Dysphagia, Malnutrition and Savorease
Dysphagia and Malnutrition.
The demands on the food market are changing. The number of Americans over age 65 is projected to more than double, from 40.2 to 88.5 million between 2010 –2050. (U.S. Census Bureau, 2012, Vincent and Velkoff, 2010). The number of people worldwide age 65 and older is estimated at 506 million as of 2008; by 2040, that number will hit 1.3 billion. In just over 30 years, the proportion of older people will double from 7% to 14% of the total world population (National Institute on Aging, An Aging World, 2008). The population over age 65 in Oregon is 489,350. Presently, the predominant race is white with Hispanic a distant second. It is projected that between 2010 and 2030, the white population age 65+ will increase by 59% compared with 160% for older minorities. Food choices for the elderly target age 80+ and not baby boomers age 50-68. The latter population is more ethnically diverse and has been exposed to more variety in their food experience. The critical issue is the lack of easy access to food for those with chewing and swallowing disorders that meets digestive needs, is satisfying, offers healthy calories, with a goal to avoid malnutrition.
Dysphagia sufferers in general fall into a subset of the rapidly growing aging population. The major conditions that predispose to dysphagia are: stroke, brain injury, ALS, Alzheimer’s disease, Huntington’s disease, multiple sclerosis, frontotemporal dementia, multiple dystrophy, cerebral palsy, Huntington Chorea and Parkinson’s disease. Complications of dysphagia can include malnutrition, depression, weight loss, dehydration, aspiration pneumonia, exacerbation of chronic lung disease and possibly death. The loss of socialization, feeding autonomy, and identity (Shune & Linville, 2017) are also real consequences of dysphagia. Malnutrition as a result of dysphagia can have a cascade of effects including delayed wound healing, immune dysfunction, increased rates of hospitalization, and increased mortality (Stratton et al., 2003; Kubrak & Jensen, 2007; Norman et al., 2008). In addition to clinical and social consequences, the economic impact is substantial. Recent data from the UK suggest that malnutrition costs in excess of €9.2 billion (equivalent to over $12 billion USD) each year, the bulk of which arises from the treatment of malnourished patients in hospitals and in long term care facilities such as nursing homes (Elia, 2006). The concern is not only in identifying the patients who are malnourished or at risk of malnutrition, but to provide an appropriate intervention to improve patient outcomes and cost. The causes of inadequate intake are multi-factorial and multi-disciplinary. These factors can include: poor appetite, poor positioning (Crogan & Alvine, 2006), poor oral health, dysphagia (Kayser-Jones,1997), level of alertness (Westergren et al., 2001) and degree of assistance required (Thomas et al., 1991). Interventions should aim to address these issues. Providing energy-dense meals and snacks to hospitalized patients can lead to improvements in body weight (Odlund-Olin et al., 1996) and shorter length of stay (Johansen et al., 2004). Conversely, lack of snack provision and failure to adapt menus to patients’ preferences, as well as lack of communication, have been identified by hospitalized patients as failures in their nutritional care (Lassen et al., 2006). Furthering the need to implement change, centers for Medicare and Medicaid Services (CMS) created guidelines for facilities managing elderly care (Federal Register/Vol 81, No.192, 2016/Rules and Regulations) requiring facilities to offer person-centered, nourishing alternative meals and snacks to residents who want to eat at non-traditional times. The current problem is that the research evidence and federal policy indicate the need for widespread change in snack availability and patient specificity, yet the current snack food solutions for dysphagia diets lack flavor, varied texture, and have no ethnic diversity. The importance of improving food enjoyment with a snack solution is shared with the need for safe, easily accessible food targeted to improving nutrition and reducing food aspiration. Meeting this goal can help reduce hospital readmissions, emergency room visits, the necessity for long term institutional care and the need for expensive feeding support.
Issues Surrounding Feeding Assistance:
Many older adults in care require some level of assistance at a meal. In fact, malnutrition and dehydration may be due to the number of patients requiring feeding assistance and the lack of time for the staff to feed them (Sandman et al., 1987; Cooper & Cobb, 1988). Further, feeding assistance decreases the availability of typical eating-related sensory cues, which may negatively impact swallow performance during meals (Shune, Moon, & Goodman, 2015). Providing intentional "finger foods" at snack time for those that typically require feeding assistance due to a restricted diet is hypothesized to increase food enjoyment and decrease caregivers' feeding involvement.
Current Snack Food Issue.
While pureed and mechanically soft food options are available to satiate a dysphagic individual’s hunger, ready-made snack options are often limited to shakes and puddings, which can be unenjoyable over time due to lack of texture variety. In addition, lack of mastication can negatively affect cognition over time (Weijenburg, 2011), which may be an impactful consequence especially for those in cognitive decline with conditions such as dementia and Alzheimer’s Disease. Existing snack foods also tend to be high in sugar, which may increase risk for tooth decay among individuals with dry mouth, creates a void in access to savory alternatives and may pose a blood sugar management challenge among diabetics. Consumers of pureed foods experience “burn out” and find that such foods lack sensory appeal, variety, and the “crunch” that is a crucial part of experiencing foods (Keller & Duizer, 2014). It has been shown that improving the flavor of foods can improve caloric intake and body weight in nursing-home patients (Mathey et al., 2001). In conclusion, the loss of food enjoyment contributes to the risk of malnourishment in the elderly and ultimately decreases quality of life. Addressing these factors can improve the lives of this population.
The largest food product companies addressing the needs of individuals with dysphagia are: Nestlé Health Science, Thick-It, Abbott Nutrition, Hormel Health Lab, and Nutricia Advanced Medical Nutrition. The only ready-made snack products for individuals on dysphagia diets are puddings and refrigerated liquid supplements. In reality, due to budgetary restriction, more commonly available snacks in facility care for dysphagia sufferers include: applesauce, yogurt, and house supplements.
INNOVATION– A Snack Food Solution.
The Oregon State University Food Innovation Center has collaborated with Taste for Life LLC to develop a line of transitional snack food products called SavoreaseTM snacks. The snacks were created to improve food enjoyment through savory snacks, with low to no sugar and satisfying, nostalgic flavors. The solution also solves for the need for improved appearance, two finger grasp snacks, better mouth feel, and texture differentiation. Individuals having reduced appetite (e.g., necessitating smaller, more frequent meals), poor dentition may also be at risk of malnutrition, and could benefit from these snack food products. Ultimately, individuals on a texture-restricted diet would be able to enjoy snacks that resemble the original foods they are accustomed to, thereby addressing food memory issues and solving the problem of food craving.
The solid snacks (crisps) take the form of a transitional food, defined according to guidelines outlined by the International Dysphagia Diet Standardization Initiative (IDDSI) as a food that starts at one texture and that readily dissolves and changes states to another texture when combined with water or saliva. The solid SavoreaseTM snacks have a dense, crispy exterior shell. This crispy exterior was intentional so that it can be easily “grasped” without crumbling thereby allowing for self-feeding in those individuals with poor hand-mouth coordination. In addition, it is structurally robust enough to be eaten with a dip to obtain additional nutritional benefit, flavor diversity and calories. The crisp dissolves rapidly in the mouth to a puree consistency with minimal mechanical force (e.g., tongue pressure to palate or tongue propulsion).
The crisps comprise a foamed matrix reinforced by a water-soluble fiber-based material. The foamed matrix provides a protein-containing substrate upon which other components in the snack food composition bind. The water-soluble fiber-based material provides a lubricating effect that allows the snack food to dissolve in the mouth and to be swallowed, even with reduced saliva presence. The food product further comprises a viscosity-increasing component and a water-binding starch. In some examples, the food product additionally comprises one or more fat source, protein source, oil flavoring, and/or dry flavoring, which may contribute to the nutritional benefit, taste, and texture of the snack food.
The dips were developed to be used in combination with the chips to provide a full snack equivalent to Boost or Ensure puddings. The flavors of Mediterranean hummus and Cuban black bean were also chosen because of their high popularity in the U.S., their ethnic appeal and nutrient density. Their texture was altered for dysphagia standards and composition and packaging developed to allow shelf stability for up to 6 months.
The soups are dry mixes in a container with a water line to allow for portability, shelf stability and ease of preparation. The flavors chosen through focus group consultation, are typically those popularly believed to be nurturing and nostalgic.
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