality of menus from LTC homes in the M3 sample. Pureed menus tended to contain lower amounts of nutrients than regular texture menus and both menus did not meet DRI recommendations for select nutrients. This study demonstrates the need for improved menu planning protocols to ensure planned diets meet nutrient requirements regardless of texture. Trial registration: ClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.
Dehydration is estimated to be present in half of long term care residents, as many do not consum... more Dehydration is estimated to be present in half of long term care residents, as many do not consume the recommended levels of fluid intake. This study aims to describe fluid intake in long term care residents and identify the factors associated with fluid intake. Data were collected from 622 long term care residents, with a mean age of 86.8 ± 7.8. Total fluid intake was estimated over three non-consecutive days. Potential resident and unit-level variables risk factors for low fluid intake were collected, such as dementia status, activities of daily living, and eating challenges. Average daily fluid intake ranged from 311-2390 mL (1104.1 ± 379.3). Hierarchical regression analysis revealed that fluid intake was negatively associated with increased age, cognitive impairment, eating challenges and increased dining room staffing. Being male and requiring more physical assistance were positively associated with intake. Variables identified to predict intake could help inform strategies and targeted interventions to improve fluid intake.
Change presents challenges and opportunities. How change happens determines success. Using eviden... more Change presents challenges and opportunities. How change happens determines success. Using evidence-based approaches can make quality improvement (QI) changes easier and more likely to achieve their full potential. How theoretically-grounded QI can be integrated into day-to-day CLC activities depends on the improvement project, the environment into which it is to be integrated, the mechanisms by which it is introduced, and how its implementation is facilitated. The Veterans Health Administration (VHA) is one of the largest healthcare providers in the U.S., with 135 nursing homes (called Community Living Centers-CLCs). Recent VHA QI initiatives in CLCs have been grounded in the "COM-B" model of behavior change. The COM-B model describes a cyclical process in which human behavior (B) is generated by three components-capability, motivation, and opportunity (COM)-which in turn affect behavior (B) in a cycle. We describe three specific QI projects grounded in COM-B: (a) VHA's Central office leadership implementing a national CLC rollout of a quality dashboard, (b) health services researchers implementing a CLC QI project to improve CLC resident and staff interactions as part of a larger research study, and (c) CLC management and staff implementing unit-based QI programs focused on increasing CLC resident engagement in life. Each of these stakeholders will discuss the unique perspectives, challenges, and opportunities of their implementation experience, aligning them through the lens of the COM-B model and sharing successful, practical lessons applicable to nursing home frontline staff, mid-level management, and systems-level leadership.
American Journal of Speech-language Pathology, Aug 9, 2019
The purpose of this study was to determine if older adults residing in long-term care were able t... more The purpose of this study was to determine if older adults residing in long-term care were able to accurately self-report their swallowing status by comparing subjective complaints of dysphagia and objective methods of swallowing screening. Method: Data were collected from 397 residents of longterm care (M age = 86.8 years ± 7.8; 263 female). Cognitive impairment scores were collected, and each resident was asked (a) if they thought they had a swallowing problem, (b) if they coughed/choked when they ate, and (c) if they coughed/choked when they drank. These responses were compared to results of a swallowing screening tool and mealtime observations of coughing and choking. Results: Residents who reported swallowing difficulties (10%, n = 41) were 8 times more likely to fail the swallowing screening ( p < .001); however, 80% of residents who failed the swallowing screening did not previously report that swallowing was an issue. There was no significant association between self-reports of coughing and choking at meals and observations. There was no difference in level of cognition between residents who accurately reported swallowing status and those who were inaccurate. Conclusions: Residents are largely unable to accurately self-report swallowing difficulties and also have difficulty accurately reporting incidences of coughing and choking. These findings suggest that concerted efforts are required to implement regular, formal swallowing screening protocols in long-term care to objectively identify those at risk.
Canadian Journal of Public Health-revue Canadienne De Sante Publique, Mar 22, 2023
Objectives Nutrition risk is a key component of frailty and screening, and treatment of nutrition... more Objectives Nutrition risk is a key component of frailty and screening, and treatment of nutrition risk is part of frailty management. This study identified the determinants of a 3-year decline in nutrition risk (measured by for older adults stratified by risk status at baseline. Methods Secondary data analysis of the comprehensive cohort sample of the Canadian Longitudinal Study on Aging (CLSA) (n = 5031) with complete data for covariates at baseline and 3-year follow-up. Using a conceptual model to define covariates, determinants of a change in nutrition risk score as measured by SCREEN-8 (lower score indicates greater risk) were identified for those not at risk at baseline and those at high risk at baseline using multivariable regression. Results Models stratified by baseline nutrition risk were significant. Notable factors associated with a decrease in SCREEN-8 for those not at risk at baseline were mental health diagnoses ), living alone at follow-up (-1.98; CI [-3.40, -0.56]), and lack of dental care at both timepoints (-0.91; CI [-1.62, -0.20]) and at follow-up only (-1.32; CI [-2.45, -0.19]). For those at high nutrition risk at baseline, decline in activities of daily living (-2.56; CI [-4.36, -0.77]) and low chair-rise scores (-1.98; CI [-3.33, -0.63]) were associated with lower SCREEN-8 scores at follow-up. Conclusion Determinants of change in SCREEN-8 scores are different for those with no risk and those who are already at high risk, suggesting targeted approaches are needed for screening and treatment of nutrition risk in primary care. Objectifs Le risque nutritionnel est l'un des principaux éléments de la fragilité et le dépistage, et le traitement du risque nutritionnel font partie de la prise en charge de la fragilité. Dans cette étude, nous avons cerné les déterminants du risque de déclin nutritionnel sur 3 ans chez les personnes âgées (mesuré par l'instrument SCREEN-8 -Seniors in the Community Risk Evaluation for Eating and Nutrition), stratifiés selon l'état de risque au départ. Méthode Nous avons analysé les données secondaires d'un échantillon de la cohorte globale de l'Étude longitudinale canadienne sur le vieillissement (ELCV) (n = 5 031) avec des données complètes pour les covariables au départ et au suivi après 3 ans. En utilisant un modèle théorique pour définir les covariables, nous avons cerné les déterminants d'un changement du score de risque nutritionnel tel que mesuré par l'instrument SCREEN-8 (un faible score indiquant un risque élevé) pour les personnes qui n'étaient pas à risque au départ et pour celles qui étaient à risque élevé au départ, en faisant appel à la régression multivariée. Résultats Les modèles stratifiés selon le risque nutritionnel au départ étaient significatifs. Les facteurs notables associés à la baisse du score SCREEN-8 chez les personnes qui n'étaient pas à risque au départ étaient les diagnostics de santé mentale 83;44,22]), le fait de vivre seul au suivi 98;40,56]) et l'absence de soins dentaires au départ et au
and less likely to fall from tripping (0.72; 0.54-0.96). Men were more likely to fall while seate... more and less likely to fall from tripping (0.72; 0.54-0.96). Men were more likely to fall while seated (1.42; 1.07-1.87) or while rising from sitting (1.49; 1.11-1.99), and less likely to fall while walking (0.61; 0.50-0.75). Falls in men were more likely to involve wheelchairs (1.50; 1.16-1.93), and less likely to involve walkers (0.57; 0.43-0.76). Falls from loss of support were more common among individuals who were less independent in performing activities of daily living (ADL), who used multiple medications, and who used mobility aids. Individuals with independent ADL and intact cognition were more likely to fall while walking, but less likely to fall while seated or while rising. Conclusion: Our results elucidate differences between older men and women in the scenarios that lead to falls, to inform strategies to prevent falls in the LTC setting.
Understanding the knowledge, attitudes, and practices (KAP) of hospital staff is needed to improv... more Understanding the knowledge, attitudes, and practices (KAP) of hospital staff is needed to improve care activities that support the detection/prevention/treatment of malnutrition, yet quality measures are lacking. The purpose was to develop (study 1) and assess the administration and discriminative potential (study 2) of using such a KAP measure in acute care. In study 1, a 27-question KAP questionnaire was developed, face validated (n = 5), and tested for reliability (n = 35). Kappa and Intraclass Correlation (ICC) were determined. In study 2, the questionnaire was sent to staff at five diverse hospitals (n = 189). Administration challenges were noted and analyses completed to determine differences across sites, professions, and years of practice. Study 1 results demonstrate that the knowledge/attitude (KA) and the practice (P) subscales are reliable (KA: ICC = 0.69 95% CI 0.45-0.84, F = 5.54, p < 0.0001; P: ICC = 0.84 95% CI 0.68-0.92, F = 11.12, p < 0.0001). Completion rate of individual questions in study 2 was high and suggestions to improve administration were identified. The KAP mean score was 93.6/128 (range 51-124) with higher scores indicating more knowledge, better attitudes and positive practices. Profession and years of practice were associated with KAP scores. The KAP questionnaire is a valid and reliable measure that can be used in needs assessments to inform improvements to nutrition care in hospital.
Purpose: As many as 74% of residents in long-term care (LTC) are anticipated to have swallowing d... more Purpose: As many as 74% of residents in long-term care (LTC) are anticipated to have swallowing difficulties (dysphagia). Low food intake is commonly reported in persons with swallowing problems, but food intake may also be affected by fatigue in the swallowing muscles. As fatigue sets in during mealtimes, the strength of the tongue may decline. Tongue strength is also known to decline with age but it is unclear how this functional change may influence food intake. In this pilot study, we explored the relationship between tongue strength and meal consumption in persons not previously diagnosed with dysphagia. Methods: The Iowa Oral Performance Instrument was used to collect maximum anterior isometric tongue-palate pressures from 12 LTC residents (5 male; mean age: 85, range 65e99). Residents were also screened for dysphagia with applesauce and a water swallow test. Each resident was observed at three different meals to record the length of time taken to eat the meal, amount of food consumed, and any indication of overt signs of swallowing difficulty (e.g. coughing). Results: Residents who displayed observable swallowing difficulties at mealtimes had significantly lower tongue strength than those without swallowing difficulties (p < 0.01). Those with lower tongue strength took significantly longer to complete meals (p < 0.05) and consumed less food. Tongue strength was not predictive of performance on the water screen and the water swallow test was not a good predictor of which participants were observed to display mealtime difficulties. Conclusion: Among seniors in long term care, reduced tongue strength is associated with longer meal times, reduced food consumption, and the presence of observable signs of swallowing difficulty. Further exploration of these relationships is warranted.
Canadian Journal of Dietetic Practice and Research, Sep 1, 2019
Many long-term care (LTC) residents have an increased risk for dysphagia and receive texture-modi... more Many long-term care (LTC) residents have an increased risk for dysphagia and receive texture-modified diets. Dysphagia has been shown to be associated with longer mealtime duration, and the use of texturemodified diets has been associated with reduced nutritional intake. The current study aimed to determine if the degree of diet modification affected mealtime duration and to examine the correlation between texture-modified diets and dysphagia risk. Data were collected from 639 LTC residents, aged 62-102 years. Nine meal observations per resident provided measures of meal duration, consistencies consumed, coughing and choking, and assistance provided. Dysphagia risk was determined by identifying residents who coughed/choked at meals, were prescribed thickened fluids, and/or failed a formal screening protocol. Degree of texture modification was derived using the International Dysphagia Diet Standardization Initiative Functional Diet Scale. There was a significant association between degree of diet modification and dysphagia risk (P < 0.001). However, there was no association between diet modifications and mealtime duration, even when the provision of physical assistance was considered. Some residents who presented with signs of swallowing difficulties were not prescribed a texture-modified diet. Swallowing screening should be performed routinely in LTC to monitor swallowing status and appropriateness of diet prescription. Physical assistance during meals should be increased.
Background: Many patients are admitted to hospital and are already malnourished. Gaps in practice... more Background: Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital. Methods: A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions. Results: Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team. Conclusions: Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care.
Journal of Human Nutrition and Dietetics, Jul 23, 2019
Background: Food intake varies among long-term care (LTC) residents and, as a result, some reside... more Background: Food intake varies among long-term care (LTC) residents and, as a result, some residents are at risk for protein-energy malnutrition and its consequences, such as sarcopenia. The present study aimed to determine whether eating occasions, as well as other factors that may vary with eating occasions (e.g. family/volunteer presence), were associated with energy and protein intake at meals and snacks. Methods: The present study comprised a secondary analysis of the cross-sectional Making the Most of Mealtimes study, including 630 residents (median age 88.00 years, range 62-107 years; 197 males) from 32 Canadian LTC homes. An analysis of variance compared protein and energy intake at meals and snacks. Mixed repeated measures linear regression testing for meal and relevant covariates (e.g. family/volunteer presence) was also conducted. Results: Energy and protein intake was significantly associated with eating occasions (F = 44.31, P < 0.001; F = 12.72, P < 0.001), with the greatest energy intake at breakfast, and the greatest protein intake at dinner. Regression analysis confirmed these findings when considering other factors. Covariates associated with higher intake included: being male (+79 kcal; +3.4 g protein), living on a dementia care unit (+39 kcal; +2.1 g protein) and family/volunteer presence at meals (+58 kcal; +2.5 g protein). Intake was lowest in the oldest age group (À59 kcal; À3.6 g protein) and for those sometimes requiring eating assistance (À36 kcal; À2.0 g protein). Conclusions: Energy and protein intake appears to be associated with eating occasions. Based on these exploratory findings, LTC homes may consider providing more protein-dense foods at breakfast. Protein and energy dense snacks could also be used more extensively to support intake.
Background: Nutrition care in hospitals is often haphazard, and malnourished patients are not alw... more Background: Nutrition care in hospitals is often haphazard, and malnourished patients are not always readily identified and do not receive the care they require. The Integrated Nutrition Pathway for Acute Care (INPAC) is an algorithm designed to improve the prevention, detection and treatment of malnutrition in medical and surgical patients. More-2-Eat is an evaluation of the implementation of INPAC care activities (e.g. screening) in five diverse medical units from different hospitals in Canada. The primary purpose is to understand how tailored implementation affects INPAC uptake and factors that impact this implementation. The principal outcome is a toolkit that can provide guidance to others. Methods: This participatory action research uses a before-after time series design to address several research questions focused on implementation and uptake of INPAC (e.g., Does the implementation of INPAC improve the detection of malnutrition? Do nutrition care related knowledge, attitudes and practices scores of unit staff change with the implementation of INPAC?). A six-month developmental phase where baseline data were collected is followed by a twelve-month implementation phase and a three-month sustainability phase. Qualitative and quantitative data are collected concurrently, and to address key research questions, these data are merged. Quantitative data are collected on-site by trained local dietitians and include chart audits of nutrition care practices and a more detailed assessment of recruited patients on quality of life, disability, frailty, food intake and barriers to food intake. Thirty-day post discharge follow up for these patients occurs by researchers via a telephone interview at three time points within baseline and implementation phases, to ascertain the same and other outcomes (e.g. readmission to hospital). Qualitative data include focus groups and key informant interviews completed by researchers, monthly teleconferences among the sites and site-completed forms that track implementation activities. Resource utilization of dietitian time for various care activities (e.g. assessment) and staff time to assist patients at mealtimes is also collected. Discussion: More-2-Eat provides an example of how implementation can be tailored when a care algorithm is embedded into routine practice. The project also highlights important learning points with respect to data collection and techniques to support implementation.
Proceedings of the 8th International Workshop on Multimedia Assisted Dietary Management
Figure 1: Sample scene from NV-Synth dataset with the associated multi-modal image data (e.g., RG... more Figure 1: Sample scene from NV-Synth dataset with the associated multi-modal image data (e.g., RGB and depth data) and annotation metadata (e.g., instance and semantic segmentation masks) derived using objects from the NutritionVerse-3D dataset [33]. There are 2 meatloaves, 1 chicken leg, 1 chicken wing, 1 pork rib, and 2 sushi rolls in this scene.
Background Mealtimes are an essential part of living and quality of life for everyone, including ... more Background Mealtimes are an essential part of living and quality of life for everyone, including persons living with dementia. A longitudinal qualitative study provided understanding of the meaning of mealtimes for persons with dementia and their family care partners. Strategies were specifically described by families to support meaningful mealtimes. The purpose of this manuscript is to describe the strategies devised and used by these families living with dementia. Methods A longitudinal qualitative study was undertaken to explore the meaning and experience of mealtimes for families living with dementia over a three-year period. 27 families [older person with dementia and at least one family care partner] were originally recruited from the community of South-Western Ontario. Individual and dyad interviews were conducted each year. Digitally recorded transcripts were analyzed using grounded theory methodology. Strategies were identified and categorized. Results Strategies to support quality mealtimes were devised by families as they adapted to their evolving lives. General strategies such as living in the moment, as well as strategies specific to maintaining social engagement and continuity of mealtime activities were reported. Conclusions In addition to nutritional benefit, family mealtimes provide important opportunities for persons with dementia and their family care partners to socially engage and continue meaningful roles. Strategies identified by participants provide a basis for further education and support to families living with dementia.
Slaughter S, et al. Qualitative analysis of a virtual research meeting summarises expertbased str... more Slaughter S, et al. Qualitative analysis of a virtual research meeting summarises expertbased strategies to promote hydration in residential care during COVID-19 and beyond. BMJ Open 2022;12:e055457.
The coronavirus disease-2019 (COVID-19) is an infectious disease that causes a variety of symptom... more The coronavirus disease-2019 (COVID-19) is an infectious disease that causes a variety of symptoms, including cough, fatigue, sore throat, and in some cases, impaired taste and smell (1, 2). Each of these symptoms can impact a person's desire and ability to eat, which prevents the body from acquiring the vitamins, minerals, and macronutrients needed to protect itself and recover from illness (3, 4). COVID-19 has also restricted access to healthcare appointments, community services, grocery shopping, and social visits with family and friends. Consequently, patients are at increased risk of developing malnutrition (3-5). As part of a larger survey about nutrition care practices as patients leave the hospital or are cared for in primary and community care, we investigated the challenges that Canadian dietitians have experienced while providing care to their patients during the COVID-19 pandemic. COVID-19 survey questions were available via an online platform (QualtricsXM) from April 25-May 31, 2020. Dietitians were asked two questions about COVID-19: i) their perception of nutrition-related challenges for patients returning to the community post-hospital discharge; and ii) how the pandemic had affected their practice. For these questions, the dietitians submitted their qualitative responses via an open comment box. Two hundred and fifty-five dietitians participated in this survey with 23.5% (n= 60) and 16.9% (n= 43) providing responses for COVID-19 questions one and two, respectively. These responses were analyzed using qualitative description with minimal interpretation (6). Decreased access to healthcare professionals and nutrition care services due to limited in-person contact and service cancellations was the most common challenge that dietitians reported for discharged patients. Nutrition counselling, education, and meal delivery programs have been shown to improve energy and protein intake as well as prevent rehospitalization (7-9). Hence, dietitians felt that barriers to accessing these resources could cause or exacerbate nutrition problems since patients would be unable to receive the nutritional supports that they required. Additionally, dietitians reported that many patients were experiencing food insecurity due to decreased income and increased anxiety regarding grocery shopping during the pandemic. This was most evident amongst populations that are at high risk of poor outcomes with COVID-19, such as older adults and individuals with
Background: Mealtimes are important to quality of life for residents in long-term care (LTC). CHO... more Background: Mealtimes are important to quality of life for residents in long-term care (LTC). CHOICE (which stands for Connecting, Honouring dignity, Offering support, supporting Identity, Creating opportunities, and Enjoyment) is a multi-component intervention to improve relationship-centred care (RCC) and overall mealtime experience for residents. The objective of this developmental evaluation was to determine: a) if the dining experience (e.g. physical, social and RCC practices) could be modified with the CHOICE Program, and b) how program components needed to be adapted and/or if new components were required. Methods: A mixed methods study conducted between April-November 2016 included two home areas (64 residents; 25 care staff/home management) within a single LTC home in Ontario. Mealtime Scan (MTS), which measures mealtime experience at the level of the dining room, was used to evaluate the effectiveness of CHOICE implementation at four time points. Change in physical, social, RCC dining environment ratings and overall quality of the mealtime experience over time was determined with linear mixed-effects analyses (i.e., repeated measures). Semi-structured interviews (n = 9) were conducted with home staff to identify what components of the intervention worked well and what improvements could be made. Results: Physical and overall mealtime environment ratings showed improvement over time in both areas; one home area also improved social ratings (p < 0.05). Interviews revealed in-depth insights into the program and implementation process: i) Knowing the context and culture to meet staff and resident needs; ii) Getting everyone on board, including management; iii) Keeping communication lines open throughout the process; iv) Sharing responsibility and accountability for mealtime goals and challenges; v) Empowering and supporting staff's creative mealtime initiatives. Conclusions: This developmental evaluation demonstrated the potential value of CHOICE. Findings suggest a need to: extend the time to tailor program components; empower home staff in change management; and provide increased coaching.
Background and Objectives: Poor food intake is common in long-term care (LTC). The mealtime exper... more Background and Objectives: Poor food intake is common in long-term care (LTC). The mealtime experience has been identified as influential, yet, research has been limited by lack of quality, standardized measures. The purpose of this study was to develop and test for inter-rater reliability the Mealtime Scan (MTS), an observational measure. Research Design and Methods: MTS was derived from the literature on ambiance, mealtime experience, social interactions at mealtimes, and social models of care. Three scales on person-centered care and physical and social environments are used to summarize key aspects observed with MTS. Two raters assessed MTS for reliability at 30 different meals conducted in 10 dining rooms, within three LTC residences. Intraclass correlation coefficient (ICC) was used to assess reliability. Results: MTS demonstrated good to excellent reliability on the three summative scales (physical ICC = 0.73, social ICC = 0.81, person-centered care ICC = 0.83) and other scalable items had good to excellent reliability (e.g., background noise ICC = 0.65, Mealtime Relational Care checklist: negative interactions ICC = 0.85). Discussion and Implications: MTS is reliable and face valid for assessing mealtime experience. Future work will explore construct validity of this measure. MTS can be used to support improving the mealtime experience for residents living in LTC.
Background: Long term care (LTC) menus need to contain sufficient nutrients for health and pureed... more Background: Long term care (LTC) menus need to contain sufficient nutrients for health and pureed menus may have lower nutritional quality than regular texture menus due to processes (e.g., recipe alterations) required to modify textures. The aims of this study were to: determine adequacy of planned menus when compared to the Dietary Reference Intake (DRI); compare the energy, macronutrients, micronutrients and fibre of pureed texture and regular texture menus across LTC homes to determine any texture, home or regional level differences; and identify home characteristics associated with energy and protein differences in pureed and regular menus. Methods: Making the Most of Mealtimes (M3) is a cross-sectional multi-site study that collected data from 32 LTC homes in four Canadian provinces. This secondary analysis focused on nutrient analysis of pureed and regular texture menus for the first week of the menu cycle. A site survey captured characteristics and services of each facility, and key aspects of menu planning and food production. Bivariate analyses were used to compare menus, within a home and among and within provinces, as well as to determine if home characteristics were associated with energy and protein provision for both menus. Each menu was qualitatively compared to the DRI standards for individuals 70+ years to determine nutritional quality. Results: There were significant provincial and menu texture interactions for energy, protein, carbohydrates, fibre, and 11 of 22 micronutrients analyzed (p < 0.01). Alberta and New Brunswick had lower nutrient contents for both menu textures as compared to Manitoba and Ontario. Within each province some homes had significantly lower nutrient content for pureed menus (p < 0.01), while others did not. Fibre and nine micronutrients were below DRI recommendations for both menu textures within all four provinces; variation in nutritional quality existed among homes within each province. Several home characteristics (e.g., for-profit status) were significantly associated with higher energy and protein content of menus (p < 0.01). Conclusions: There was variability in nutritional quality of menus from LTC homes in the M3 sample. Pureed menus tended to contain lower amounts of nutrients than regular texture menus and both menus did not meet DRI recommendations for select nutrients. This study demonstrates the need for improved menu planning protocols to ensure planned diets meet nutrient requirements regardless of texture. Trial registration: ClinicalTrials.gov ID: NCT02800291, retrospectively registered June 7, 2016.
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Papers by Heather Keller