food acceptance and intake of regular and texture ... · decreased muscle mass. a diet that...
TRANSCRIPT
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Food acceptance and intake
of regular and texture-
modified meals by nursing
home residents
Michelle Steenvoorden Master Thesis Food Innovation and Health
Department of Food Science, University of Copenhagen
February – August 2018
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University of Copenhagen Faculty of Science
Department of Food Science Section Food Design and Consumer Behaviour
Food acceptance and intake of regular and texture-
modified meals by nursing home residents
Master Thesis Food Innovation and Health (30 ECTS) Submitted: August 1st, 2018 Defended: August 16th, 2018
Michelle Steenvoorden [email protected]
Academic supervisors
Wender L.P. Bredie, Professor of Sensory Science, University of Copenhagen
Anne Marie Beck, Senior Associate Professor, University College Copenhagen
Industrial supervisors
Susanne Wolff, Scientific Advisor, Nestlé Health Science
Majken Alexander, District Manager for Public Customers, Oscar A/S (Nestlé
Professional)
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Summary Institutionalized elderly have a high risk of developing chewing and swallowing problems due to muscle degeneration and malnutrition. This forms part of a vicious circle, where lower muscle mass leads to increased chewing and swallowing problems, which leads to malnutrition, which leads to decreased muscle mass. A diet that includes texture-modified food could help break this vicious circle by making food easier to chew and thus increasing nutrient intake, but is rarely applied. This is mainly due to the social barrier on texture-modified food, as well as the fact that texture-modified meals are usually limited to elderly that have been diagnosed with dysphagia, a more severe form of chewing and swallowing problems. A “new normal” nursing home diet, where all elderly residents receive texture-modified food, may help break this social barrier, and ensure that even those with mild chewing and swallowing problems receive texture-modified food that should help increase their nutrient intake. However, little research is available on elderly nursing home residents’ liking and intake of texture-modified food, and how this is related to their severity of chewing and swallowing problems. This study aimed to test how a dinner menu with a texture-modified meat component compares in elderly liking and intake to regular nursing home dinner meals, and whether this is influenced by the severity of self-perceived chewing and swallowing problems experienced by the examined elderly nursing home residents. For this, elderly nursing home residents from the Dronning Anne Marie Centret in Frederiksberg, Denmark, were recruited as participants. Participants were given a questionnaire regarding their self-perceived chewing and swallowing problems as well as their food-related quality of life. Furthermore, participants took part in a consumer test where their liking and food intake was measured for dinner meals consisting of regular nursing home food, as well regular nursing home food with a texture-modified meat component. The results of this study showed that texture-modified food was both liked and eaten less than the regular nursing home food by the participants. Only the liking of appearance showed no difference between the texture-modified and control treatment. Furthermore, participants with a greater severity of self-perceived chewing and swallowing problems also experienced a reduced food-related quality of life. These self-perceived chewing and swallowing problems were, however, neither correlated to the liking and intake of regular nursing home meals, nor texture-modified meals. On the other hand, there was a significant positive relationship between food-related quality of life and both intake and liking. The results of this study can be interpreted in multiple ways, possibly suggesting that giving texture-modified food to elderly nursing home residents will not prevent malnutrition, but it also possible that liking and intake of texture-modified food could improve after a longer exposure period and further product optimization. Regardless, further research is needed to identify optimal texture-modified food for elderly, which may vary according to interindividual differences in food preference. Whether a “new normal” nursing home diet, where all elderly residents receive texture-modified food, will help against malnutrition in nursing homes therefore remains to be seen.
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Preface This thesis is the result of 6 months of work at the University of Copenhagen’s Design and Consumer Behaviour section, part of the Department of Food Science, and at Dronning Anne Marie Centret in Frederiksberg, Denmark. This Master Thesis represents 30 ECTS, and is a requirement for obtaining a degree as Master of Science in Food Innovation and Health. I would like to sincerely thank my supervisors Wender Bredie (WB), Anne Marie Beck (AB), Majken Alexander (MA) and Susanne Wolff (SW) for their continued support and enthusiasm during the course of this work. They have provided me with valuable comments during my work, but at the same time allowed me to steer my own course. Furthermore, they have enabled me to gain a better insight of the industry and academics in this field. I would like to thank the Dronning Anne Marie Centret, and all of its employees, for making this study possible. This includes the management, caretakers, and kitchen staff. Particularly, I would like to thank the residents of the Dronning Anne Marie Centret; without their participation this study could not have taken place. Furthermore, this study would not have been possible without the help of the 19 student volunteers from the University of Copenhagen and University College Copenhagen, who provided valuable help with the data collection of the consumer test. I would like to give special thanks to Eva Leedo, who helped me with participant recruitment and administration of the first questionnaire. Furthermore, I would like to thank Signe Okkels for her help with the pilot study, as well as the insightful discussions that we have had on the topics of this work. Also, I would like to thank the employees of the Technical University of Denmark who took part in the pilot study for their valuable contribution. I would like to thank my friends and family, without whose support I would not be where I am today. Lastly, I would like to thank my husband Rob van Gemert (RvG) for always being there for me when things got tough, as well as for helping with data collection during the consumer study, performing the role of independent assessor in the analysis of meal photographs, and proofreading the final manuscript.
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Contents
Summary .................................................................................................................................... iv
Preface ........................................................................................................................................ v
1. Introduction ............................................................................................................................. 1
1.1 Aim and research questions .......................................................................................................... 2
1.2 Outline........................................................................................................................................... 3
2. Background .............................................................................................................................. 4
2.1 The elderly population .................................................................................................................. 4
2.1.1 Eating difficulties among elderly ............................................................................................ 4
2.1.2 Malnutrition among elderly ................................................................................................... 5
2.1.3 Food-related Quality of Life ................................................................................................... 5
2.2 Diagnosis, treatment and prevention ........................................................................................... 6
2.2.1 Tools for the diagnosis of chewing and swallowing problems .............................................. 6
2.2.2 Treatment .............................................................................................................................. 7
2.2.3 Prevention .............................................................................................................................. 7
2.3 Consumer test with elderly ........................................................................................................... 8
3. Methodology ......................................................................................................................... 10
3.1 Study population ......................................................................................................................... 10
3.2 Study set-up ................................................................................................................................ 10
3.2.1 Pilot test ............................................................................................................................... 11
3.2.2 Questionnaire study ............................................................................................................. 11
3.2.3 Consumer test ...................................................................................................................... 12
3.3 Organization in practice .............................................................................................................. 16
3.4 Sample size calculation ............................................................................................................... 17
3.5 Data analysis ............................................................................................................................... 17
3.6 Ethics ........................................................................................................................................... 19
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4. Results ................................................................................................................................... 20
4.1 Participant characteristics ........................................................................................................... 20
4.2 Chewing and swallowing function .............................................................................................. 20
4.3 Food-related quality of life ......................................................................................................... 21
4.4 Food intake and food acceptance ............................................................................................... 21
4.4.1 Food intake .......................................................................................................................... 21
4.4.2 Food acceptance .................................................................................................................. 25
4.4.3 Trends over time .................................................................................................................. 28
4.5 Repeated consumption ............................................................................................................... 29
4.6 Relationships between DRACE, SWFL, food intake and food acceptance .................................. 29
5. Discussion .............................................................................................................................. 31
5.1 Strengths ..................................................................................................................................... 33
5.2 Limitations ................................................................................................................................... 34
5.3 Future perspectives .................................................................................................................... 36
6. Conclusion ............................................................................................................................. 38
References ................................................................................................................................. 39
Appendices ................................................................................................................................ 44
Appendix A – Letter of informed consent ......................................................................................... 44
Appendix B – Participant Information Sheet .................................................................................... 45
Appendix C - Pilot Study .................................................................................................................... 46
Appendix D – Questionnaire DRACE and SWFL ................................................................................ 50
Appendix E – Meal Composition ....................................................................................................... 52
Appendix F – Caretaker Information sheet ....................................................................................... 56
Appendix G – News item DAMC ....................................................................................................... 59
Appendix H – Instruction guide volunteers ...................................................................................... 60
Appendix I – Questionnaire Consumer test ...................................................................................... 64
Appendix J – Food intake and observation sheet ............................................................................. 66
Appendix K – Reference materials .................................................................................................... 67
Appendix L – Letter from the Ethical Committee ............................................................................. 72
Appendix M – Results ....................................................................................................................... 74
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1. Introduction Health gradually declines with age. As health declines, elderly increasingly start to suffer from problems during the chewing and swallowing of food. For instance, health problems such as cancer, stroke and dementia can all cause chewing and swallowing problem (Humbert & Robbins, 2008). Furthermore, aging is also associated with a decrease in skeletal muscle mass and muscle strength, i.e. sarcopenia, which can cause among other things problems during chewing and swallowing of foods (Cabre et al., 2009). It is estimated that 50 - 75% of institutionalized elderly may experience discomfort during chewing and swallowing (O'Loughlin & Shanley, 1998). Regardless of the cause, elderly with chewing and swallowing problems have an increased risk of developing malnutrition, which in turn leads to increased risk of morbidity and mortality, as well as a decreased quality of life (Wright et al., 2005). The relationship between malnutrition and problems with chewing and swallowing constitutes a vicious circle. Those who experience chewing and swallowing problems take up less energy and nutrients, contributing to loss of strength of the muscles involved in chewing and swallowing, leading to increased chewing and swallowing problems (Hudson et al., 2000). If elderly are trapped in this vicious circle long enough they may even develop sarcopenic dysphagia, and experience complications such as food entering the respiratory system and associated instances of pneumonia. Because malnutrition is an important link in this vicious circle, an effective treatment of chewing and swallowing problems of elderly in nursing homes may therefore be to increase their nutritional intake. However, this will usually require modification of the diet to make it more palatable. Texture modification (soft, gratin and creamy) has become one of the most common forms of intervention for chewing and swallowing problems and is widely considered important for promoting safe and efficient swallowing (Keller et al, 2012; Ney et al, 2009). However, many people with chewing and swallowing problems don’t accept these foods, because they do not like the taste, appearance and monotony of the texture-modified foods (Keller & Duizer, 2014; Swan et al, 2015). Furthermore, there is a large social barrier amongst elderly with regard to consuming texture-modified food, as it signifies increased frailty and dependence on others (Miller et al., 2006). Elderly that consume a texture-modified diet therefore often experience a reduction in their food-related quality of life, as they are ashamed to be eating texture-modified food (Swan et al., 2015). Therefore, most elderly with chewing and swallowing problems prefer the regular nursing home meals, even if they cannot chew it as well, and even at the increased risk of choking, also seriously limiting their food-related quality of life (Leiter & Windsor, 2007). It is known that a food’s sensory parameters, such as taste, appearance, texture, and smell, are important for the experience of a meal. By stimulating all senses, appetite usually increases (Cardello, 1994). The taste is not only in the food but also largely in the minds and the memory of the meal being served. Therefore, people with chewing and swallowing problems could benefit from a diet that is not only texture-modified, but also resembles traditional foods that they know in outward appearance and taste. Using a thickener and molds, texture-modified food can be given a recognizable taste and appearance, which should increase its acceptance by elderly and eventually also the intake. Such a modified menu may therefore decrease the risk of malnutrition in elderly and increase their pleasure in eating, and with that increase their food-related quality of life. However, the novelty of this approach means that few studies have investigated elderly liking and acceptance of such a texture-modified diet (Ettinger et al., 2014; Ilhamto et al., 2014).
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Even if elderly nursing home residents receive this novel form of texture-modified food, this will not remove the social barrier against texture-modified food. Furthermore, it is best to prevent the development of the malnutrition vicious circle as soon as possible, preferably even before any definitive observation of chewing and swallowing problems can be made. Therefore, there may be potential in offering texture-modified meals to all residents of a nursing home. If all nursing home residents were to receive meals that also contain texture-modified components, this should help remove the social barrier against them, and thus increase food-related quality of life. Furthermore, if it is assumed that there will be no difference between the intake of the novel texture-modified meals compared to regular nursing home meals, after the social barrier on texture-modified food has been removed, then this should help prevent the development of chewing and swallowing problems in nursing home residents. The malnutrition vicious circle will not be able to develop because elderly will then no longer suffer from a reduced nutrient intake when muscle mass starts to decrease, which will in turn slow down the further decrease of muscle mass. In this study, we will refer to this concept of providing all nursing home residents with texture-modified meals as part of their diet as “the new normal”.
1.1 Aim and research questions The aim of this study is to test how a dinner menu with a texture-modified meat component compares in elderly liking and intake to regular nursing home dinner meals, and whether this is influenced by the severity of self-perceived chewing and swallowing problems experienced by the examined elderly. In order to reach this objective, several research questions and hypotheses are developed:
• What is the severity of self-perceived chewing and swallowing problems among elderly living in the studied nursing homes and how is this affecting the food-related quality of life?
o H1: “Elderly with a greater severity of self-perceived chewing and swallowing problems experience a reduced food-related quality of life.”
• How does overall liking, and the liking of appearance, smell, taste, and texture of the modified menu compare to those of the regular food of the nursing home, and how is this influenced by the chewing and swallowing problems and the food-related quality of life perceived by the participants?
o H2a: “Elderly with more severe self-perceived chewing and swallowing problems have a higher liking for the texture-modified menu, compared to the regular menu.”
o H2b: “Elderly with a lower food-related quality of life have a higher liking for the texture-modified menu, compared to the regular menu.”
o H3a: “Elderly, regardless of severity of self-perceived chewing and swallowing problems, like the texture modified menu at least as well as the regular menu.”
o H3b: “Elderly, regardless of food-related quality of life, like the texture modified menu at least as well as the regular menu.”
• How does the food, energy, and protein intake from the modified menu compare to that from the regular food of the nursing home, and how is this influenced by the chewing and swallowing problems and the food-related quality of life perceived by the participants?
o H4: Elderly have a higher food, energy and protein intake from the texture-modified menu than from the regular menu, regardless of severity of self-perceived chewing and swallowing problems and food-related quality of life.”
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1.2 Outline This thesis contains six chapters. Chapter one introduces the topic covered in this thesis and familiarizes the reader with the aim of this study, the research questions, and the hypotheses. Chapter 2 contains a literary study which outlines the subject background. Chapter 3 describes the methodology applied in this study, which is comprised of both a questionnaire study as well as a consumer test, both conducted with elderly nursing home participants in a nursing home in Frederiksberg, Denmark. The results of this study are subsequently presented in Chapter 4. Chapter 5 contains a discussion of the results, which also highlights the strengths and weaknesses of the study, and addresses the prospects for the future development of the ‘new normal’ diet described within this study. Lastly, Chapter 6 presents the final conclusions of this study and answers the research questions presented in the introduction.
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2. Background
2.1 The elderly population Worldwide the number of older people is increasing faster than any other age group, with the number of people over 80 years growing the fastest (Huber et al., 2009). This growth is driven by the rising life expectancy, large baby boom cohorts and low birth rates. This trend can also be seen in Denmark, where now one in four Danes has passed 60 years, compared to only one-fifth in 2000 (Statistics Denmark, 2015). Of this group 10% lives in a nursing home, and of these the majority (67%) are over eighty years old (Kofod, 2008). The coming decades the elderly population will continue to grow worldwide, along with the number of individuals in need for special nutrition. It is often stated that the aging population presents new societal challenges and increases pressure on national health care systems (Key figures on Europe, 2013). However, not everybody ages at the same rate, with large variations in functional abilities, physical and mental health among similarly-aged elderly. This indicates that the elderly population is highly heterogeneous group, in which some are healthy until a late age and others become dependent at a younger age already. Recent studies show that people stay healthier and more active up to a later age, when compared to the past (Falk et al., 2014). Nevertheless, in very old ages many lose the ability to live independently because of impaired mobility, physical or mental health problems. This increased dependency and frailty among elderly often means that those elderly have to move to nursing homes.
2.1.1 Eating difficulties among elderly Many elderly experience a decline in chewing and swallowing function during the mealtime, making it more difficult for them to process harder food-products such as meat and hard vegetables. This decline in chewing and swallowing function can occur during healthy ageing, as result of sarcopenia (Humbert & Robbins, 2008) or as a result of a variety of diseases. Sarcopenia is the gradual loss of muscle mass and muscle strength in the body, also in the muscles used for chewing and swallowing, causing eating difficulties. Eventually, if muscles are not trained enough and dietary intake is not adequate, the gradual loss of chewing and swallowing function as result of sarcopenia can transform in a more severe state called dysphagia. Dysphagia is characterized by food entering the respiratory system during eating, where it can cause choking and lead to pneumonia. Usually, treatment is only applied to individuals diagnosed with this severe dysphagia, even though many more elderly may suffer from the milder chewing and swallowing problems. It is stated in the literature that more than 50% of the institutionalized elderly have identifiable signs and symptoms of chewing and swallowing problems (O'Loughlin & Shanley, 1998). However, it is rarely noticed as a health concern by the older people. Moreover, nursing home staff is most often only aware of a handful of people suffering from it. In spite of this, chewing and swallowing problems can cause an inadequate dietary intake, which if untreated, contributes to malnutrition, increased risk for frailty, decreased quality of life and eventually morbidity (Wright et al., 2005). Furthermore, chewing and swallowing problems can be associated with a variety of other diseases. Over 50% of acute stroke patients tend to have problems during chewing and swallowing (Martino et al., 2005). Furthermore, many people suffering from Parkinson’s disease, Alzheimer’s disease and Multiple Sclerosis encounter difficulties during chewing and swallowing. All of these diseases are also frequently present in nursing home residents, further signifying that nursing home residents are at severe risk of chewing and swallowing problems.
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Overall, an increased prevalence of eating difficulties is related to both the presence and the degree of cognitive impairment and goes beyond the scope of chewing and swallowing disorders. For instance, many elderly suffer from sensory dysfunction, a decline in taste and decreased smell sensitivity (Nordin, 2017). This dysfunction of the senses increases with age. Furthermore, a loss of appetite and motoric malfunction, including manipulation of food on the plate and transportation of the food to the mouth, can cause a reduced intake and increased risk of undernutrition among elderly (Jacobsson et al., 2000). Another condition causing difficulties during eating is xerostomia, a dry mouth, often seen as a side effect of many types of medication (Hopcraft & Tan, 2010). Many frail elderly have this, mainly because this group tend to take many medicines. The amount of saliva produced is important in the chewing and swallowing processes for properly lubricated food particle movement inside the mouth (Rothenberg & Wendin, 2015). Moreover, many older people suffer from positioning problems, among others hanging at the table or sliding of the chair, causing problematic situation for the older individual during mealtime (Aguilera & Park, 2016). These eating difficulties can affect food choice (Sidenvall et al., 1994), change the amount and variety of food eaten, and influence the social context of the meal and of the meal experience (Gustafsson et al., 2003).
2.1.2 Malnutrition among elderly The eating difficulties mentioned above can cause elderly to reduce their food intake, which eventually can lead to malnutrition. Malnourished elderly are at a higher risk of experiencing falls, prolonged hospitalization and institutionalization, postoperative complications and infections, delayed and complicated wound healing, reduced quality of life and increased risk of mortality (Wright et al., 2005). Thus, it is important that elderly continue to receive an adequate amount of nutrients in their daily food intake. Elderly have different energy and nutrient requirements than adults. During ageing the body composition will naturally change due to a decline in muscle mass and muscle strength (i.e. sarcopenia) and the increased amount of fat tissue (Maeda & Akagi, 2016). This process can be accelerated through poor nutrition, sedentary lifestyles and underlying disease states. For this reason, elderly are recommended to increase the proportion of protein in their diet from 10-20E%, which is recommended for adults, to 15-20E% (Pedersen & Ovesen, 2016). This means that a protein intake of 1.0-1.5 g per kg bodyweight per day or 20-30 g protein per meal is recommended for elderly to maintain the nitrogen balance (Bauer et al., 2015). Since elderly do not consume enough food due to various reasons, they are at greater risk for getting insufficient protein leading to a state of undernutrition (Volkert & Sieber, 2011). Notably, proteins are mainly found in the dense and hard-to-chew meat component of the dish. When elderly suffer from chewing and swallowing problems, this is often the leftover food. Thus, increasing the protein intake of elderly suffering from chewing and swallowing problems would be an important step toward combating their malnutrition.
2.1.3 Food-related Quality of Life Food being an essential part of living, it is an important human concern, and can be a source of both satisfaction and dissatisfaction (Grunert et al., 2007). Moreover, the food that people consume may have both positive and negative effects on somebody’s well-being. Malnourished elderly rate their well-being as lower in comparison with other groups (Olin et al, 2005), and indeed dysfunction in mobility resulting from inadequate food intake is a strong predictor for need of help and low quality of life (Stenzelius et al, 2005). This indicates that food is an essential part of the quality of life (Grunert et al., 2007). So to fight malnutrition and increase elderly’s quality of life a “good diet” needs to be provided, which does not only meet the required nutritional needs of the elderly, but it should also maintain “eating pleasure”. People that do not experience pleasure during the consumption of the meal, tend to have a decreased food intake (Grunert et al., 2007). Providing eating pleasure becomes even more crucial when older people become institutionalized and lose a
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part of their independence. A study by Sulmont-Rossé et al. (2012) shows that eating pleasure of elderly and satisfaction with the consumed meals decreases significantly when they become dependent. Several studies have already been conducted to show how changes in the meal experience can increase elderly’s food-related quality of life. In nursing homes it has been shown that family-style meals stimulate daily energy intake and protect against malnourishment (Nijs, 2006). An important explanation is that social facilitation promotes the feeling of having the meal in the company of others with stimulating conversations, extension of meal duration and extra attention of the staff (Nijs, 2006). However, in order to facilitate the food-related quality of life of the elderly not only changes need to be made to the meal environment, but also to the consumption experience itself. Finding ways to manage the earlier mentioned eating difficulties may help in increasing elderly people’s enjoyment of food consumption. Grunert et al. (2007) developed the satisfaction with food-related life (SWFL) questionnaire, which consists of 5 questions on a 5-point scale identifying the food-related quality of life by making of an overall assessment of a person’s food and eating habits (Grunert et al., 2007). The outcome of this questionnaire is quantitative and can be used as a dependent variable in intervention studies (Grunert et al., 2007). Moreover, recent studies suggest that the SWFL scale directly describes overall life satisfaction (Schnettler et al., 2013).
2.2 Diagnosis, treatment and prevention Most eating difficulties, including chewing and swallowing problems, are not recognized as such. They are experienced as a part of getting older and becoming frailer (Steele et al., 1997). As such, the signs and symptoms of chewing and swallowing problems are rarely noticed as a health concern by the elderly. The serious complications that can result from long-term untreated chewing and swallowing problems mean that it is important that these problems are diagnosed and treated, and if possible prevented altogether.
2.2.1 Tools for the diagnosis of chewing and swallowing problems Many methods, invasive and non-invasive, are available to diagnose chewing and swallowing problems. Invasive methods, such as the videofluoroscopic swallowing study (VFSS) and the fiberoptic endoscopic evaluation of swallowing (FEES) provide dynamic imaging of the swallowing function but need to be administered by speech therapists. This makes the use of these techniques in scientific studies expensive and infeasible (Edmiastion et al, 2010). Moreover, there are many non-invasive methods available, including bedside screening tools and self-reported questionnaires. In a systematic review Park et al. (2015) give an overview of 29 different non-invasive instruments. The Gugging Swallowing Screen (GUSS) and Standardized Swallowing Assessment (SSA) were identified as the tools with the highest sensitivity and highest psychometric quality. However, as these tools need to be administrated by nurses, these tools are also not feasible for use in studies that have no resources available for the use of qualified nurses. The above-mentioned tools are usually used to obtain a clinical diagnosis of chewing and swallow problems. However, to be able to identify whether or not a person is suffering from milder chewing and swallowing problems, a different tool is needed. This can for instance be done via self-reported questionnaires (Park et al., 2015). The use of these questionnaires eliminates the need for nurses and speech therapists to conduct the screening and can be conducted by the researchers themselves. Many questionnaires are available, and different ones will be optimal for studies with different requirements. When the requirement is that the questionnaire that should be easy to use, reliable, have a short administration time, and should provide a severity grading of the chewing and swallowing risk, the DRACE (Dysphagia Risk Assessment for the Community-dwelling Elderly) questionnaire will be the optimal questionnaire to use. The DRACE questionnaire was developed to evaluate the deterioration of chewing and swallowing function in community-dwelling elderly (Miura
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et al., 2007). One advantage of this method is that the questionnaire only consists of 12 questions, which assures a short administration time. Moreover, the questionnaire is significantly and positively correlated to the results of the 3-oz water test and provides reliable results (Miura et al., 2007). Furthermore, the DRACE can be used to do risk identification and severity grading of chewing and swallowing problems (Park et al., 2015).
2.2.2 Treatment Different things can be done to reduce the risk of malnutrition for those that suffer from eating difficulties, including training of the muscles, eating assistance, oral supplementation and food/drink modification (Abdelhamid et al., 2015). Another promising method would be the use of texture-modified food. These are foods that have soft textures and/or reduced particle size (Cichero, 2015). Modifying the texture of food is a common strategy used for the treatment of people with severe chewing and swallowing problems (Rothenberg & Wendin, 2015). Furthermore, the consumption of these foods can also have positive outcomes for elderly suffering from muscle atrophy, gradual loss in sensory perception and loss in appetite (Aguilera, 2016). The way in which nursing homes usually prepare texture-modified food is to first prepare it in the same way as the food for all residents. However, after preparation, the total meal will be blended and served like a gray goo. However, as liking of the appearance of the food is a big driver for food choice and food consumption, many people refuse to eat these blended meals and prefer to eat the regular meals that they find harder to chew, even taking the risk of choking on the regular food (Keller & Duizer, 2014). With the aging population, further development of texture-modified food is a big opportunity for the food industry. However, in spite of this, products for this market segment in Europe have been slow to emerge (Costa & Jongen, 2010; Scott-Thomas, 2012). Several companies, have a special product line for individuals with chewing and swallowing disorders, consisting of purees and thickened beverages. These are prepared by the use of different ingredients or the application of innovative processing techniques. Varying fat content, changing size of fat droplets, adding thickeners and using emulsifying agents are common approached used in industry for food texture modification (Wendin, 2001). OSCAR A/S, a Danish company which is part of Nestlé Professional, applies a version of texture modification which uses molds to make the modified food resemble its original shape. First, the meal is prepared in its regular way. Then, each separate meal component is blended, after which several additional ingredients are added. Among other eggs, cream and starch are added to ensure a solid consistency after baking of the mixture. Furthermore, OSCAR meat fonds and/or pastes are added to increase the flavor intensity of the products. When everything is mixed together, it is put into molds, which resemble the original meal components. The filled molds are then baked so that a solid texture is obtained that is easy to chew and swallow. In this way, a texture-modified meal is obtained that still has a pleasant texture while also looking like the original non-modified meal.
2.2.3 Prevention Prevention is better than treatment, and the malnutrition vicious circle is best broken before the stage of dysphagia is reached. If we assume that elderly with early-stage chewing and swallowing problems will have a higher food intake if their food would be easier to chew, it would be beneficial to provide also these elderly with texture-modified meals. Texture modified meals can also help elderly with other forms of eating difficulties, as texture modification easily facilitates additional food modifications such as flavour enhancement, protein and other nutrient enrichment.
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Making texture modified food ‘the new normal’ would mean that all residents of a nursing home would receive the same texture-modified meal, also those not yet experiencing chewing and swallowing problems. If all nursing home residents eat would occasionally be given texture-modified food, this should help reduce the social barrier associated with texture-modified food, while providing residents with chewing and swallowing problems a meal that is easier to consume. This should help prevent development or worsening of chewing and swallowing problems by increasing nutrient intake. Moreover, reducing the social barrier can help take away the shame that many people feel when they are in the need of consuming the modified meals, which should increase the food-related quality of life. However, severely modifying the texture of all meal components will likely be too much of a change, especially for elderly who do not yet experience severe chewing and swallowing problems. Meat is usually the part of the meal that is hardest to chew, also for elderly without severe chewing and swallowing problems. Furthermore, meat usually also contains the most proteins out of all meal components. Therefore, modifying only the meal’s meat component texture for all residents would be a promising approach to the ‘new normal’. In short, ‘the new normal’ describes an effort to prevent malnutrition amongst nursing home residents by having all residents consume a meal that has a texture-modified component. This should increase food intake by those who have some form of chewing and swallowing problems, while reducing the social barrier associated with texture-modified food. The degree of texture modification, as well as the frequency with which texture-modified food is provided, is open for debate.
2.3 Consumer test with elderly In order to detect the true potential for the newly developed product, or in this case a modified product, and to retrieve information for possible product improvements, several tests can be performed. The collected data can then be further used in research and development (Fuller, 2011). Normally a distinction is made between sensory and consumer tests. In sensory tests, such as difference tests or descriptive test, a trained panel (10-15 people) evaluates the product and makes an analytical evaluation. However, in a consumer test, actual consumers (normally, between 50-100) will be requested to provide their attitude and acceptance or preference for the studied product to ensure that the desired characteristics are successfully delivered (Moskowits, Beckley & Resurreccion, 2012). In order to be able to translate the collected data to a general population it is important to perform these tests on the right consumer segment. So, if the product is aimed to be consumed by a certain target population the test should be conducted within a group representable for this population (Moskowits, Beckley & Resurreccion, 2012). Therefore, when testing a product that is meant for frail and institutionalized elderly, these people should also be the ones to test the product. Working with frail and institutionalized elderly is both challenging and costly. Many elderly suffer from dementia or other physical and cognitive impairments, and have limited attentional abilities (Metheven, 2016). Therefore, often a substitute population is chosen to test with, in the form of healthy elderly in the age of 60-75 years. However, healthy elderly in the age of 60-75 years are not comparable to frail and institutionalized elderly of the same age. Institutionalized elderly at this high age most often encounter many eating difficulties, don’t find the pleasure in food that they used to, and suffer from sensory losses and sensory threshold changes, meaning that they have other preferences than younger or more healthy elderly (Metheven, 2016). These factors have to be taken into account when developing a methodology for consumer tests involving elderly participants.
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When conducting consumer tests with elderly, the researcher should be aware of the information they want to obtain from the study and which information elderly are capable of providing. Therefore, several elements of the hedonic measurements need to be given special thought when testing with elderly. According to Metheven et al (2016), older adults may struggle with simple testing methods: visual difficulties may make them unable to see scoring cards or line scales, hearing impairment may result in difficulties in relaying instructions, confusion can cause issues in understanding the requirements of the test, poor dexterity can make handling or sorting samples and responses more difficult, they can have difficulties in writing and expressing themselves, and some participants may become fatigued if the amount of tasks they need to perform is too large. Moreover, nursing home residents experience more problems with the above than the average population of older adults (Maitre et al., 2015). Therefore, instead of using a standard 9-point hedonic scale, which is the most commonly used scale, an alternative scale, suitable for the elderly, needs to be used when performing a consumer test with elderly. One promising alternative scale would be the seven-point category scale with labels and pictograms (Maitre et al., 2015). This scale makes use of seven categories because elderly have a tendency to score on the positive end of the scale (Maitre et al., 2015), and seven categories will still ensure sufficient discriminatory power. Furthermore, the smiley-faces on the scale will help guide the elderly in making their choice. Moreover, when testing in frail elderly, researchers should adapt themselves to the constraints of the environment and the participants’ frailty. Therefore, a realistic setting would be a home use test. In a home use test the product is brought to the place where participants normally consume it. For instance, when doing consumer tests with frail institutionalized elderly, a home test would take place in the nursing home. Home tests are the costliest method available but will provide the most representative and reliable information (Resurreccion, 1988). However, when testing in a nursing home, it is important to be careful in the approaches used, and to work within the daily behavioural patterns of the residents. It would for example not always be possible to seat participants at individual tables, because they are used to sitting and eating together with certain other residents and assign great value to this. Furthermore, when testing with frail elderly, more assistance of the researchers will be needed during the data collection process than when working with healthy adults. Clear instructions, which often need to be repeated, need to be given to the participants. Therefore, most likely one investigator will be able to take care of no more than two to four subjects at a time.
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3. Methodology The study was conducted at the Dronning Anne Marie Centret (DAMC), a nursing home in Frederiksberg, Denmark. The first contact with the DAMC was initiated by one of the supervisors (MA). Thereafter, all principal communication with DAMC was maintained by MS. This included multiple meetings with the DAMC manager for the recruitment of DAMC to the study, as well as communicating with DAMC’s kitchen staff and the caretakers to facilitate the study.
3.1 Study population The target group of this study was elderly nursing home residents. In this study, elderly are considered to be people older than 65 years of age. Individuals were not eligible to participate in the study when they were allergic or intolerant to any of the test foods, suffered from diabetes, consumed low-fat or vegetarian/vegan diets, already consumed a texture-modified diet, required tube feeding, or when nursing home staff considered their cognitive abilities to be insufficient (e.g. diagnosis of severe dementia). Before recruiting the participants, the researcher (MS) spoke with the head caretakers of the different wards to receive a shortlist with the names of the residents that would be eligible to participate in the study. Recruitment of the participants was spread over two days. Whereas at the moment of recruitment there were 69 persons living in the nursing home, only 39 were found capable enough to participate. Eventually the eligible participants were approached directly by the researcher (MS) and a Danish speaking assistant (EL) in their own room or in the common areas. They were given an introduction to the study and were then asked to participate. If they agreed to participate, they were asked to sign an informed consent form (Appendix A). Furthermore, they received an information sheet (Appendix B), so that they and their families could inform themselves more about the study. Eventually, a total of 29 participants were recruited among the nursing home’s elderly residents.
3.2 Study set-up An overview of timeline of this study, including preparation work, pilot studies, and data collection, is given in Figure 1. Preparations took place over the entire course of this study, pilot studies took place in April 2018, and data collection took place in April and May 2018. All data were collected in the Danish language. This study made use of a multimethod approach, combining a questionnaire study that collected data on the prevalence and severity of the self-perceived chewing and swallowing problems experienced by the participants, as well as their food-related quality of life, with a consumer test that collected data on food liking and food intake of a partly texture-modified menu. To test the suitability of the research tools and data collection methods of the planned study, and to test for the time required to perform the various tasks during the data collection, multiple pilot studies were performed ahead of the actual study. The results of these pilot studies were used to make changes to the study methodology and planning. Moreover, this information was used to develop instruction guides for the study’s volunteers and nursing home staff, to ensure a consistent data collection process.
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Figure 1: Study overview, showing the different stages of the study preparation, pilot studies, and data collection.
3.2.1 Pilot test Before the actual start of this study, several pilot studies were performed to test the feasibility of the applied tools and the experimental time schedules of both the questionnaire study and the consumer test of this study. A first pilot test, involving testing the questionnaire study and the consumer test, was performed with five visitors of the day care center at the DAMC. A second pilot study to test the feasibility of hedonic scales was performed with a convenience sample at the Danish Technical University. Moreover, just before staring the consumer test, a trial run was done with the actual participants. A more detailed overview of the research methodology and results of the pilot study can be found in Appendix C.
3.2.2 Questionnaire study First, a questionnaire study was performed to collect data on the prevalence and severity of the self-perceived chewing and swallowing problems experienced by the participants, as well as their food-related quality of life. For this, data was collected using a paper questionnaire survey (Appendix D). The questionnaire was administered by the researcher (MS) and a Danish speaking assistant (EL), immediately after the recruitment of the participants. Moreover, participants were told that no right or wrong answers existed. The questionnaire consisted of multiple elements. First, baseline data such as gender and age were asked. Then, the degree to which participants feel that they experience chewing and swallowing problems were evaluated using the ‘Dysphagia risk assessment for the community-dwelling elderly’ (DRACE) questionnaire (Miura et al., 2007). This questionnaire was chosen because it is non-invasive, does not have too many questions, is easy in handling, and because it has been validated as being positively correlated to the (invasive) 30 ml water test (Miura et al., 2007). The DRACE questionnaire consists of 12 questions based on physical symptoms associated with chewing and swallowing problems. Participants were asked to score the symptoms on a 3-point scale based on their own experience with these symptoms during the past year: ‘0’, none; ‘1’, mild; ‘2’, severe. A person with a cumulative score between 2 and 4 was assessed as being at risk of having self-perceived chewing
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and swallowing problems. Furthermore, a cumulative score higher than 5 was assessed as having self-perceived chewing and swallowing problems. The DRACE questionnaire has been validated in the English as well the Japanese language (Miura et al., 2007). For this study however, the DRACE questionnaire was translated into Danish. In order to validate the translation a forward and backward translation approach was used (Guillemin et al., 1993). This means that after translation the questionnaire was translated back to English by three independent native Danish speakers with a good command of English. This was followed by a pilot study with members of the actual target population to test how the questions were received by this group. After the DRACE questions, participants were asked about their food-related quality of life via the ‘satisfaction with food-related life’ (SWFL) questionnaire (Grunert et al., 2007). SWFL consists of five questions that can be measured independently or grouped into a single dimension. For each question the participants evaluated their degree of agreement with a five-point Likert scale (from 1 = disagree completely to 5 = agree completely), where a higher level means a better SWFL score. The SWFL questionnaire was considered to be a good tool for this study, because the SWFL scale can be seen as a direct measure of overall life satisfaction (Schnettler et al., 2013). Furthermore, the quantitative outcome of this questionnaire can be used as a variable during the statistical analysis, and the questionnaire has been validated in the Danish language (Grunert et al. 2007). Lastly, participants were requested to score their overall satisfaction with their current menu at the DAMC on a 5-point Likert scale, ranging from 1 = very dissatisfied to 5 = very satisfied. This was done to see if satisfaction with their current diet would be a confounding factor in the food intake and food liking of participants.
3.2.3 Consumer test To investigate how a “new normal” diet of texture-modified food would affect the food intake and acceptance of nursing home residents, a consumer test was performed. This consumer test was designed as a crossover study, which can tolerate lower sample sizes than a randomized control study (Jones & Kenward, 2014). During the consumer test, participants tested four different dinner meal types for food liking and food intake: chicken, pork, lamb, and beef. Over the course of the study, each meal was served to the participants twice: once as a regularly-prepared control meal (treatment A), and once as a texture-modified meal (treatment B). In total, the participants therefore received eight dinner meals as part of this study, on eight different test days. These test days were divided over the entire month of May, so that participants had a limited number of test days per week. It was made sure that there was always at least one regular non-test day in between test days. The DAMC consists of two wings (a North and South wing) with two departments each. The floor plan of these wings was used in the study to divide the participants among two groups: group I (South and North ground floor) and group II (South and North first floor). Systematic randomization was used for the allocation of the meals (Table 1). All participants received the same meal at a certain test day. However, during the first period the participants in group I were served the control meal, whereas the participants in group II were served the modified meal. In the second period this order was reversed, with group II having been served the control meal and group I having been served the modified meal.
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Table 1: Crossover study design. In the first period group I consumed meal A (regular nursing home meal, control), whereas group II consumed meal B (texture-modified meal). During period 2 the consumption pattern was vice versa with group I consuming meal B and group II consuming meal A.
Group I (South and Nord ground floor)
Group II (Nord) (South and Nord first floor)
Period Treatment Period Treatment
1 A 1 B
2 B 2 A
3.2.3.1 Sample preparation
Four dinner meal types were developed in collaboration with the kitchen staff of the nursing home and Nestle Professional Food A/S (Table 2). These four meal types constitute typical dinner meals that the participants can expect to receive in the nursing home. Four different types of meat were chosen (i.e. chicken, pork, lamb, and beef), to reduce the confounding effect of participant dislikes for a certain meat type. Each meal type was prepared with two different treatments (i.e. control and texture-modified) and consisted of four components, i.e. meat, vegetables, potatoes and gravy. During the experiment only the meat component of the texture-modified meal was modified, whereas the other components were identical. This was done because the pilot study showed that modification of the entire meal would be too much of a change for the participants, and because the meat component of the meal is usually the hardest to chew while containing the most proteins. The quantities of the meals were set as follows after consulting the nursing home: meat (60 g), vegetables (50 g), potatoes (100g) and gravy (100 g). An overview of the energy and protein content of the different meals can be found in Appendix E.
Table 2: Overview of the meal types that were served in the nursing home and their serving dates.
Meal type Period 1 Period 2
Grilled chicken with cucumber salat, mashed potatoes and gravy
29 April
13 May
Pork ribs with red cabbage salat, potatoes and gravy
02 May
15 May
Roasted lamb with tzatziki, potatoes and gravy. 06 May
11 May
Beef stew with asparagus, carrots, peas, and potatoes
08 May
23 May
The control meals were prepared by the nursing home kitchen staff in the same way as they would normally prepare all their other meals. The modified meat components, on the other hand, were prepared by the principal researcher and the developer from Nestle Professional Food A/S (MS & MA). The modification of the meat component was based on a previously-found “best-practice” by Nestle Professional Food A/S. The first step to preparing the modified meat was to prepare it as the regular non-modified meat. Thereafter, the meat was cut in pieces and put into a blender. Several ingredients were added during the blending, including egg, cream, starch, and a Nestle-produced fond, according to a specific meat-dependent recipe. Each blended meat was thereafter put into a silicone mold, after which it was baked in an oven. The baking gives the texture-modified meat a slightly firmer consistency, while the mold helps it resemble the original component again.
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After preparing the different meal components, these were stored in containers in the refrigerators. Then, 3 hours before serving, the containers with the meal components were taken out of the fridge to be prepared for serving. The meal components that were meant to be served cold were weighted into small bowls, with an accuracy of ±3 grams, after which they were refrigerated again until served to the participants. For the meal components that were meant to be served warm, two different methods were used for heating and plating up. On the first 3 test days, the components that were meant to be served hot were plated up immediately after having been taken out of the fridge, with an accuracy of ±3 grams. The plates were then wrapped in aluminum foil, and placed into an oven until the meal had a core temperature of 75°C. The plates were then stored in thermal containers, until served to the participants. However, after the third test day it was clear that this method often resulted in food that was experienced by the participants to be too dry. Therefore, from the 4th day onwards, the containers with the meal components that were meant to be served warm were put in the oven first, until their core reached a temperature of 75°C. Approximately one hour before serving, the containers were taken out of the oven and the researcher (MS) plated up the meals under heating lamps. Each component was weighed separately onto the plates with an accuracy of ±3 grams. Plates were than wrapped in plastic foil and stored in thermal containers until served to the participants. Before serving, the components that were meant to be served cold were added to the plate.
3.2.3.2 Mealtime procedure
During the test day, the participants were informed by the caretakers that they had to answer some questions again during dinner that day. Caretakers were informed of their task by the researcher (MS) in person and were given an information sheet (Appendix F). Moreover, a reminder of the study was put in the monthly magazine of the DAMC and displayed at the television in the common areas (Appendix G). The study was carried out in the four common areas of the nursing home, where the residents usually received their dinner. The organization of the meal did not differ from the standard procedure. In general, nursing home residents were not moved from their regular dinner table seat during dinner, regardless of whether they participate in the study or not. However, the final decision of whether or not to move the participants from their regular seat was left up to the caretakers present at the different wards. The non-participating residents were also present, and received their dinner in the usual manner by the caretakers. At every ward, dinner was served to both the participants and non-participating residents between 17:00 and 17:30. At every ward 3 volunteers were present. One volunteer combined the cold and warm meal components on the plates before they were served out, weighed the plates before they were served out, weighed the plates after consumption, and took photographs of the plates after consumption. Two Danish-speaking volunteers served out the meals, helped the participants with answering the questions, and took in the plates again after consumption. To ensure consistent data collection, all volunteers were provided with an instruction guide which they had to read before the study. Furthermore, before data collection on every test day, the researcher (MS) gave an instructional talk to all volunteers of that day. The instruction guide for the volunteers can be found in Appendix H. The timeline of a test session of the consumer test is shown in Figure 2. Before serving of the meal, each participant’s meal was weighed by a volunteer. At the same time, the participants received a questionnaire from one of the Danish-speaking volunteers, containing questions they were meant to answer before, during and after eating their meal (Appendix I). After they had received their questionnaire, participants were given a brief explanation of when to fill in which questions, and they were asked about their appetite. Then a “display” meal was served. After serving of the display meal, the participants answered questions about the appearance and smell of the meal. Right after
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answering these questions, the display meal was taken back in and their test meal was served. During eating, they answered questions about taste, texture, and overall liking of the meal. Furthermore, once the participants finished eating, they answered a last question about if they would like to consume this kind of meal more often. Then, the plates were removed, after which they were weighed and photographed (less than 15 minutes after the meal). After the test, desserts and coffee were then offered to the participants as is usually done in the nursing home after dinner. This was no longer part of the consumer test, and therefore intake of drinks and dessert was not recorded. Throughout the test, the Danish-speaking volunteers assisted the participants with answering the questions of the questionnaire.
Figure 2: Flowchart displaying volunteer-participant interaction.
The choice to serve a display meal before the actual test meal, which was used to score participants’ liking of appearance and smell, was made after the pilot study (Appendix C). Participants should answer questions on appearance and smell before actually eating the meal, to avoid having the experience of tasting the meal affect their scoring of the appearance and smell. However, during the pilot study it became clear that participants would immediately start eating their meal after it was served to them, even when instructed to only start eating the meal after having scored their liking of the meal’s appearance and smell. Therefore, during the consumer test, it was decided to prepare one display meal for every four participants. This display meal would then be passed around by the volunteers to the participants, so that the participants could look at it and smell it, but not eat it. In this way, it was possible to have the participants score their liking of the meal’s appearance and smell without having the participants eat from the meal already.
3.2.3.3 Measurements
Food Intake – Food, energy, and protein intake was assessed by weighing plates before and after the meal using the same electronic scales (precision ± 1g), thereby calculating the weight of the meal that was consumed and that was left over. This was done to assess whether there was a difference in food intake between the texture-modified diet and the control diet. On each ward, one volunteer was responsible for weighing the participants’ plates before and after consumption. Participant-specific plate weight data were recorded on an observation sheet (Appendix J). To ensure that there could be no mix-up of plates of different participants, a label with the unique participant number was attached to the bottom of every plate. The gold standard for measuring nutritional intake would actually be to weigh each meal component prior and after eating (Appelton, 2009). However, this is also very time consuming, especially with multiple components on the plate (Wansink, 2009). Therefore, to make sure that data could still be collected on the consumption of the meal’s individual components, plates were not only weighed
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before and after consumption, but also photographed after consumption. For this, the validated photographic method from Pouyet et al. (2014) was used in this study. Each participant’s plate was photographed after the meal by the volunteer that was also responsible for weighing the plates, with a label stating the participant number included in the photograph. The photographs were then analyzed by the researcher (MS) and one independent assessor (RvG). From the image, they independently estimated the percentage of each meal component (meat, vegetables, gravy and potato) left on the plate. To help with this estimation, reference photos were used that showed 0%, 25%, 50%, or 75% consumption weight of each separate meal component (Appendix K). The weight intakes of the different meal components were then calculated for each participant based on the amount they had been served. Adding these weights up gave an estimation of the total food intake. Energy and protein intakes were then calculated by applying component-specific standard energy and protein values obtained from Frida Food Data (Danish Technical University, 2015), the DAMC kitchen, and Nestle Professional Food A/S. Food liking - Acceptability of meals were assessed with a questionnaire adjusted to match with the physical and cognitive abilities of the participants. The questionnaire consisted of 7 questions in a bigger font size, volunteers assisted when needed, and the amount of questions asked was limited. A 9-point category scale would be the ideal tool to assess acceptability of meals. However, due to the reduced cognitive abilities of the nursing home residents, a 9-point category scale offers too many choices and makes it difficult for elderly to properly be able to discriminate between the different choices (Methven et al., 2016). On the other hand, a 3- or 5-point category scale would likely result in too little discrimination within the results, as elderly tend to predominantly score on the positive side of the scale (Maitre et al., 2015). Therefore, this study made use of the ‘7-point categorical scale combining labels and pictograms’ (Maitre et al., 2015) to assess acceptability of the test meals (Figure 3). This is a 7-point category scale, which furthermore makes it easier for elderly to discriminate between the different choices by adding smiley-faces to the different choices. This scale has been designed and validated specifically for dependent elderly people (Maitre et al., 2015). Both appetite (1 = not at all, 7 = a lot), as well as liking of smell, taste, texture, and their overall liking (1 = dislike it a lot’ - 7 = ‘like it a lot’) were scored with this 7-point category scale. Lastly, after having consumed the meal, participants were also asked whether they would like to consume the meal again. For this question, a 3-point category scale was used (No, Maybe, Yes).
Figure 3: Seven-point category scale combining labels and pictograms, developed in the AUPALESENS
program (Maitre et al., 2015). In this study, the English text was translated to Danish. Only little research has been done so far into which type of hedonic scale works best for sensory tests that involve frail elderly, with most of the focus having been on testing with healthy elderly (Maitre et al., 2015). Therefore, before deciding on using the validated scale from Maitre et al. (2015) a pilot study was conducted (Appendix C), in which two hedonic scales were tested: the seven-point category scale combining labels and pictograms, and a “speedometer” scale that was newly developed during this study. The scale that proved to be best suited for frail elderly, the seven-point category scale combining labels and pictograms, was used in the subsequent consumer test. The full questionnaire of the consumer test is displayed in Appendix I.
3.3 Organization in practice The different components of the study involved many stakeholders performing different tasks. The help of the caretakers of the DAMC was needed for the coordination of this study, such as guiding
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the researchers through the nursing home and introducing them to its residents, and for reminding the participants on test days that they would take part in a test during dinner. The help of the nursing home’s kitchen staff was needed in the meal preparation of the consumer test. Furthermore, several volunteers from outside of the nursing home were needed to help with the data collection during the consumer test, 13 volunteers per evening. The volunteers were students of the University of Copenhagen and University College Copenhagen in the study areas of food, nutrition and nursing. Volunteers that helped during administration in the study received a thank-you gift, made available by Nestle Professional Food A/S, as a token of appreciation for their help. The value of the contents of these gift boxes were scaled according to the person’s time spent helping with the study.
3.4 Sample size calculation To be able to calculate an appropriate sample size for this study, a power analysis and sample size calculation was performed. However, the outcome of such an analysis depends on the type of data. This study was designed to have two primary data outcomes, i.e. acceptance of the meals measured on a hedonic rating and food intake. Because liking scores require a higher number of participants to be able to detect significant differences than food intake scores do (Ziylan et al., 2016), the power analysis and sample size calculation was performed based on liking scores. No studies could be found that could be used to calculate minimum sample size based on liking data from a categorical sale. Therefore, it was chosen to base the calculations for now on a continuous scale. According to Kremer et al. (2014), a difference in liking of 10 mm on a 100 mm visual analogue scale (VAS) is considered relevant and a standard deviation of 19 mm in meal liking is expected. Using the equation described by (Kadam & Bhalerao, 2010), and setting a statistical power (β) of 80% and a p-value (α) of 0.05, approximately 57 participants would have to take part in this study (Equation 1).
𝑛 = 2(𝑍𝛼+𝑍1−𝛽)2𝜎2
∆2 → 2(1.960+0.8416)2192
102 = 57 (1)
The sample size calculation from Equation 1 is based on the assumption that continuous data is collected, whereas this study collected categorical data. Because of the lower resolution of categorical data compared to continuous data, a higher sample size will be needed to obtain the same statistical power. However, the consumer test of this study was conducted via a crossover design, where participants undergo both the experimental condition and the control condition, and therefore serve as their own control (Jones & Kenward, 2014). This makes the study statistically efficient, meaning that fewer participants are needed for the same statistical power. It can therefore be expected that the higher sample size needed due to use of a categorical scale will roughly balance out the lower sample needed due to the use of a crossover design. Due to logistic reasons and time-constraints, the experiment was carried out with fewer than 57 participants. However, in the experimental design of this study, each participant is also their own control. Furthermore, for both treatment types, four repeats were performed in the form of four different meal types. Thus, in this study each participant yields eight observations. The consumer test had a total of 23 participants which, when assuming that there will be no missing data, yields a total of 184 observations, with 92 observations per treatment. Thus, it is assumed that this study has sufficient participants to obtain good statistical power.
3.5 Data analysis The data were analyzed in the statistical program R version 3.2.2 (R Core Team, 2016). In this study, p-values less than 0.05 were regarded as significant.
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Data were tested to see whether their distribution deviated from a normal distribution using the
Shapiro-Wilk test and qq-plots. Next, frequencies and descriptive statistics were generated for the
demographic data, as well as the responses to the DRACE, SWFL, and consumer test. Descriptive
data are presented as means ± SD. The risk of subjective chewing and swallowing problems (DRACE)
and the satisfaction with food-related life (SWFL) were determined according to the total score of
these items at the baseline questionnaire. Cronbach’s alpha was calculated for the SWFL data, in
order to estimate internal consistency of the items. Moreover, the analysis of the frequencies and
descriptive statistics showed that several continuous variables (age, DRACE score, and SWFL score)
had too great a spread in values compared to the sample size of this study, which would make it
difficult to find any statistically-significant relationships involving these variables. Therefore, it was
decided to reduce these variables to three ordinal categories, with the category values based on the
median of the original continuous variable, to generate more equally distributed groups. The
variable age was compressed to three dimensions (under 84 years, 85-92 years, older than 92 years).
The variable DRACE was also reduced to three dimensions (low [0-1], medium [2-4], and high [>5]).
Furthermore, the SWFL score was concentrated to three dimensions (low [<12], medium [13-19],
and high [>20]). These modified variables will be called categorized age, categorized DRACE, and
categorized SWFL throughout the rest of the text.
Then, the results of the consumer test were analyzed further. Paired t-tests were used to test for significant differences between the two treatments, and were performed on both the intake and liking data. Furthermore, to detect within-treatment and between-meal differences for all four meal types, a mixed linear model was used (Equation 2), using the Lmertest package in R (Kuznetsova et al., 2014).
𝑦 = 𝑏intercept + 𝑏Mealtype + 𝑏Mealtreatment + 𝑏SWFLcat + (effectconsumer + 𝜖) (2)
The dependent variables (𝑦) of these analyses were food intake, energy intake, protein intake, and the hedonic scores for overall liking and the liking for the sensory modalities. The design variables of meal type and meal treatment were set as fixed factors. Furthermore, to account for the possible effect of covariates (ward, wing, test period, test day, test order, categorized DRACE, categorized SWFL, and categorized age) on the dependent variable, the effect of covariates was tested and non-significant covariates were stepwise removed from the model. Only the categorized SWFL score was retained in the model as a significant covariate. Moreover, because the elderly participants can vary in their emotional, environmental, or physiological state on a day-by-day basis, a random effect for consumer was also added into the model. Tukey’s HSD was used for post-hoc comparisons. Next, preference mapping was done using Principal Component Analysis (PCA) on the centered food intake and consumer liking data, to further zoom in on individual differences. Thereafter, a hierarchical cluster analysis was applied on the centered food intake and consumer liking data to identify consumer clusters. Both the PCA and cluster analysis were performed with the FactoMineR and factoextra packages in R (Lê et al., 2008; Kassambara & Mundt, 2016). Then, to further test that there were no influences of test day on the food intake and consumer liking, a regression analysis was performed. For this, the data on food intake and consumer liking were separated into four subsets according to consumer group and meal treatment, and a regression analysis was performed on each subset. Furthermore, a one-way ANOVA analysis was performed to test whether there were any significant differences in intake or liking between the meals served on days 1-3 and days 4-8. This was done because of the change in the way the plates were heated and plated up.
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Furthermore, associations between the chewing and swallowing function, SWFL, appetite, food intake, and food liking were analysed using bivariate analysis with Pearson’s correlation coefficient.
3.6 Ethics This study worked with a vulnerable group, i.e. elderly in care facilities. Therefore, according to European regulation (Directive 2001/20/EC) this study needed to be presented to the Ethical committee. After reviewing the study protocol, the Danish Ethical committee concluded that formal approval of the study was not required. The letter (journal-number: 18017217) can be found in Appendix L. Moreover, all tools used in this study have been used before in studies among elderly living in nursing homes and proven to be suitable for this group. Furthermore, informed written consent was obtained from the participating nursing home residents before the beginning of the study (Appendix A). Participants were informed that participation is voluntary, non-invasive, harmless and that it only required a little extra effort. Participants could cancel participation at any time. Moreover, participants were asked for their consent of the photographing that was taking place during the study. During data collection, it was continuously checked whether the participants were still willing to participate.
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4. Results
4.1 Participant characteristics 29 nursing home residents (21 woman, 8 men; age 66-101, mean 87.1) were recruited for the study. An overall summary of the subject characteristics can be found in Table 3a. All 29 participants finished the DRACE and SWFL questionnaires. However, only 23 completed the food acceptance and intake test. A summary of the subject characteristics of those 23 participants can be found in Table 3b. Notably, when comparing Table 3a with Table 3b, it can be observed that the participants who dropped out during the food acceptance and intake test had, on average, a higher DRACE score, a lower SWFL score, and a lower satisfaction with diet than those who completed the food acceptance and intake test.
Table 3 a: Socio-demographic and baseline characteristics for the 29 participants initially recruited for the
study.
Characteristic (n=29) Mean ± SD Median Range
Age 87.07 ± 7.57 88.00 66 - 101
DRACE score (scale 0-24) 1.97 ± 1.99 2.00 0 - 6
SWFL score (scale 5-25) 16.34 ± 6.50 17.00 5 - 25
Satisfaction with diet (scale 1-5) 3.48 ± 1.53 4.00 1 - 5
b: Socio-demographic and baseline characteristics for the 23 participants finishing the DRACE
questionnaire, SWFL questionnaire and food intake/acceptance test.
Characteristic (n=23) Mean ± SD Median Range
Age 87.09 ± 8.17 89.00 66 - 101
DRACE score (scale 0-24) 1.39 ± 1.67 0.00 0 - 5
SWFL score (scale 5-25) 16.74 ± 6.56 19.00 5 - 25
Satisfaction with diet (scale 1-5) 3.78 ± 1.39 4.00 1 - 5
4.2 Chewing and swallowing function The mean DRACE score of all participants (n=29) was 1.97 ± 1.99. The per-variable results of their DRACE questionnaire are shown in Table 4. There were 4 (13.8%) participants who had a cumulative score of ≥5, suggesting being at severe self-perceived risk of chewing and swallowing discomfort. Moreover, 11 (37.9%) participants had at least one severe symptom that could indicate problems during chewing and swallowing of foods and drinks. However, 12 (41.4%) participants indicated to have no chewing or swallowing problems at all. The most mentioned symptom was “having difficulties while chewing the food” (n=11, 37.9%), followed by “food or liquid coming back in the throat” (n=6, 20.7%). No participants noted an episode of fever during the last year.
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Table 4: Frequencies of the 12 questions on the DRACE questionnaire (n=29).
Variables (n=29) Never Sometimes Frequently
Have you felt that you take a longer time to eat than before? 24 3 2
Have you had at least one episode of fever? 29 0 0
Have you had difficulties with swallowing beverages? 28 0 1
Have you had difficulties chewing hard food? 18 5 6
Have you experienced food spilling out of your mouth? 28 1 0
Have you ever choked while eating? 24 4 1
Have you ever choked while drinking beverages? 24 4 1
Have you ever swallowed food and had it go up your nose? 28 1 0
Have you ever had a change in your voice after a meal? 28 1 0
Have you ever produced sputum during a meal? 25 2 2
Have you ever felt like you had a lump in your throat while swallowing?
26 2 1
Have you ever had food or liquid from your stomach come back up into the throat?
23 6 0
4.3 Food-related quality of life The results of the SWFL questionnaire for all participants (n=29) are shown in Table 5. On a scale from 5 to 25, participants scored an average of 16.34 ± 6.50. Among the responses on SWFL items, “I am generally pleased with my food” was scored the highest, whereas “My life in relation to food and meals is close to my ideal” was scored the lowest. The value of Cronbach’s α for the SWFL scale was 0.87, indicating internal consistency of the measurement items.
Table 5: Mean and standard deviation (SD) of the 5 questions in the SWFL questionnaire
Variables (n=29) Mean ± SD
Food and meals are positive elements in my life 3.28 ± 1.65
I am generally pleased with my food 3.86 ± 1.53
My life in relation to food and meals is close to my ideal 2.83 ± 1.54
With regard to food, the conditions of my life are excellent 3.21 ± 1.61
Food and meals give me satisfaction in daily life 3.17 ± 1.69
Total 16.34 ± 6.50
4.4 Food intake and food acceptance
4.4.1 Food intake Participants consumed significantly less of the texture modified meals than of the control meals (Table 6). However, no significant differences were observed in energy intake between treatments, whereas protein intake was significantly lower for texture-modified meals than for the control meals. Zooming in at the different meal components, intake of vegetables is significantly reduced in texture-modified meals when compared to the control meals. However, this reduced vegetable consumption does not result in a significantly lower vegetable protein intake. Conversely, although meat intake does not significantly differ between control and texture-modified meals, meat protein intake is significantly less in texture-modified meals than in the control meals.
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Table 6: Food, energy and protein intake shown for the different meal components and different treatments. Paired t-tests were used to test for differences between treatments.
Control Texture-modified Significance
Food intake (g) Total 182.9 ± 73.5 157.2 ± 81.6 *
Meat 44.2 ± 24.1 38.1 ± 21.5 ns
Vegetables 25.4 ± 19.9 19.4 ± 18.7 *
Potato 64.7 ± 34.1 55.9 ± 32.0 ns
Gravy 50.6 ± 26.9 43.9 ± 30.6 ns
Energy intake (KJ) Total 888.1 ± 362.2 798.5 ± 396.7 ns
Meat 407.9 ± 254.8 391.6 ± 220.6 ns
Vegetables 58.5 ± 49.7 43.4 ± 46.5 ns
Potato 273.6 ± 145.0 235.9 ± 135.6 ns
Gravy 147.0 ± 95.7 125.1 ± 101.6 ns
Protein intake (g) Total 14.0 ± 6.8 8.8 ± 4.8 ***
Meat 11.7 ± 6.4 6.7 ± 3.9 ***
Vegetables 0.4 ± 0.7 0.4 ± 0.7 ns
Potato 1.3 ± 0.8 1.1 ± 0.8 ns
Gravy 0.5 ± 0.2 0.4 ± 0.3 ns Significant levels: * P < 0.05, ** P < 0.01, *** P < 0.001.
When looking at the different meal types (chicken, pork, lamb, or beef), a linear mixed model showed that meal type has a significant impact on food intake (p<.05) and protein intake (p<.001), but not on energy intake (Table 7). Paired t-tests showed that the chicken and pork meals differed significantly in food intake between the control and texture-modified meal (p<.05 & p<.01, respectively), whereas no differences in food intake were observed for the lamb and beef meals (Table 7). The pork and beef meals differed significantly in protein intake between the control and texture-modified meal (p<.001 & p<.001, respectively), whereas no differences in protein intake were observed between the treatments of chicken and lamb. Furthermore, Table 7 also shows the results of within-groups Tukey post-hoc tests. An overview of food, energy, and protein intake on a per-meal and per-component basis, including differences between the control and texture-modified treatment, can be found in Appendix M.
Table 7: Food, energy and protein intake shown for the different meal types and different treatments. Paired t-tests were used to test for differences between treatments. An ANOVA and
Tukey post-hoc test was done to test for within-group differences of the meal types.
Control Texture-modified Significance
Food intake (g) Chicken 208.3 ± 68.0a 171.8 ± 76.2ab *
Pork 171.6 ± 67.8a 130.2 ± 71.9a **
Lamb 169.4 ± 75.6a 151.9 ± 76.6ab ns
Beef 182.5 ± 79.5a 175.2 ± 96.6b ns
Energy intake (KJ) Chicken 982.7 ± 359.8b 879.0 ± 349.6a ns
Pork 926.5 ± 299.4b 704.9 ± 379.4a **
Lamb 690.6 ± 296.4a 798.2 ± 377.9a ns
Beef 839.8 ± 366.8ab 844.7 ± 473.9a ns
Protein intake (g) Chicken 12.8 ± 5.9ab 10.3 ± 4.3b ns
Pork 14.6 ± 4.8b 6.4 ± 3.7a ***
Lamb 11.2 ± 6.5a 9.6 ± 4.7b ns
Beef 13.4 ± 6.8ab 8.0 ± 4.7ab *** Significant levels: * p < 0.05, ** p < 0.01, *** p < 0.001. Different letters in the same columns indicate significant differences according to Tukey’s post-hoc test, with separate post-hoc tests being performed for food, energy, and protein intake.
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4.4.1.1 Individual differences
To investigate differences between individuals in food intake, energy intake and protein intake, a Principal Component Analysis (PCA) was performed on mean-centered data together with a hierarchical cluster analysis, with participants as the scores and the meal type and treatment as the loadings. Both food, energy, and protein intakes show a large spread on their respective PCA plots (Figure 4), with different participants attracting different meal types and treatments on the PCA axes. Furthermore, for both food, energy, and protein intake, participants can be subdivided into two clusters. Regarding food intake, two participants form a cluster that is far-left of the center of the first PCA axis, with all other participants forming another cluster that’s close to the center of both PCA axes. Similarly, regarding energy intake, a single participant forms a cluster that is again far-left of the center of the first PCA axis, with all other participants forming another cluster that’s close to the center of both PCA axes. Regarding protein intake, seven participants form a cluster that is located left of the center of the first PCA axis, with all other participants forming a cluster that is located right of the center of the first PCA axis. Notably, participant number 16 is in all three left-leaning clusters of food, energy, and protein intake. It is also participant 16 that is the only participant with a high risk of self-perceived chewing and swallowing problems that had fully completed the consumer test. Figure 5 gives an overview of the differences in mean food, energy, and protein intake between the respective clusters.
Cluster
Cluster
(a)
(b)
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Figure 4: PCA biplots of food intake (a), energy intake (b), and protein intake (c), with participants as scores and their intake for the different meals as loadings. Colours indicate which cluster participants
belong to.
Figure 5: Representation of the average intake of food (a), energy (b), and protein (c) per product
and per cluster.
Ener
gy in
take
(g)
Cluster
Pro
tein
inta
ke (
g)
Foo
d in
take
(g)
(c)
(a)
(c)
(b)
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4.4.2 Food acceptance Table 8 gives an overview of the means and standard deviations for overall liking, as well as liking of appearance, taste, and texture, for both the control and the texture-modified meal treatment. Of the 175 observations that were done for liking of the meal odour, 93 values were missing. Therefore, it was decided to not incorporate this variable in further analyses. Participants did not significantly differ between their liking of the appearance of the two meal treatments. However, scores for taste liking, texture liking, and overall liking of the texture-modified meals were significantly lower than for the control meals.
Table 8: Overall liking, as well as liking of appearance, taste, and texture shown for the different treatments. Paired t-tests were used to test for differences between treatments.
Control “Texture-modified” Significance
Overall 5.74 ± 1.39 4.56 ± 1.81 ***
Appearance 5.49 ± 1.67 5.37 ± 1.83 ns
Taste 5.76 ± 1.41 4.95 ± 1.90 **
Texture 5.50 ± 1.65 4.30 ± 2.12 *** Significant levels: * p < 0.05, ** p < 0.01, *** p < 0.001
Zooming in at the different meals showed that not only the meal treatment, but also the meal types (chicken, pork, lamb, or beef) had a significant effect on liking scores (Table 9). A linear mixed model showed that meal type had a significant impact on overall liking (p<.001) and liking of taste (p<.001) and texture (p<.001), but not on liking of appearance. Using a Tukey post-hoc test to examine within group effects showed that no significant differences between meal types are observed for any of the sensory modalities in the control treatment (Table 9). Similarly, no significant differences were observed for texture and overall liking of the texture-modified treatment. However, the liking of taste of the texture-modified treatment showed a significant difference between meal types: The taste of the texture-modified beef was liked significantly better than the taste of the texture-modified pork.
Paired t-tests, performed for each meal type, showed no significant differences between treatments for the liking of taste of the chicken and pork meals, and for the texture of the lamb meals, whereas all other meal-specific taste, texture, and overall liking scores were significantly lower for the texture-modified treatment than for the control treatment (Table 9).
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Table 9: Overall liking, as well as liking of appearance, taste, and texture shown for the different meal types as well as the different treatments. Paired t-tests were used to test for differences
between treatments.
Control “Texture-modified”
Significance
Appearance Chicken 5.70 ± 1.66 a 5.19 ± 1.99 a ns
Pork 5.38 ± 1.53 a 5.55 ± 1.73 a ns
Lamb 5.43 ± 1.85 a 5.17 ± 1.70 a ns
Beef 5.45 ± 1.68 a 5.62 ± 1.96 a ns
Taste Chicken 5.68 ± 1.25 a 5.29 ± 2.00ab ns
Pork 5.33 ± 1.62 a 4.24 ± 2.14a ns
Lamb 5.87 ± 1.74 a 4.95 ± 1.61ab *
Beef 6.13 ± 0.87 a 5.33 ± 1.74b **
Texture Chicken 5.64 ± 1.59 a 4.57 ± 2.04 a **
Pork 5.76 ± 1.43 a 4.57 ± 2.06 a *
Lamb 5.04 ± 2.01 a 4.17 ± 2.35 a ns
Beef 5.61 ± 1.59 a 3.90 ± 2.07 a **
Overall Chicken 5.95 ± 1.09 a 4.62 ± 1.88 a **
Pork 5.57 ± 1.43 a 4.38 ± 1.88 a *
Lamb 5.48 ± 1.70 a 4.52 ± 1.83 a *
Beef 5.96 ± 1.30 a 4.71 ± 1.76 a ** Significant levels: *p < 0.05, ** p < 0.01, *** p < 0.001. Different letters in the same columns indicate significant differences according to Tukey’s post-hoc test, with separate post-hoc tests being performed for appearance, taste,
texture, and overall liking.
4.4.2.1 Individual differences
To investigate differences between individuals in the liking of appearance, taste, texture, and overall experience, a Principal Component Analysis (PCA) was performed on mean-centered data together with a hierarchical cluster analysis, with participants as the scores and the meal type and treatment as the loadings. All liking categories show a large spread on their respective PCA plots (Figure 6), with different participants attracting different meal types and treatments on the PCA axes. No clear grouping is visible between the control and texture-modified treatment. Furthermore, on all liking categories, participants can be subdivided into multiple clusters. Five separate clusters could be identified for overall liking, two for liking of appearance, eight for liking of taste, and four for liking of texture.
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Figure 6: PCA biplots of overall liking (a), as well as liking of appearance (b), taste (c), and texture (d), with participants as scores and their liking scores for
the different meals as loadings. Colours indicate which cluster participants belong to.
(a) (b)
(c) (d)
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4.4.3 Trends over time A regression analysis on the data indicated that the order of the test days did not have a significant
effect on food intake or overall liking (Figure 7 and 8, respectively). Moreover, a one-way ANOVA
analysis indicated that no significant differences were observed in intake or acceptance between the
meals served on days 1-3 and days 4-8, which could result from the change in the way the plates
were heated and plated up.
Figure 7: Mean scores for overall liking on the different days within testing periods, per group and
treatment. Regression lines indicate the trend over time, but none showed a statistically-significant
effect. The shaded area shows the confidence intervals of the regression lines.
Figure 8: Mean scores for food intake on the different days within testing periods, per group and
treatment. Regression lines indicate the trend over time, but none showed a statistically-significant
effect. The shaded area shows the confidence intervals of the regression lines.
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4.5 Repeated consumption When participants were asked whether they would like to eat the consumed meal again in the future, over 75% indicated that they would be willing to consume the control meal again (Table 10). However, participants seemed to be divided about the willingness to consume the texture-modified meal again. Only 44.2% of the participants indicated that they would be willing to consume the texture-modified meal again, whereas 45.3% did not want to consume the texture-modified meals again. Notable is also that a larger proportion of participants were indifferent towards consuming the texture-modified meals again, compared to the control meals. Similar results are visible when zooming in at the different meal types (Appendix M).
Table 10: Frequencies of participants’ willingness to eat the tested meal again, shown for both treatments.
Control (n=88) Texture-modified (n=86)
Yes 76.1% (67) 44.2% (38)
No 21.6% (19) 45.3% (39)
Maybe 2.3% (2) 10.5% (9)
4.6 Relationships between DRACE, SWFL, food intake and food acceptance A bivariate analysis (n= 29), using Pearson correlation coefficient, showed a significantly negative correlation between the chewing and swallowing function (DRACE) and the SWFL (r = -.41, p <.001), as well as between DRACE and the subjective satisfaction with the current diet (r = -.21, p <.01). Moreover, the SWFL score was positively correlated to the subjective satisfaction with the current diet (r =.74, p <.001). This high correlation between SWFL and satisfaction with current data may indicate that multicollinearity between these two variables exist. Furthermore, another bivariate analysis (n=23) indicates that intake of food, energy, and protein is positively correlated to overall liking, and to liking of the different sensory modalities (Table 11).
Table 11: Correlation between food liking and food intake, with correlation coefficients and statistical
significance calculated using Pearson’s correlation coefficient.
Food intake Energy intake Protein intake
Overall liking .34 *** .32 *** .39 ***
Appearance liking .33 *** .29 *** .15 *
Taste liking .40 *** .35 *** .38 ***
Texture liking .23 ** .26 *** .35 ***
*** p <.001, ** p <.01, * p <.05
A one-way ANOVA showed that the participants’ pre-meal appetite ratings did not change significantly between sessions, with a mean appetite score of 3.96 ± 1.97. A bivariate analysis showed that the appetite score was negatively correlated with the DRACE score (r = -.22 p <.01), and positively correlated with the SWFL score (r = .54, p<.001). Furthermore, appetite was positively correlated with food intake, energy intake, protein intake, overall liking, taste liking, and willingness to eat again (Table 12). Moreover, this analysis also indicated that food intake, energy intake, protein intake, overall liking, taste liking, texture liking, and willingness to eat again were not significantly related to the DRACE score, but were significantly correlated to the SWFL scores (Table 12). Liking of appearance was significantly related to neither the DRACE score, nor the SWFL score.
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Table 12: Correlation between DRACE, SWFL, and appetite and food liking, food intake, and willingness to eat the served meal again, with correlation coefficients and statistical significance
calculated using Pearson’s correlation coefficient.
DRACE SWFL Appetite
Food intake -.03 .36*** .36***
Energy intake -.07 .41*** .40***
Protein intake -.14 .38*** .32***
Overall liking .05 .33*** .22**
Appearance liking .11 .20 .05
Taste liking -.06 .40*** .36***
Texture liking -.02 .23** .13
Willingness to eat again .04 .30*** .30***
*** p <.001, ** p <.01, * p <.05
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5. Discussion This study showed no improved liking or nutritional intake for texture-modified meals, as opposed to regular nursing home meals. On average, food intake of the texture-modified meals was lower than for regular nursing home meals. Furthermore, both overall liking as well as liking of taste and texture were, on average, lower for texture-modified meals than for regular nursing home meals, whilst there was no significant difference in the liking of appearance.
These results are contrary to the expectation that texture-modified food, which is easier to chew and swallow, would be preferred over food with a tougher texture. There are several factors that could help explain these results. Firstly, reduced intake and liking of the texture-modified meals may be partly explained by food neophobia, i.e., the fear for the consumption of unknown or novel foods (Pliner & Salvy, 2006). This was, after all, the first time that many of the elderly participants experienced texture-modified foods. As most of our food preferences are learned through experiences (Rozin & Vollmecke, 1986), it could be expected that both food liking and intake of the novel texture-modified food would increase after repeated exposure. Thus, it is possible that both liking and intake of the texture-modified food would have improved after more frequent exposure. However, over the course of this study, no positive trend over time in either liking or intake of the texture-modified food was observed. This could possibly be explained by the frequency of testing. Many participants indicated that the frequency and number of test days were too intense, and had they known this beforehand they would not have participated. Even though the study’s eight test days were spread over four weeks in an attempt to reduce the participants’ fatigue, it is possible that no upwards trend was observed in the liking and intake of texture-modified food due to increasing participant fatigue with the study.
Secondly, the liking and intake of the texture-modified food may have been influenced by ideational factors, i.e. previous knowledge about the nature of a product (Rozin, 1990). For instance, many elderly associate texture-modified food with increased frailty, because they notice the dysphagia meals being consumed by the frailest people in the nursing home. This may trigger a food rejection mechanism: people at this age do not want to consider themselves as frail and don’t want to lose more of their independence, especially when they have lost parts of their independence already by having moved to a nursing home. As meat is often seen as the main component of the meal in Danish culture (O'Doherty Jensen, 2002), it is possible that this food rejection mechanism can still be triggered when only the meat component has been texture-modified.
Thirdly, interactions amongst participants and non-participating residents could have influenced the results. In the case of the texture-modified meals, participants could sometimes see that they received a different meal from non-participating residents, which could have negatively influenced these results. For instance, when one of the participants came into the dining area to participate in the study a non-participating resident would tell them a couple of times that they would be served their “baby food” again. Moreover, the interaction between the caretakers and participants changed on the study days. For instance, it could be observed that in some wards caretakers would not give participants the same attention as they would normally receive. And as it is not only the food but the entire meal-experience, including environment, that influences how people enjoy their meal (Meiselman, 2008), this could have influenced the results too.
Aside from the reduced intake and liking of texture-modified food, the results of this study also showed other interesting patterns. First of all, there was no significant difference in the average liking of the appearance of the texture-modified meals, compared to the regular nursing home meals. This could indicate that one of the major hurdles regarding texture-modified food - to make it look as appealing as regular food - has already been taken. This suggests that further improvements
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towards this form of texture-modified food should mainly focus on taste and texture. It should be noted that, in this study, the liking of taste and texture of the texture-modified meals was still positive, on average. However, this could also be due to the tendency of elderly to be reluctant in using the negative side of liking scales (Cordello et al., 2004; Sulmont-Rosee, 2018), and the fact that dependent elderly giving higher liking scores than independent elderly (Maitre et al., 2015). This also seems to be supported by the observation that 45.3% of participants indicated not to want to eat the texture-modified meal again, in spite of the generally-positive liking scores.
Total food intake of the texture-modified meals was lower than that of the control meals. Notably however, when looking at the individual meal components, it is only the vegetables that are eaten significantly less in the texture-modified meals than in the control meals. This is an unusual result, as only the meat component of the meal was changed between the control and texture-modified meals, and it is difficult to find a possible explanation for this observation. Furthermore, the observed significant differences in food intake did not result in any significant differences in energy intake between the texture-modified and control meals. However, total protein intake was significantly higher for the control meals when compared to the texture-modified meals. Zooming in on the individual meal components, it appears that this is mainly due to the significantly-higher protein intake of the control meat, compared to the texture-modified meat. Even though food intake of the meat component did not differ significantly for the two different treatments, the texture-modification process of the meat caused a reduction in the protein content, as dilution with e.g. cream and eggs was necessary to obtain the desired texture.
Moreover, it was noticeable that even when participants would have consumed the entire meal, they wouldn’t have reached the 20-30 gram protein per meal that is recommended for elderly to maintain the nitrogen balance (Bauer et al., 2015). So, both in the case of the control meal and the modified meal, the recommended daily protein intake is not reached. Based on observations in the nursing home, the portion sizes of the test meals provided to participants of this study were larger than those provided to the other residents of the nursing home. This indicates that the non-participating residents also generally receive too little proteins in their meal, unless this is somehow compensated by their other daily meals. Therefore, regardless of texture modification, malnutrition in nursing homes can be combated by increasing the protein content of the meals. This can be done by increasing the portion size, but because of the decreased appetite of elderly people, large portions can be too intimidating and actually reduce food intake (Ziylan et al., 2016). This was also noticed during this study, where multiple participants already indicated that the served portions in this study were too big and, therefore, were not appealing to them. Protein enrichment of the meal would be a promising alternative. The most effective method for protein enrichment would probably be the addition of protein powder into the meals. This has already been attempted by Nestlé Professional (M. Alexander, personal communication), but it was found that protein powders had a negative impact on taste, texture, and appearance. Furthermore, it can be too expensive to ensure that all essential amino acids are included in the enrichment, but if this is not done than malnutrition can still appear.
Food intake was correlated to food liking. This suggests that by further increasing the liking of the texture-modified food, intake can be increased as well. However, this correlation between food liking and intake was only on the order of 0.2-0.4, showing that food liking only partially explained food intake. This suggests that there should be other factors that influence food intake. Identifying these may further aid in increasing the intake of texture-modified food.
Notably, the DRACE score of the participants was significantly correlated to their SWFL score. This indicates a relationship between the severity of an individual’s chewing and swallowing problems, and their food-related quality of life. This illustrates the importance of trying to reduce the pace at
33
which chewing and swallowing problems develop, as this may lengthen the time at which institutionalized elderly maintain a higher food-related quality of life. However, the severity of chewing and swallowing problems experienced by the participants was not directly correlated to food intake or food liking, neither for the control meals nor for the texture-modified meals. This suggests that elderly nursing home residents with a high risk of chewing and swallowing problems would not benefit extra from receiving the texture-modified meals used in this study. However, the absence of a correlation between food liking/intake and DRACE score could also have resulted from the fact that this study had relatively few participants with a high DRACE score.
Aside from food liking, the only variable that was significantly correlated to food intake was the food-related satisfaction with life, which was found through the SWFL questionnaire. The SWFL score was also significantly correlated with food liking. This shows that, in this study, participants with a better food-related satisfaction of life had a better liking for the food they were given, and ate more of it as well. These results suggest that by increasing their food-related quality of life, food liking and food intake of elderly nursing home residents might be increased as well. This could perhaps be achieved by increasing the quality of the food, but could also be achieved by improving the environment in which the food is consumed (Meiselman, 2008).
There was a large inter-individual variability in liking and intake of the control meals as well as the texture-modified meals in this study, as could clearly be observed in e.g. the spread and clusters visible in the PCA plot. The larger standard deviations for liking and intake of the texture-modified meals show that this inter-individual variability is even larger for the texture-modified meals than for the control meals. This shows the importance of individual preferences when it comes to food liking and intake. Thus, to increase food liking and intake, meals should be designed based on individual preferences, instead designing them from a ‘one size fits all’ point-of-view. However, it is also true that commensality of the food can also increase enjoyment of the meal, because eating similar food generally increases social bonding (Fischler, 2011). Thus, to combat malnutrition in elderly nursing homes, a potential ‘new normal’ method of preparing and serving meals could be to offer different versions of the same dish to residents, where the texture of the dish could be changed according to the resident’s preferences. However, this approach would likely greatly increase the cost of meals, as additional kitchen staff will be required, and both caretakers and kitchen staff will need to be trained better to be able to accommodate the different preferences of the residents. Therefore, an alternative ‘new normal’ could be to have several days in the week where regular meals are served, and several days in the week where residents receive a meal that has in some way had its texture made softer. This will provide texture-modified food for those that could benefit from it, whilst at the same time providing food that keeps the chewing muscles in shape. This should slow down the development of chewing and swallowing problems, which will help prevent malnutrition and increase overall food-related quality of life.
This study made use of direct and intense texture modification of the food, as is generally also done for dysphagia patients. However, for elderly who only experience mild chewing and swallowing problems, it may be preferable to modify the texture of food in a less intensive way. For instance, boiling of vegetables, mashing of potatoes, or grinding of meat are all methods to ease the texture of food, without directly evoking the association with dysphagia meals. It is therefore possible that such mild methods of texture modification could also achieve an increase in food liking and intake, by making the food easier to chew and swallow, while at the same time causing less of an emotional impact, which should further help maintain a good food-related quality of life (Swan et al., 2015).
5.1 Strengths The use of pilot tests before starting the actual experiments greatly improved the quality of the
results of this study, as this allowed for the feasibility testing of multiple different methodological
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approaches. For instance, it was initially planned to have all meal components texture modified.
However, a trial run clearly showed that the elderly participants were abundantly negative about an
all-modified meal. Therefore, because meat is often seen as the main component of the meal, is
usually the primary source of protein in the meal, and is also often the hardest to chew for elderly, it
was decided to only modify the meat component of the meal. This was also more in line with
designing a ‘new normal’ nursing home meal.
This study made use of a cross-over design. Thus, the influence of confounding covariates, such as
testing order, ward location, and nursing staff could be reduced (though not completely eliminated).
Furthermore, it enabled for the usage of paired t-tests. Therefore, in spite of the small sample size,
the use of a cross-over design made sure that statistically-significant results could still be obtained.
To increase the validity of the results, this study only made use of validated scales. This ensures that
the results of this study will be comparable with past and future studies that use similar methods.
Performing food acceptance and intake studies with elderly nursing home residents is challenging
and is therefore not done very often. However, when doing a food acceptance and intake study, it is
important that the participant group is the same as the target group. Therefore, this study has made
sure to have elderly nursing home residents as the participant group, improving the validity of the
results. One of the reasons that food acceptance and intake studies are hard to do with elderly
nursing home residents as participants is that this target group is especially vulnerable to
disturbances in their daily patterns, which can have significant influences on any experimental
results (Maitre et al., 2015). Therefore, during this study, the elderly participants were kept in their
home setting as much as possible. This ensured that factors such as an unfamiliar testing location did
not impact the results. Furthermore, performing the experiments in the home setting of the
participants ensured that contextual factors that are also present outside of the experiments were
incorporated in the study.
5.2 Limitations
One of greatest limitations impacting this study were the restrictions imposed by the choice of target group; namely elderly nursing home residents. Many residents of the nursing home were excluded from participating in this study on account of being too frail, meaning that the sample population of this study may not be an accurate representation of general nursing home residents. This made it difficult to compare food intake and liking results between participants with different levels of frailty. For instance, at the beginning of the study, four participants were identified as being at severe risk of self-perceived chewing and swallowing problems by the DRACE questionnaire. Out of these four, only one participant continued with the study until the end. Furthermore, the many exclusions from the study due to frailty, as well as restrictions imposed by available time and resources, meant that the sample size of this study was relatively small. The cross-over design of this study made sure that statistically-significant results could still be obtained, even with a sample size of 23. Nevertheless, it is likely that a larger sample size, ideally from multiple nursing homes, would have yielded more results as statistically-significant, especially regarding the frailer participants.
The methodology used in this study was also limited by the target group, as well as the available time and resources. For instance, a continuous scale would have been preferred over a categorical scale for the questions regarding food liking, because a continuous scale is more discriminative. However, elderly are known to have difficulties interpreting continuous hedonic scales. Category scales, on the other hand, have been successfully used in product discrimination studies with institutionalized people (Appleton, 2009; Laureati et al., 2008) and people with dementia (Piwnica-Worms et al., 2001), and are the most frequently used hedonic scales for elderly people. Thus, a categorical scale was used in this study instead of a continuous scale, in spite of the reduction in
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discriminatory power. Furthermore, participants would ideally have received their meals in a controlled environment that limited interactions between the participant and other participants, non-participants, and researchers, such as a testing booth. However, elderly nursing home residents in general do not cope well with changes in their daily routine. For instance, during the trial day, participants from one ward were all placed together at the same tables, instead of being seated at their usual seat. As a result, many of those participants became confused, disoriented, and unwilling to take part in the study that day. This sensitivity to changes in the daily routine meant that tests needed to be carried out in the regular dining area of the nursing home. Furthermore, it meant that most participants sat at the table with the residents they were used to sitting with, regardless of whether those residents were participating in this study or not. In this study, only one out of four wards was able to consistently place participants at the same table. Given that the linear mixed model showed no effect of ward on liking or intake, it is assumed that the results of the ward where participants consistently sat together are comparable to those of the other wards. Nevertheless, the absence of a controlled environment means that interactions between participants and other participants, as well as non-participants, could have influenced the overall results of this study.
Furthermore, interactions between participants and researchers could have further influenced the results. Due to the frailty of the participants, there was a close and personal interaction between researchers and participants when the meals were being served, and when the liking scores were filled out, which could have influenced the results. For instance, Maitre et al. (2015) states that elderly can positively bias the results, because they want to please the researchers, who are “taking care” of them during the test sessions. This effect could also differ between wards, because different wards had different volunteers. Although the volunteers had received consistent instructions on how to perform their tasks, how each volunteer interacts with the elderly participants is also dependent on personality and previous experience in interaction with elderly. Also, the interactions between participants and researchers could have further influenced the results of this study because the volunteers that distributed the meals and helped filling in the liking questions were not always the same on all test days. As much as possible, it was tried to have the same volunteers working on the same wards, but not all volunteers were available on all days. This meant that some wards had a greater heterogeneity in research volunteers than others, possibly influencing results. However, the results of the linear mixed model showed that there was no effect of ward on intake and liking scores. This means that if the results were influenced by a participant-researcher interaction, at least the effect seems to have been consistent amongst wards.
Although the preparation of meals was standardized as much as possible, some differences did occur between test days. Most notably, after the third testing day a change was made in the way the meals were heated and plated up. Initially, the meals were first plated up, then wrapped in aluminium foil, then placed into the over and heated up, and then placed in a thermal container. However, this method of heating appeared to result in dry and tough meat, which no longer looked very appealing. Therefore, from the fourth testing day onwards, the food was first heated up in large containers in the oven, then plated up under heat lamps, after which the plates were wrapped in plastic wrap and placed in thermal containers. It is possible that this change in preparation method could have had an influence on results, although an ANOVA showed no significant differences in intake and liking scores between the 1st-3rd and 4th-8th test days.
During this study, it was clear that participants experienced age-associated losses in chemosensory acuity. For instance, during the study it was observed that products which tasted strong to the researchers could still have a bland taste to the participants. Moreover, this study showed a large number of missing data for the liking of product odour. This was the result of many participants no longer having a fully-functional sense of smell. Thus, it is possible that the taste liking of the texture modified food could have been higher if the food had been given a stronger taste.
36
This study used the DRACE questionnaire to collect information on the participants’ severity of chewing and swallowing problems. This questionnaire is based on self-reporting, which makes it a convenient tool if the time and resources for more in-depth objective assessments are not available. Furthermore, Miura et al. (2007) suggest that DRACE is a validated alternative to the objective 3-oz water test, making it a proper alternative to such invasive procedures. However, more recently, Magalhães Junior et al. (2018) have argued that all currently-available self-reporting questionnaires for oropharyngeal dysphagia in elderly are unsuitable, including DRACE. This conclusion appears to be supported by the current study. For instance, several participants which could be observed to have a severely-impaired set of dentures still scored a 0 on the self-reported DRACE questionnaire. Furthermore, contrary to initial expectation, DRACE score was not found to be a significant factor in the linear mixed model. The DRACE questionnaire may therefore not have been the best method to assess the participants’ severity of chewing and swallowing problems, but constraints in available time and resources meant that no suitable alternatives were available.
Furthermore, constraints in time and resources meant that food intake measurements were obtained via the validated photographic method from Pouyet et al. (2014), instead of weighing every single meal component separately before and after consumption. This may have influenced the accuracy of the data on food, energy, and protein intake.
Moreover, had more time and resources been available for this study, additional background information could have been collected, such as Body Mass Index, undernutrition risk, cognitive status, medical diagnosis or existing comorbidities of the participants. It is possible that this additional information could have helped in explaining the found significant differences between the texture-modified meal and control meal. Moreover, it may have helped explain where the interindividual variability comes from.
5.3 Future perspectives
The texture-modified food given to participants of this study was both preferred and eaten less than the control food. Therefore, before any follow-up studies are carried out, product optimization needs to be done first. This study suggests that taste and texture should be the main design variables for further product optimization, because liking for these sensory modalities was significantly lower for the texture-modified food compared to the control meals. An experimental design should then be set up, using a multidimensional approach in which different combinations of texture and taste modification are tested for consumer liking. Here, the reduced sense of taste and smell of elderly should be taken into account, meaning that very strong taste values should also be tested. Moreover, protein and energy content should always be maintained according to levels recommended for diets of small eaters. A sequential approach would then likely be the best way to explore the product space and find the optimum, as it minimizes the amount of testing moments needed for the frail elderly participants. When developing new foods, it is important that a multidimensional approach is used instead of targeting one sensory dimension (Kremer, Holthuysen & Boesveldt, 2014). For example, many studies that only have focused on flavor enhancement have not given proof of its effect on food intake and food liking (Doets & Kremer, 2016; Sulmont-Rossé, 2018).
Eventually, when a product with optimum qualities is discovered, a mere exposure study can be performed. Such a study aims to test whether repeated consumption of a certain food increases preference and liking for this food (Zajonc, 2001). On average 8-15 exposures are needed to increase liking of novel product (Zajonc, 2001). The current study suggests an opening for a mere-exposure study, as many participants indicated that they would be willing to try the texture-modified meal again. Such a mere exposure study should also ensure that a follow-up study will not be affected by
37
food neophobia. Moreover, if sufficient time and resources are available, it would be beneficial for any follow-up study to collect more background data on the participants than only the basis demographic data. This would better allow for the accounting of interindividual differences.
After an initial product optimization and mere exposure study has been performed, a follow-up study should then be performed to see whether texture-modification of meals in nursing homes could become ‘the new normal’, while helping to prevent malnutrition. Ideally, this study would be a longitudinal study, where those who participated in the previous mere exposure study will consistently receive texture-modified food (with the optimum recipe identified by the product optimization study) as part of their diet. The frequency at which they will receive this texture-modified food could be determined based on the experiences of the mere exposure study, and could also vary on the individual level to account for interindividual differences in preference and acceptance of the texture-modified food. At several points in time during the longitudinal study, measurements should be done on food acceptance of the texture-modified diet. Furthermore, additional measurements should be performed on BMI (measured through weight and height), severity of chewing and swallowing problems (measured by a more objective method than DRACE) and other health parameters that could have been changed over the scope of the study. These measurements should be done with a frequency low enough so as not to cause participants to become fatigued with the study. The results of such a study should be able to show whether malnutrition can be reduced amongst elderly nursing home participants, by having inclusion of texture-modified meals in the standard nursing home food as ‘the new normal’.
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6. Conclusion This study showed that institutionalized elderly with a greater severity of self-perceived chewing and swallowing problems experience a reduced food-related quality of life. However, these self-perceived chewing and swallowing problems were not correlated to the liking and intake of regular nursing home meals, nor of texture-modified meals. On the other hand, food-related quality of life did have a significantly positive effect on both food intake and liking, regardless of treatment. The elderly participants of this study accepted a texture-modified meal less than a regular meal. Notably, there was no significant difference in participants’ liking of the appearance of the texture-modified or control treatment. However, participants liked the taste and texture of the texture-modified meals less than that of the control meals. Similarly, the elderly participants ate less of the texture-modified meals than of the control meals, and also had a lower protein intake when consuming the texture modified meals than when consuming the regular meals. The reduced liking and intake of texture-modified food when compared to regular nursing home food indicates that further product optimization is necessary for texture-modified food if it is to be introduced as a ‘new normal’ diet in nursing homes. Particularly, this product optimization should be focused on improving the meal’s taste and texture. Furthermore, additional measures should be taken to further increase the protein content of texture-modified meals. After product optimization, a strategy can then be developed to further introduce texture-modified meals to nursing homes as a ‘new normal’ diet. However, when doing so, the inter-individual differences among nursing home residents should be taken into account. Thus, after further product optimization and development of an implementation strategy, it can be tested whether introduction of texture-modified food as a ‘new normal’ diet in nursing homes will indeed be able to reduce the risk of malnutrition among elderly by helping to prevent the development of severe chewing and swallowing problems.
39
References Abdelhamid, A., Bunn, D., Copley, M., Cowap, V., Dickinson, A., Gray, L., ... & Poland, F. (2016).
Effectiveness of interventions to directly support food and drink intake in people with dementia:
systematic review and meta-analysis. BMC geriatrics, 16(1), 26.
Aguilera, J. M., & Park, D. J. (2016). Texture-modified foods for the elderly: Status, technology and
opportunities. Trends in Food Science & Technology, 57, 156-164.
Appleton, K. M. (2009). Increases in energy, protein and fat intake following the addition of sauce to
an older person’s meal. Appetite, 52(1), 161-165.
Bauer, J. M., & Diekmann, R. (2015). Protein supplementation with aging. Current Opinion in Clinical
Nutrition & Metabolic Care, 18(1), 24-31.
Burgess, A. M., & Burgess, C. G. (2007, December). Aging-in-place: present realities and future
directions. In Forum on Public Policy: A Journal of the Oxford Round Table (Vol. 1). Forum on Public
Policy.
Cabre, M., Serra-Prat, M., Palomera, E., Almirall, J., Pallares, R., & Clavé, P. (2009). Prevalence and
prognostic implications of dysphagia in elderly patients with pneumonia. Age and ageing, 39(1), 39-
45.
Cardello, A. V. (1994). Consumer expectations and their role in food acceptance. In Measurement of
food preferences (pp. 253-297). Springer, Boston, MA.
Cichero, J. A. Y. (2015). Texture-modified meals for hospital patients. In Modifying Food Texture (pp.
135-162).
Costa, A. I. A., & Jongen, W. M. F. (2010). Designing new meals for an ageing population. Critical
Reviews in Food Science & Nutrition, 50, 489-502.
Doets, E. L., & Kremer, S. (2016). The silver sensory experience–A review of senior consumers’ food
perception, liking and intake. Food Quality and Preference, 48, 316-332.
Edmiaston, J., Connor, L. T., Loehr, L., & Nassief, A. (2009). Validation of a dysphagia screening tool
in acute stroke patients. American Journal of Critical Care, ajcc2009961.
Ettinger, L., Keller, H. H., & Duizer, L. M. (2014). A comparison of liking of pureed food between two
groups of older adults. Journal of nutrition in gerontology and geriatrics, 33(3), 198-209.
Falk, H., Johansson, L., Östling, S., Thøgersen Agerholm, K., Staun, M., Høst Dørfinger, L., & Skoog, I.
(2014). Functional disability and ability 75-year-olds: a comparison of two Swedish cohorts born 30
years apart. Age and ageing, 43(5), 636-641.
Fischler, C. (2011). Commensality, society and culture. Social Science Information, 50(3-4), 528-548.
Frida Food Data. (2015). Food Database version 1, National Food Institute, Technical University of
Denmark. URL: http://frida.fooddata.dk
Fuller, G.W. (2011). New Product Development. From Concept to Marketplace, third edition. Taylor
and Francis Group, LLC.
40
Griep, M. I., Borg, E., Collys, K., & Massart, D. L. (1998). Category ratio scale as an alternative to
magnitude matching for age-related taste and odour perception. Food quality and preference, 9(1-
2), 67-72.
Grunert, K. G., Dean, M., Raats, M. M., Nielsen, N. A., & Lumbers, M. (2007). A measure of
satisfaction with food-related life. Appetite, 49(2), 486-493.
Guillemin, F., Bombardier, C., & Beaton, D. (1993). Cross-cultural adaptation of health-related quality
of life measures: literature review and proposed guidelines. Journal of clinical epidemiology, 46(12),
1417-1432.
Gustafsson, I. B., Öström, Å., Johansson, J., & Mossberg, L. (2006). The Five Aspects Meal Model: a
tool for developing meal services in restaurants. Journal of foodservice, 17(2), 84-93.
Hopcraft, M. S., & Tan, C. (2010). Xerostomia: an update for clinicians. Australian dental journal,
55(3), 238-244.
Huber, M., Rodrigues, R., Hoffmann, F., Gasior, K., & Marin, B. (2009). Facts and figures on long-term
care. Europe and North America, Wien: European Centre for Social Welfare Policy and Research.
Hudson, H. M., Daubert, C. R., & Mills, R. H. (2000). The interdependency of protein-energy
malnutrition, aging, and dysphagia. Dysphagia, 15(1), 31-38.
Humbert, I. A., & Robbins, J. (2008). Dysphagia in the elderly. Physical medicine and rehabilitation
clinics of North America, 19(4), 853-866.
Ilhamto, N., Keller, H. H., & Duizer, L. M. (2014). The effect of varying ingredient composition on the
sensory and nutritional properties of a pureed meat and vegetable. Journal of nutrition in
gerontology and geriatrics, 33(3), 229-248
Jacobsson, C., Axelsson, K., Österlind, P. O., & Norberg, A. (2000). How people with stroke and
healthy older people experience the eating process. Journal of clinical nursing, 9(2), 255-264.
Jones, B., & Kenward, M. G. (2014). Design and analysis of cross-over trials. Chapman and Hall/CRC.
Kadam, P., & Bhalerao, S. (2010). Sample size calculation. International journal of Ayurveda research,
1(1), 55.
Kassambara, A., & Mundt, F. (2016). Factoextra: extract and visualize the results of multivariate data
analyses. R package version, 1(3).
Keller, H., Chambers, L., Niezgoda, H., & Duizer, L. (2012). Issues associated with the use of modified
texture foods. The journal of nutrition, health & aging, 16(3), 195-200.
Keller, H. H., & Duizer, L. M. (2014). What do consumers think of pureed food? Making the most of
the indistinguishable food. Journal of nutrition in gerontology and geriatrics, 33(3), 139-159.
Key figures on Europe: 2013 digest of the online Eurostat yearbook, 2013. Eurostat pocket books,
1830-7892, Luxembourg: Office for Official Publications of the European Communities.
Kofod, J. E. (2008). Becoming a nursing home resident: An Anthropological Analysis of Danish Elderly
People in Transition. University of Copenhagen.
41
Kremer, S., Holthuysen, N., & Boesveldt, S. (2014). The influence of olfactory impairment in vital,
independently living older persons on their eating behaviour and food liking. Food Quality and
Preference, 38, 30-39.
Kuznetsova, A., Brockhoff, P. B., & Christensen, R. H. B. (2014). lmerTest: Tests for random and fixed
effects for linear mixed effect models. R package version 2.0-11. URL http://CRAN. R-project.
org/package= lmerTest.
Laureati, M., Pagliarini, E., & Calcinoni, O. (2008). Does the enhancement of chemosensory stimuli
improve the enjoyment of food in institutionalized elderly people?. Journal of Sensory Studies, 23(2),
234-250.
Lê, S., Josse, J., & Husson, F. (2008). FactoMineR: an R package for multivariate analysis. Journal of
statistical software, 25(1), 1-18.
Leiter, A., Windsor, J. (1996). Compliance of geriatric dysphagia patients with safe swallowing
instructions. Journal of medical speech-language pathology, 4, 289-300
Maeda, K., & Akagi, J. (2016). Treatment of sarcopenic dysphagia with rehabilitation and nutritional
support: a comprehensive approach. Journal of the Academy of Nutrition and Dietetics, 116(4), 573-
577.
Maitre, I., Symoneaux, R., & Sulmont-Rossé, C. (2015). Sensory testing in new product development:
working with older people. In Rapid Sensory Profiling Techniques (pp. 485-508).
Magalhães Junior, H. V., Pernambuco, L. D. A., Lima, K. C., & Ferreira, M. A. F. (2018). Screening for
oropharyngeal dysphagia in older adults: A systematic review of self‐reported questionnaires.
Gerodontology.
Martino, R., Foley, N., Bhogal, S., Diamant, N., Speechley, M., & Teasell, R. (2005). Dysphagia after
stroke: incidence, diagnosis, and pulmonary complications. stroke, 36(12), 2756-2763.
Meiselman, H. L. (2008). Experiencing food products within a physical and social context. In Product
experience, 559-580.
Methven, L., Jiménez-Pranteda, M. L., & Lawlor, J. B. (2016). Sensory and consumer science methods
used with older adults: A review of current methods and recommendations for the future. Food
quality and preference, 48, 333-344.
Miller, N., Noble, E., Jones, D., & Burn, D. (2006). Hard to swallow: dysphagia in Parkinson’s disease.
Age and ageing, 35(6), 614-618.
Miura, H., Kariyasu, M., Yamasaki, K., & Arai, Y. (2007). Evaluation of chewing and swallowing
disorders among frail community‐dwelling elderly individuals. Journal of oral rehabilitation, 34(6),
422-427.
Moskowitz, H. R., Beckley, J. H., & Resurreccion, A. V. (2012). Sensory and consumer research in food
product design and development. John Wiley & Sons.
Murray, J. M., Delahunty, C. M., & Baxter, I. A. (2001). Descriptive sensory analysis: past, present and
future. Food research international, 34(6), 461-471.
Ney, D. M., Weiss, J. M., Kind, A. J., & Robbins, J. (2009). Senescent swallowing: impact, strategies,
and interventions. Nutrition in clinical practice, 24(3), 395-413.
42
Nijs, K. A., De Graaf, C., Siebelink, E., Blauw, Y. H., Vanneste, V., Kok, F. J., & Van Staveren, W. A.
(2006). Effect of family-style meals on energy intake and risk of malnutrition in Dutch nursing home
residents: a randomized controlled trial. The Journals of Gerontology Series A: Biological Sciences
and Medical Sciences, 61(9), 935-942.
Nordin, S. (2017). Sensory Perception of Food and Aging. In Food for the Aging Population, 57-82.
Olin, A. Ö., Koochek, A., Ljungqvist, O., & Cederholm, T. (2005). Nutritional status, well-being and
functional ability in frail elderly service flat residents. European journal of clinical nutrition, 59(2),
263.
O'Doherty Jensen, K. (2002). Gradient blends: the art of discerning and doing the appropriate thing.
In The Way We Think, Vol I (pp. 245-265). University of Southern Denmark.
O'Loughlin, G., & Shanley, C. (1998). Swallowing problems in the nursing home: a novel training
response. Dysphagia, 13(3), 172-183.
Park, Y. H., Bang, H. L., Han, H. R., & Chang, H. K. (2015). Dysphagia screening measures for use in
nursing homes: a systematic review. Journal of Korean Academy of Nursing, 45(1), 1-13.
Pedersen A. & Ovesen L. (2016). Anbefalinger for den danske institutionskost. København:
Fødevarestyrelsen
Piwnica-Worms, K. E., Omar, R., Hailstone, J. C., & Warren, J. D. (2010). Flavour processing in
semantic dementia. Cortex, 46(6), 761-768.
Pliner, P., & Salvy, S. (2006). Food neophobia in humans. Frontiers in Nutritional Science, 3, 75.
Pouyet, V., Cuvelier, G., Benattar, L., & Giboreau, A. (2015). A photographic method to measure food
item intake. Validation in geriatric institutions. Appetite, 84, 11-19.
R Core Team (2016). R: A language and environment for statistical computing. R Foundation for
Statistical Computing, Vienna, Austria. URL: https://www.R-project.org/.
Resurreccion, A. V. A. (1988). Applications of multivariate methods in food quality evaluation. Food
technology (USA).
Rothenberg, E., & Wendin, K. (2015). Texture modification of food for elderly people. In Modifying
food texture, 163-185.
Rozin, P., & Vollmecke, T. A. (1986). Food likes and dislikes. Annual review of nutrition, 6(1), 433-456.
Rozin, P. 1990. Development in the food domain. Developmental psychology, 26, 555.
Schnettler, B., Miranda-Zapata, E., Sánchez, M., Grunert, K. G., Lobos, G., Adasme-Berríos, C., ... &
Hueche, C. (2017). Measurement invariance in the Satisfaction with Food-related Life scale: A
comparison of Chilean and Spanish university students. Food quality and preference, 57, 79-86.
Scott-Thomas, C. (2012). URL: http://www.foodnavigator.com/Science/R-D-challengeDeveloping-
texture-modified-foods-for-the-elderly
Sidenvall, B., & Fjellstrom, C. (1994). The meal situation in geriatric care—intentions and experiences.
Journal of Advanced Nursing, 20(4), 613-621.
Statistics Denmark (2015). Denmark in figures 2015. Statistics Denmark, Copenhagen, Denmark. URL:
http://www.dst.dk/pukora/epub/upload/19006/denmark2015.pdf
43
Steele, C. M., Greenwood, C., Ens, I., Robertson, C., & Seidman-Carlson, R. (1997). Mealtime
difficulties in a home for the aged: not just dysphagia. Dysphagia, 12(1), 43-50.
Stenzelius, K., Westergren, A., Thorneman, G., & Hallberg, I. R. (2005). Patterns of health complaints
among people 75+ in relation to quality of life and need of help. Archives of gerontology and
geriatrics, 40(1), 85-102.
Sulmont-Rossé, C., Maître, I. and Van Wymelbeke, V. (2012). Aupalesens: improving pleasure of
elderly people for fighting against malnutrition. In: Vitagora (ed.) 7 ème Congrès international goût
nutrition santé. Dijon.
Sulmont-Rossé, C., Symoneaux, R., Feyen, V., & Maître, I. (2018). Improving Food Sensory Quality
With and For Elderly Consumers. In Methods in Consumer Research, Volume 2 (pp. 355-372).
Swan, K., Speyer, R., Heijnen, B. J., Wagg, B., & Cordier, R. (2015). Living with oropharyngeal
dysphagia: effects of bolus modification on health-related quality of life—a systematic review.
Quality of Life Research, 24(10), 2447-2456.
Wansink, B. (2009). Measuring food intake in field studies. Handbook of Assessment Methods for
Eating Behaviours and Weight-related Problems: Measures, Theory and Research, 327-345.
Wendin, K., 2001. Sensory dynamics in emulsion products differing in fat content. Thesis, Chalmers
University of Technology, Sweden.
Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005). Comparison of energy and protein intakes of
older people consuming a texture modified diet with a normal hospital diet. Journal of Human
Nutrition and Dietetics, 18(3), 213-219.
Volkert, D., & Sieber, C. C. (2011). Protein requirements in the elderly. International Journal for
Vitamin and Nutrition Research, 81(2), 109.
Zajonc, R. B. (2001). Mere exposure: A gateway to the subliminal. Current directions in psychological
science, 10(6), 224-228.
Ziylan, C., Kremer, S., Eerens, J., Haveman-Nies, A., & de Groot, L. C. (2016). Effect of meal size
reduction and protein enrichment on intake and satiety in vital community-dwelling older adults.
Appetite, 105, 242-248.
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Appendix A – Letter of informed consent
Informeret samtykke “Mad til Alle”
Erklæring fra forsøgspersonen Jeg har fået skriftlig og mundtlig information og jeg ved nok om formål, metode, fordele og ulemper til at sige ja til at deltage. Jeg ved, at det er frivilligt at deltage, og at jeg altid kan trække mit samtykke tilbage uden at miste mine nuværende eller fremtidige rettigheder til behandling. Jeg giver samtykke til, at deltage i forskningsprojektet og til at billederne der bliver taget under studiet bliver brugt i forbindelse med beskrivelsen af resultaterne. Desuden, at jeg må kontaktes i forbindelsen med deltagelsen i dette projekt. Jeg har fået en kopi af dette samtykkeark, samt en kopi af den skriftlige information om projektet til eget brug. _____________________________ ___________________________ Navn på forsøgspersonen Dato og underskrift Erklæring fra den, der afgiver information: Jeg erklærer, at forsøgspersonen har modtaget mundtligt og skriftlig information om forsøget. Efter min overbevisning er der givet tilstrækkelig information til, at der kan træffes beslutning om deltagelse i forsøget. ____________________________ ___________________________ Navn på informationsgiveren Dato og underskrift
45
Appendix B – Participant Information Sheet
Informations papir “Mad for alle”
Mit navn er Michelle Steenvoorden og jeg en studerende ved Københavns universitet. Jeg er i gang
med et forskningsprojekt omkring hvordan man kan lave mad i plejehjem bedre, specielt for folk der
oplever problemer med at tygge og synke. Vi har lavet en ny type mad der er nemmere at tygge og
synke, og vil gerne vide hvordan det er i forhold til dine normale måltider. For at finde ud af om du
kan lide den nye mad, vil vi komme forbi Dronning Anne Marie centeret over flere omgange,
forberede maden for dig, og spørge til om du kan lide det. Vi vil også gerne vide om dine
præferencer for mad er relateret til nogle tygge eller synke problemer. I starten vil plejepersonalet
derfor gå rundt med et spørgeskema for at stille dig en række spørgsmål relateret til dine oplevelser
med at tygge og synke. Din deltagelse vil være til stor hjælp for at udvikle bedre plejehjems måltider.
Vi håber du vil have lyst til at deltage i vores studie.
Med venlig hilsen
Michelle Steenvoorden Master Student Food Innovation and Health Københavns universitet
46
Appendix C - Pilot Study Overall three pilot studies were conducted. The first pilot study had the aim to validate the use of
the DRACE questionnaire, decide on which hedonic scale to use during the consumer test, to make
an estimation of the administration time needed with elderly participants, and to see if any other
unforeseen difficulties may come up. This first pilot study gave non-conclusive results with regard to
which hedonic scale to use in the consumer test. Therefore, a second pilot study was conducted with
employees of the Danish Technical University (DTU). Here the aim was to further investigate the
potential of the two different preselected hedonic scales for the consumer test. Lastly, a third pilot
study was conducted which consisted of a full trial run of the consumer test. This was done to
identify any potential flaws in the study design, already give part of the volunteers some experiences
in performing the tests with the elderly participants, to fine-tune the time schedule for the test days,
and to see if any unforeseen complications would arise. The methodology and outcome of each of
the three pilot studies is described below.
PILOT 1: Methodology The first pilot study was conducted with six visitors of the day-care centre at the Dronning Anne Marie Centret in Frederiksberg. All six participants were female and were between 83 and 99 years old (μ = 89.5). Five out of six participants finished the entire study. The person who stopped did this because of a loss of motivation. The caretakers seated the participants around a table in the activity room, situated at the other end of the room than where the other visitors were. First, the DRACE and SWFL questionnaire was tested. The participants were interviewed one at a time by one of the researchers (MS & SO). Second, food acceptance was tested during the lunch meal, using the regular lunch meal of the nursing home. The meal was served at 12.30. The different components of the meal got served as a buffet on the table, from which the residents could take the amount of food they wanted themselves. Then they were asked to give their liking of the meal. For this, two different hedonic scales were tested. Therefore, the participants were split up into two groups, with each group receiving a different hedonic scale to note down their liking score. The first scale tested was a seven-point category scale combining labels and pictograms (Figure C1). This scale has previously been designed and validated for people living in nursing homes (Matre et al., 2015). Furthermore, category scales are generally easy to use and comprehend (Griep et al, 1998). Also, a large rating scale is advised in consumer studies with elderly since they tend to rate towards the positive scale to please the investigators who are taking care of them (Maitre et al., 2015).
Figure C1 Seven-point category scale combining labels and pictograms, developed in the
AUPALESENS program (Maitre et al., 2015) Moreover, a “speedometer” scale, newly-developed for this study, was examined. This speedometer scale consisted of a semicircle with a rotatable arrow fixed at its center, making it resemble a speedometer (Figure C2). Participants should use the arrow to indicate their answer to the questions of consumer test on a semicircle sheet underneath the arrow. The text on the sheet is meant to help participants answer the question: the bottom left will read “Dislike a lot”, the center will have a line through it and read “Neither like nor dislike”, and the bottom right will read “Like a lot”. Using a marker, the participant can mark the location of the point of the arrow on the sheet below the
47
arrow. The advantage of the speedometer scale is that it provides a playful approach to measuring the participant’s response, which is expected to improve the ability of participants with poor cognitive skills to answer the questions and reduce their fatigue (Metheven, 2016). Furthermore, it should help participants to think more about their answer, and its resemblance to a speedometer should make it easy to recognize and understand. Furthermore, the only help required from volunteers in answering the question would be to help note down the location of the arrow tip and replace the sheet. This means that the bias introduced by having volunteers help answer questions should be reduced, and the manpower needed is reduced as well.
Figure C2 Newly developed “speedometer” scale
Outcome During the conduction of the DRACE and SWFL questionnaire, it became clear that a better introduction to the study and the questions should be given before the questionnaire was administered. This is because the participants were noticeably confused with the purpose of the questionnaire. However, participants understood the questions and were able to answer all of them easily. It took approximately 10 minutes per participant to fill in this part of the study. Aside from some aesthetic changes, no other changes need to be made to the questionnaire. The buffet setting of the food acceptance test caused some disorder at the table. It was noticed here that the participants were distracted quite easily, and that both simplicity and consistency in the study approach is needed. Due to the disorder, miscommunication occurred between the two researchers (MS & SO) about when to initiate which part of the test. This caused the lack of a clear starting point and disorder throughout the entire session. Therefore, it was decided that a clear introduction should be written down for the volunteers, with clear steps throughout the entire session, to ensure that all tests are performed consistently. The participants should be given a brief introduction on what is expected of them before they receive their food. Then, they should be given a pre-prepared plate instead of an open buffet. Next, in consistent steps, they should perform the various tasks of the test. Although the participants of this pilot test were not that frail yet, they already needed some help in filling in the answers. Therefore, it is of importance that enough volunteers and caretakers are available to help the residents with conducting this part of the study. When testing the two different hedonic scales for liking scores, it appeared that the participants using the 7-point scale were understanding the task better than the ones using the “speedometer”. The questions were presented on paper to the participants using the 7-point scale, but not to the participants using the “speedometer”. This made it easier for the participants with the 7-point scale
48
to follow the structure and fill in the questions. Furthermore, the participants using the “speedometer” didn’t use the arrow to indicate the answer but just pointed at the point that indicated their answer. Moreover, they only used the indicator lines as answer options and didn’t use the entire continuous spectrum of the scale. Based on these findings it would be suggested to use the 7-point scale in the continuation of this study. Further development of the speedometer tool is needed before it can be used. Recommendations for further development of the tool would be to make a separate questionnaire on paper and separate tool. Moreover, the size of the tool should be reduced to fit it easier at the dinner table. Furthermore, it is recommended to remove the indicator lines and introduce a gradation of color to help visualization of the intensity of their liking/disliking of the meal.
PILOT 2: Methodology Based on the outcomes of the first pilot study, the speedometer hedonic scale was changed by adding clear instructions to the sheet (including pictograms), removing the indicator lines, and adding a gradual colour change. This new version of the speedometer scale is shown in Figure C3. Using this new speedometer scale, and the previously-used 7-point category scale, a second hedonic scale pilot study was performed with a convenience sample (n=12) at the Danish Technical University. On two separate days, participants were asked to rate their liking of two different types of lemon cake. On each day, a different scale was used.
Figure C3: Speedometer hedonic scale, as improved after the first pilot study.
49
Outcome Participants quickly understood how to use the 7-point Likert scale, but were often confused with how to use the speedometer scale. Several participants needed to be reminded multiple times how they should use the speedometer scale, and many participants did not bother to use the arrow when choosing their answer. One participant even used the speedometer scale the wrong way around, in spite of the new colour scheme. On the basis of this pilot study, it was decided that the newly-developed speedometer scale was not suitable for use as a hedonic scale in this study. Thus, during the consumer test, the 7-point Likert scale was used.
PILOT 3: Methodology The third pilot study that was performed consisted of a trial run of the consumer test. For this, the same methodology was used as is described in the Methods section of the main text: half of the participants were given texture-modified food and the other half were given regular nursing home food, and during the meal the volunteers administered the 7-point Likert questionnaire to score the participants’ liking of the food. The only major difference between the methodology of this trial run and that of the later consumer test was that, during the trial run, all the modified meal’s components were texture modified (Figure C4).
Figure C4: The texture-modified meal as served during pilot study 3. Note that all components of the meal have been texture-modified.
Outcome The trial run yielded valuable insights into how the consumer test could best be performed. First and foremost, regarding the texture-modified meal, it was clear that it was a bad idea to modify the texture of all of the meal’s components. A great majority of participants that received the texture-modified food were negative about the food, signifying that modifying all of the meal’s components was too large of a jump. Therefore, it was decided that, during the consumer test, only the meat component would be texture-modified. This component is usually the hardest to chew, and also contains the most proteins out of all the meal’s components. Furthermore, the trial run already made it clear that a few participants were unfit for participating after all. These participants were therefore excluded from the future consumer test sessions. The trial run also highlighted the importance of a good time schedule and checklist of the test day, as well as a good instruction guide for the volunteers. Overall, the trial run was a valuable practice experience for the researcher (MS) and the volunteers, which helped to streamline the subsequent test sessions and contributed to a greater consistency of the results.
50
Appendix D – Questionnaire DRACE and SWFL
Hvad er dit køn?
o Mand
o Kvinde
Hvad er din alder?_______
Følgende spørgsmål er relateret til din evne til at synke mad og drikkevarer. Vælg venligst
den mulighed, der bedst beskriver din oplevelse i det sidste år.
Slet ikke Lidt længere Meget længere
1 Tager det dig længere tid at spise et måltid end før?
O O O
De nedenstående oplysninger omhandler oplevelser i forbindelse med et måltid, indenfor
det sidste år.
Aldrig En gang imellem
Hyppigt
2 Har du haft mindst en episode af feber?
O O O
3 Har du haft problemer med at synke drikkevarer?
O O O
4 Har du haft problemer med at tygge hård mad?
O O O
5 Har du oplevet, at du spildte mad ud af munden?
O O O
6 Har du fået noget galt i halsen, mens du spiste?
O O O
7 Har du nogensinde hostet i forbindelse med, at du drak drikkevarer?
O O O
8 Har du nogensinde haft en episode med mad, der kom op i din næse?
O O O
9 Har du nogensinde haft en ændring i din stemme efter et måltid?
O
O
O
Afdeling:
o Syd stuen
o Syd 1. Sal
o Nord stuen
o Nord 1. Sal
51
Aldrig En gang imellem
Hyppigt
10 Har du nogensinde haft kraftig spytproduktion under et måltid?
O O O
11 Har du nogensinde følt, at du havde en klump i halsen, når du skulle synke mad?
O O O
12 Oplever du nogensinde sure opstød fra mad eller drikkevarer, du har indtaget?
O O O
Tænk venligst på de ting, du gør og oplever i forhold til mad og måltider, og angiv derefter
din vurdering af hvert spørgsmål ved hjælp af 1-5 skalaen nedenfor?
Meget uenig
Uenig Hverken enig eller
uenig
Enig Meget enig
13 Mad og måltider er lyspunkter i mit liv.
1 2 3 4 5
14 Generelt set er jeg meget tilfreds med min mad.
1 2 3 4 5
15 Mad og måltider giver mig en masse tilfredsstillelse i hverdagen.
1 2 3 4 5
16 Når det gælder mad og måltider er mit liv tæt på at være ideelt.
1 2 3 4 5
17 Når det gælder mad har jeg en fortrinlig tilværelse.
1 2 3 4 5
Tænk på dine måltider overodnet (ift dem du får her på plejehjemmet), og beskriv din
tilfredshed hermed:
Meget utilfreds
Utilfreds Hverken tilfreds eller
utilfreds
Tilfreds Meget tilfreds
18 Hvor tilfreds er du med din nuværende mad?
1 2 3 4 5
52
Appendix E – Meal Composition
Meal 1: Chicken with cucumber salat, mashed potatoes and gravy
Control meal
Modified meal
Portion size (g)
Energy content
(KJ)
Protein content
(E%)
Protein content
(g)
Portion size (g)
Energy content
(KJ)
Protein content
(E%)
Protein content
(g)
Meat 60 503 40.0 11.8 60 621 31.1 11.4 Vegetables 50 110 7.0 0.5 50 110 7.0 0.5
Potatoes 100 435 7.4 1.9 100 435 7.4 1.9
Gravy 100 225 6.0 0.8 100 225 6.0 0.8 Total 310 1273 20.0 15.0 310 1391 17.7 14.5
53
Meal 2: Rack of pork with red cabbage salat, potatoes and gravy
Control meal
Modified meal
Portion size (g)
Energy content
(KJ)
Protein content
(E%)
Protein content
(g)
Portion size (g)
Energy content
(KJ)
Protein content
(E%)
Protein content
(g)
Meat 60 457 42.0 11.3 60 721 23.1 9.8 Vegetables 50 69 17.0 0.7 50 69 17.0 0.7
Potatoes 100 418 6.0 1.5 100 418 6.0 1.5
Gravy 100 252 7.0 1.0 100 252 7.0 1.0 Total 310 1196 20.6 14.5 310 1460 15.1 13
54
Meal 3: Roasted lamb with tzatziki, potatoes and gravy
Control meal
Modified meal
Portion size (g)
Energy content
(KJ)
Protein content
(E%)
Protein content
(g)
Portion size (g)
Energy content
(KJ)
Protein content
(E%)
Protein content
(g) Meat 60 444 61.0 15.9 60 627 31.9 11.8
Vegetables 50 148 19.0 1.7 50 148 19.0 1.7
Potatoes 100 418 6.0 1.5 100 418 6.0 1.5 Gravy 100 252 7.0 1.0 100 252 7.0 1.0
Total 310 1262 27.0 20.1 310 1445 18.7 16.0
55
Meal 4: Beef stew with carrots and peas and potatoes
Control meal
Modified meal
Portion size (g)
Energy content
(KJ)
Protein content
(E%)
Protein content
(g)
Portion size (gram)
Energy content
(g)
Protein content
(E%)
Protein content
(g) Meat 60 458 65.0 17.5 60 516 30.6 9.2
Vegetables 50 107 28.0 1.8 50 107 28.0 1.8 Potatoes 100 418 6.0 1.5 100 418 6.0 1.5
Gravy 100 438 3.0 0.8 100 438 3.0 0.8
Total 310 1421 25.7 21.6 310 1479 15.3 13.3
56
Appendix F – Caretaker Information sheet Starting the coming week, a study as part of my Master thesis at the University of Copenhagen will be
conducted at the Dronning Anne Marie Centeret. The study will take place over 10 days, spread out
over 6 weeks during dinner time. An overview of test days can be found in the below table. On each
test day, there will be 6 Danish-speaking volunteers assisting with the study (1 for every 5
participants), and Michelle Steenvoorden will be there to coordinate. This means that 4 volunteers
will be helping in the south wing and 2 volunteers in the north wing.
Test days
Period 1 Period 2
29 April 13 May
02 May 15 May
06 May 11 May
08 May 23 May
In total, 30 residents of DAMC have agreed to participate in the study. An overview of these
participating residents can be found in the following Table.
Room number Name Room number Name
Syd Stuen Syd 1. Sal
Nord Stuen Nord 1. Sal
Due to private considerations the personal information, such as names and room numbers are removed from this table
What will a test day look like?
The time schedule of a test day will look as follows:
● 15:00 Michelle will be present and go by each ward to talk with the nurses about the test day,
and the important things to keep in mind.
● 16:30 The study volunteers will arrive at the main entrance, where Michelle will give them
instructions, and guide them to the wards where they will be introduced to the nurses.
● 16:00-16:30 The kitchen staff will heat up the dinner meals in the kitchen oven, including the
test meals of the test participants. The meals will then be sent to the wards, where the nurses
will plate them up.
○ Gratinkost meals will also be heated up in the kitchen oven, and then plated up in the
wards.
○ For each ward, one additional test meal will be prepared as a display meal. This meal
will already be plated up by the kitchen staff, as it needs to be presented to the
participants at 17:15.
57
○ It is important that each test meal will be plated up similarly to the display model. We
will also measure the food intake of the participants, so the weights of the different
meal components should not differ too much between plates.
● 17:00-17:10 Participating residents will enter their respective wards’ dinner areas.
● 17:15 Volunteers will take the heated-up display test meal, and present this to the
participating residents. The participants will rank their liking of how the meal looks and
smells. They will not eat the meal. The volunteers will help the participants in answering the
questions.
● 17:20-17:30 The non-participating residents will now also have entered the dinner areas and
the nurses will prepare
● 17:30 Meals will be served out. The volunteers helping with the study will serve out the meals
to the test participants.
○ When eating, the participants will score their liking of the test meal’s taste and
texture, as well as their overall liking of the meal. The volunteers will help the
participants in answering these questions.
○ After finishing their meal the participants will also be asked to indicate if they would
like to consume the meal more often.
● 18:00-18:30 When the participants have finished eating, the volunteers will take the plates of
the participants back to the kitchen. There, a volunteer will weigh each participant’s plate,
including leftovers, on a scale. The volunteer will also make a photograph of the leftovers on
the scale, to record the plate weight and get a visual image of how much of each meal
component was eaten.
● 18:30 The test will come to an end. Participating residents will receive dessert and coffee like
all other residents.
What will be expected of the nurses?
In the test day overview above, tasks are listed for both the nurses and volunteers. The following list
gives a clear and concise picture of what will be expected of the nurses specifically.
● Inform the participating residents about the test during the day that the test will take place.
○ Inform the participants that they have to answer some questions during dinner time.
○ Inform the participants that will be served gratinkost that they will receive a “special
meal”. An overview of when regular meals and when gratinkost will be served in
which ward can be found in the below table.
● Guide residents in time to the dining wards. Participating residents will be expected to be in
the ward 20 minutes earlier than the other residents: at 17:00-17:10.
● Plate up the test meals. The test meals should be plated up at the same time as the other
meals: around 17:15-17:30. It is important that each test meal is plated up similarly to the
display model that is plated up by the kitchen staff. We will also measure the food intake of
the participants, so the weights of the different meal components should not differ too much
between plates.
● Help out the volunteers with “difficult” participants. The nurses are more experienced with
working with the elderly nursing home residents, and the volunteers may sometimes need a
little bit of help in getting the participants to cooperate.
58
● During the dinner, administer medication to the residents as usual. However, no medication
should be administered to the participants while they are answering questions, so they won’t
be distracted.
Period 1
(26 April - 08 May)
Period 2
(13 May - 03 June)
Regular Syd og Nord stuen Syd og Nord 1. Sal
Gratinkost Syd og Nord 1. Sal Syd og Nord stuen
59
Appendix G – News item DAMC
60
Appendix H – Instruction guide volunteers Dear volunteer, Thank you for taking the time to help with this study! This sheet is meant to inform you about the background of the study, what a test day will look like, and what will be expected of you. Read this document thoroughly before you come to volunteer. Aim of this study Getting older goes together with a gradual decline in muscle mass and muscle strength, which among other things can lead to chewing and swallowing discomfort during the consumption of food. Elderly with these problems have an increased risk of developing malnutrition, which in turn leads to increased risk of mortality, as well as a general decreased quality of life. Chewing and swallowing problems are especially common among elderly care recipients. However, unless they are diagnosed with the more-severe dysphagia affliction, elderly in nursing homes will generally not be given special treatment for their chewing and swallowing problems. In an initial questionnaire performed at the nursing home you will be volunteering at, over half of the participants show symptoms of chewing and swallowing problems. This shows how important it is that these elderly people are helped. One way to help elderly with chewing and swallowing problems is to give them meals that have been texture-modified. Texture modifications means that, after cooking, the texture of the food is changed so that it becomes easier to chew and swallow. This modification can be done, for instance, by blending or mashing the food. The problem here, is that many elderly with chewing and swallowing problems don’t accept these texture-modified foods, because they do not like the taste, appearance and monotony of the texture-modified foods and are ashamed of eating this alternative menu. Therefore, most elderly with chewing and swallowing problems prefer the regular nursing home meals, even with the risk of choking, seriously limiting their quality of life. It seems clear that we can help elderly with chewing and swallowing problems by improving the quality of texture-modified food. This should increase elderly’s acceptance of the food by increasing their liking of it. It should also increase their nutritional intake, which will reduce loss of muscle mass and prevent chewing and swallowing problems from getting worse. Therefore, the aim of this study is to compare how much nursing home residents like their regular dinner meals, compared to meals that have been prepared in a novel way to help elderly with chewing and swallowing problems. We also aim to investigate the difference in intake of the regular meals and novel meals. The novel meals that we will test in this study are both texture-modified and protein-enriched, and have been made to resemble the look and taste of the non-modified meal. Test days The study will take place over 10 days, spread out over 6 weeks, at the Dronning Anne Marie Centeret in Frederiksberg. On each test day, there will be 6 volunteers assisting with the elderly (1 for every 5 participants), 4 volunteers will assist in sample preparation and food intake measurements, and Michelle Steenvoorden will be there to coordinate.
The nursing home The study will take place at: Dronning Anne Marie Centeret Solbjerg Have 7, Frederiksberg The nursing home has 69 residents, of which 30 have agreed to participate in the study. Due to privacy concerns it is important that no names of participants are released in general public.
61
The nursing home consists of a North wing and a South wing, with two floors per wing. In total, the nursing home has 4 different dining areas: one on each floor of each wing. The study will be spread out over these 4 dining areas, so that the participants eat at their usual dining area and are not taken out of their daily routine. On different days, you may therefore be in a different dining area. The nursing home has a nursing staff that will be present throughout the study. Should you encounter any problems with the participants, you can always ask the nursing staff for help. Any study-related questions are best addressed to Michelle Steenvoorden, who will be present to coordinate. What will a test day look like? The time schedule of a test day will look as follows:
● 16:30 You and the other volunteers will arrive at the main entrance of the nursing home,
where Michelle will brief you on the plan for the day, and you have a chance to ask any
questions you may have. Furthermore, she will guide you to the wards where you will be
introduced to the nurses.
○ You will be expected to be there no later than 16:30. The elderly participants are
used to a fixed time schedule, so please be there a little earlier to make sure you will
not be late. If you find yourself running late after all, please contact Michelle as soon
as possible.
● 16:00-16:45 The kitchen staff will heat up the dinner meals in the kitchen oven, including the
test meals of the test participants. The meals will then be sent to the wards, where the nurses
will plate them up.
○ The Non-Danish speaking volunteers will help the nurses with plating up the food. As
further explained below, it is really important that this in done in an accurate manner,
to make it possible to calculate food intake.
● 17:00-17:10 Participating residents will enter their respective wards’ dinner areas.
○ You may be requested to assist in helping the residents make their way to the dinner
area.
● 17:10-17:15 Danish-speaking volunteers will introduce themself to the residents they are
responsible for and give them a brief explanation of the test that is going to follow.
○ It is important to do this every time you come to volunteer, also when you are on the
same ward for several occasions. Most of the residents we work with don’t have a
strong memory.
○ It is important to clearly explain the steps of the test (see below), when they should
answer which question, and how they should answer the questions (see below).
● 17:10-17:30 Non-Danish speaking volunteers will help during the meal preparation in the
kitchen of the respective ward.
○ For each ward, one additional test meal will be prepared as a display meal. This meal
will already be plated up by the kitchen staff, as it needs to be presented to the
participants at 17:15.
○ It is important that each test meal will be plated up similarly to the display meal, both
in the way it looks and regarding the amount of the meal’s components. We will also
measure the food intake of the participants, so the weights of the different meal
components should not differ too much between plates.
62
● 17:15 First, Danish speaking volunteers will ask the residents to score their level of appetite
on a 7-point scale with smiley faces and labels (Attached questionnaire). Secondly, they will
take the heated-up display test meal (there will be one display meal for each ward), and
present this to the participating residents, one at a time. The participants will be asked to
rank their liking of how the meal looks and smells. Participants will not eat the meal. Danish
speaking volunteers are expected to help the participants in answering the questions if they
have any difficulties in understanding the question or writing down their answer.
○ Most of the participants are not able to fill in the score sheet themselves and help is
probably needed.
● 17:20-17:30 The non-participating residents will now also have entered the dinner areas and
the nurses will have prepared the food for non-participating residents.
● 17:30 Meals will be served out. Danish speaking volunteers will be expected to serve out the
meals to the test participants. The participants will be requested to score their liking of the
meal when eating it.
○ When eating, the participants will score their liking of the test meal’s taste and
texture, as well as their overall liking of the meal. The Danish-speaking volunteers will
help the participants in answering these questions, if needed.
○ After finishing their meal, the participants will also be asked to indicate if they would
like to consume the meal more often.
● 18:00-18:30 When the participants have finished eating, Danish-speaking volunteers will
collect their answer sheets. They will also take the plates of the participants back to the
kitchen. Before taking the plate back to the kitchen however, they will place a piece of paper
on the plate that indicates the room number of the participant (they will have received these
pieces of paper from Michelle at the start). In the kitchen, a non-Danish speaking volunteer
will weigh each participant’s plate, including leftovers, on a scale, and record the weight and
participant room number on a list. The volunteer will also make a photograph of the leftovers
on the scale, whereby it is important to include the participant’s room number in the
photograph.
○ Before taking in the answer sheets of the participants, make sure the participant’s
room number is listed on the sheet.
○ It is important that every plate, including leftovers, is correctly linked to the
participant it belonged to. This is why a piece of paper with the participant’s room
number is put on the plates.
○ It is important to take the plate pictures in a consistent way. You can use your own
mobile phone to take the pictures, just make sure that the picture is taken straight
from above the plate, the pictures are sharp, the entire plate with leftovers is in the
picture, the weight on the scale is in the picture, and the paper with the participant’s
room number is in the picture. You will receive a tripod which will be set to the
correct height and to which you can attach your mobile phone.
○ Before weighing a plate, always make sure the scale is set back to zero.
● 18:30 The test will come to an end. Participating residents will receive dessert and coffee like
all other residents (served by the nurses). You and the other volunteers will go to the main
entrance, and hand over the answer sheets and intake measurement of the participants to
Michelle. You will also forward the photos you have taken of the plates to Michelle. Here
Michelle will do a short debriefing.
63
Important reminders You will be working with frail elderly, who can suffer from a variety of ailments. They may for instance be hard of hearing, easily distracted, or will need your assistance in answering the test’s questions. Above all, it is important that you remain patient, polite, and calm. However, time is limited, and some participants like to “mess around” with you. It is therefore also important that you try and keep them focused on the test.
Most participants will likely require you to guide them to an answer of how much they like the food. You can do this by first asking if they like it or do not like it. Then, if they for instance like it, you can ask if they like it a bit, just like it, or like it a lot. The scale that the participants will use to answer the questions contains smileys. It is important that you clarify to the participants that these smileys are meant to indicate how much they like the food, and not how happy the food makes them.
64
Appendix I – Questionnaire Consumer test
Hvor meget appetit har du i øjeblikket?
Hvad synes du om udseendet af måltidet?
Hvad synes du om duften af måltidet?
Hvad synes du om smagen af måltidet?
65
Hvad synes du om konsistensen af måltidet?
Hvad synes du overordnet om måltidet?
Vil du spise måltidet igen?
o Nej
o Måske
o Ja
66
Appendix J – Food intake and observation sheet
Date____________
Department
Plate weight Photo taken
Participant Number
Name Before After Before
Comments
67
Appendix K – Reference materials
The following tables give an indication of how the developed reference materials looked. As example the reference materials for the pork meals (control and texture-modified) are displayed.
Vegetables
100%
75%
50%
25%
Red cabbage salat (pork meal)
68
Potatoes
100%
75%
50%
25%
69
Gravy
100%
75%
50%
25%
70
Meat Modified
100%
75%
50%
25%
71
Meat Control
100%
75%
50%
25%
72
Appendix L – Letter from the Ethical Committee
73
74
Appendix M – Results
FOOD INTAKE
The following tables show mean food intake, energy intake, and protein intake, including standard
deviation, per treatment, split out in both meal type and meal component. A paired t-test was used
to test for significant differences between treatments, where * p < 0.05, ** p < 0.01, *** p < 0.001.
Different letters in the same columns indicate significant differences according to Tukey’s HSD test,
with a separate post-hoc test being performed for each meal component.
Food intake (g) Control “Texture-
modified” Significance
Total Chicken 208.3 ± 68.0a 171.8 ± 76.2ab *
Pork 171.6 ± 67.8a 130.2 ± 71.9a **
Lamb 169.4 ± 75.6a 151.9 ± 76.6ab ns
Beef 182.5 ± 79.5a 175.2 ± 96.6b ns
Meat Chicken 53.9 ± 27.8b 45.2 ± 20.9b ns
Pork 52.3 ± 18.0b 30.9 ± 19.8a ***
Lamb 34.0 ± 23.3a 39.9 ± 20.0ab ns
Beef 37.7 ± 20.8a 36.8 ± 23.9ab ns
Vegetables Chicken 31.3 ± 20.2b 24.6 ± 19.9bc ns
Pork 16.0 ± 17.3a 9.1 ± 13.2a *
Lamb 21.9 ± 20.8ab 14.3 ± 16.4ab ns
Beef 31.9 ± 17.5b 30.1 ± 19.0c ns
Potato Chicken 75.9 ±32.5b 59.9 ± 32.5a *
Pork 66.5 ± 28.6ab 56.2 ± 27.2a ns
Lamb 62.6 ± 36.7ab 55.8 ± 32.6a ns
Beef 54.5 ± 36.2a 52.0 ± 36.7a ns
Gravy Chicken 58.4 ± 23.0bc 43.1 ± 28.4ab *
Pork 40.4 ± 27.6a 34.1 ± 29.5a ns
Lamb 44.5 ± 29.5ab 41.8 ± 31.8ab ns
Beef 58.4 ± 23.9c 56.3 ± 30.5b ns
Energy intake (KJ) Control “Texture-
modified” Significance
Total Chicken 982.7 ± 359.8b 879.0 ± 349.6a ns
Pork 926.5 ± 299.4b 704.9 ± 379.4a **
Lamb 690.6 ± 296.4a 798.2 ± 377.9a ns
Beef 839.8 ± 366.8ab 844.7 ± 473.9a ns
Meat Chicken 452.2 ± 233.4b 467.3 ± 217.3b ns
Pork 524.5 ± 180.6b 371.3 ± 237.9ab **
Lamb 251.6 ± 172.5a 417.1 ± 209.0ab ***
Beef 287.7± 158.4a 316.8 ± 205.8a ns
Vegetables Chicken 68.9 ± 44.4b 54.2 ± 43.9b ns
Pork 22.2 ± 24.0a 12.6 ± 18.4a *
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Lamb 64.7 ± 61.7b 42.2 ± 48.6b ns
Beef 68.4 ± 37.6b 64.4 ± 38.6b ns
Potato Chicken 330.0 ± 141.4b 260.6 ± 141.2a *
Pork 277.9 ± 119.4ab 234.9 ± 113.7a ns
Lamb 261.7 ± 153.5ab 233.2 ± 136.4a ns
Beef 227.7 ± 151.4a 217.4 ± 153.6a ns
Gravy Chicken 131.6 ± 51.8a 97.0 ± 63.9a *
Pork 102.0 ± 69.7a 86.0 ± 74.4a ns
Lamb 112.5 ± 74.4a 105.7 ± 80.2a ns
Beef 255.9 ± 104.7b 246.3 ± 133.4b ns
Protein intake (g) Control “Texture-
modified” Significance
Total Chicken 12.8 ± 5.9ab 10.3 ± 4.3b ns
Pork 14.6 ± 4.8b 6.4 ± 3.7a ***
Lamb 11.2 ± 6.5a 9.6 ± 4.7b ns
Beef 13.4 ± 6.8ab 8.0 ± 4.7ab ***
Meat Chicken 10.7 ± 5.5ab 8.6 ± 4.0b ns
Pork 13.0 ± 4.5b 5.0 ± 3.2a ***
Lamb 9.0 ± 6.2a 7.8 ± 3.9b ns
Beef 11.0 ± 6.1ab 5.7 ± 3.7a ***
Vegetables Chicken 0.3 ± 0.2a 0.2 ± 0.2ab ns
Pork 0.2 ± 0.2a 0.1 ± 0.2a *
Lamb 0.7 ± 0.7b 0.5 ± 0.5b ns
Beef 1.1 ± 0.6c 1.1 ± 0.6c ns
Potato Chicken 1.4 ± 0.6b 1.1 ± 0.6b *
Pork 1.0 ± 0.4a 0.8 ± 0.4a ns
Lamb 0.9 ± 0.5a 0.8 ± 0.5a ns
Beef 0.8 ± 0.5a 0.8 ± 0.5a ns
Gravy Chicken 7.9 ± 0.2a 5.8 ± 0.2a *
Pork 0.4 ± 0.3a 0.4 ± 0.3a ns
Lamb 0.5 ± 0.3a 0.4 ± 0.3a ns
Beef 0.5 ± 0.2a 0.4 ± 0.2a ns
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REPEATED CONSUMPTION:
The below table shows participant’s willingness to eat the served meal again, shown for each treatment and split out by meal type.
Chicken Pork Control
(n=22) Texture-modified
(n=21) Control
(n=21) Texture-modified
(n=21)
Yes 90.9% (20) 47.6% (10) 71.4% (15) 42.9% (9)
No 9.1% (2) 52.4% (11) 23.8% (5) 52.4% (11)
Maybe 0.0% (0) 0.0% (0) 4.8% (1) 4.7% (1)
Lamb Beef Control
(n=23) Texture-modified
(n=23) Control
(n=23) Texture-modified
(n=21)
Yes 60.9% (14) 39.1% (9) 82.6% (19) 33.3% (7)
No 34.8% (8) 43.5% (10) 17.4% (4) 47.6% (10)
Maybe 4.3% (1) 17.4% (4) 0.0% (0) 19.0% (4)