The Journal of Nutrition, Health & Aging©

Volume 15, Number 3, 2011

FOOD CONSUMPTION AND TEXTURE IN NURSING HOMES

ANALYSIS OF THE FOOD CONSUMPTION OF 87 ELDERLY NURSING HOME

RESIDENTS, DEPENDING ON FOOD TEXTURE
A. MASSOULARD1, H. BONNABAU2,3, L. GINDRE-POULVELARIE1, A. BAPTISTEV, P.-M. PREUX2,3,
C. VILLEMONTEIX1, V. JAVERLIAT1, J.-L. FRAYSSE1,4, J.-C. DESPORT1,2,5
1. LINUT nutrition network (Limousin Nutrition personnes âgées); 2. EA 3174, Faculty of Medicine, Limoges, France; 3. Biostatistics Unit, University Hospital, Limoges, France;
4. SADIR Assistance, Toulouse; 5. Nutrition Unit, University Hospital, Limoges, France. Address for correspondence: Pr JC Desport, unité de nutrition, Hôpital Universitaire Dupuytren,
87042 Limoges cedex, France; e-mail: nutrition@unilim.fr

Abstract: Objectives: Texture–modified food (chopped, mashed, or mixed) is often used for patients, and
particularly for dependent elderly people facing swallowing disorders or dental problems. Food must be
energy and protein enriched, because dilution is needed for preparation, and several meals like bread can be
removed. The aim of the study was to assess the food consumption of residents in four French nursing
homes depending on diet texture. Design/Participants/Measurements: The food consumption of 87 elderly
people followed by a nutrition network, randomly taken and living in nursing homes in which texture-
modified food enrichment was practiced was evaluated according to the type of texture used. Results:
13.8% of residents had chopped texture and 29.9% mixed texture. There was no relationship between used
food textures and nutritional status residents. Calorie consumption was below the recommended intakes for
elderly nursing home residents in France, whatever the type of texture. The mixed texture had more protein
than the normal one and was better balanced regarding fat intake. Protein consumption was at the lower
limit of the recommended intakes. Residents in overweight were those whose food consumption relative to
their weight was the lowest. Conclusion: It seems important to check the mode of preparation of
texture–modified food in nursing homes and to assess the real energy and protein consumptions of residents
receiving this food.

Key words: Nutrition, elderly, nursing home, texture.

Non standard abbreviations: HHA: High Health Authority; FFA: French Food Agency.

Introduction and objectives
For medical reasons, as well in hospitals as in elderly
institutions, the feeding can be achieved using modified textures
(mashed, chopped, mixed, semi-fluid or smooth). It is the case
for neurological or otorhinolaryngological diseases when people
face swallowing disorders or oral dental problems (1, 2). These
diseases are common in nursing homes. However, a dilution is
needed to prepare food, especially mixed food, which can lead
to a drop in energy and protein densities, vitamins, trace
elements and minerals. Furthermore, in the mixed diet, bread
and raw vegetables may be limited or eliminated, which is one
more risk of lower intakes or food imbalance. An enrichment of
the texture-modified food is then usually recommended, at least
in energy and protein (2). However no data is available from
French nursing homes. The main objective of the study was to
assess the actual food consumption of residents in nursing
homes depending on the texture of their diet: normal, chopped
or mixed, in order to know if modified textures could achieve
energy and proteins needs of residents.
Methods
Food consumption of 87 residents living in four nursing
homes located in the French region of Limousin was evaluated
by a nutrition network. All institutions had signed with the
Received October 6, 2009
Accepted for publication August 8, 2010
network an informed convention for care and studies on
residents. All residents or their relatives gave their informed
consent to nutritional assessments. All residents had chewing
and/or swallowing difficulties. Institutions reported that they
practiced an enrichment of texture-modified food. Food
consumption was randomly measured in relation with the
texture of food. It was made either with residents who had a
nutritional identified disease (malnutrition or overweight), or as
part of another study of food consumption. Enriched
preparations data sheets were provided by the food sectors.
Statements were made by dieticians by the technique of
weighing the food consumption during 24 hours or were done
by a diet survey completed by the care staff, thanks to semi-
quantitative reading grids based on the recommendations of the
French National Nutrition and Health Plan (3). The data were
processed by the Bilnut® software (IUT Tours, France),
computing calorie and protein intake, and the percentages of
protein, fat and carbohydrates in the food consumed. The
residents were weighed in underwear with an electronic scale,
and their size measured using either a height gauge or Chumlea
et al. formulas from their knee height (4). The Body Mass
Index (BMI) was calculated along with the variation of the
weight of residents. The Mini Nutritional Assessment (MNA®)
was achieved (5). The malnutrition criteria were the French
criteria from the High Health Authority (HHA) of 2007, using
BMI, MNA® and loss of weight (6). Patients were considered
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The Journal of Nutrition, Health & Aging©
Volume 15, Number 3, 2011
JNHA: NUTRITION
malnourished when BMI was <21 or weight loss >= 10% in six
months or 5% in one month, or global MNA® was <17 (global
MNA® was performed when short-form MNA® was <11),
normal when BMI was 21-29.9, obese when, in the absence of
malnutrition (according to previous weight loss criteria), BMI
was >= 30. The variables were described by their mean +/-
standard deviation for quantitative values, and by numbers and
percentages for qualitative variables. Student’s test, analysis of
variance followed by a post hoc test of Tukey, Mann Whitney’s
and Kruskal-Wallis’ tests were used for quantitative variables
according to the normality of distributions. For qualitative
variables, the Chi2 test or Fisher's exact test were chosen based
on the theoretical number. Statistical analysis was performed
with SAS software (version 9.1.3, SAS Institute, Cary, USA).
Statistical significance was assessed at the p= 0.05 level.
Results
75.9% of the 87 residents surveyed were women and 24.1%
were men. Their mean age was 85.8+/-9.3 year old, weight
66.5+/-18.7 kg, BMI 26.8+/-6.5, weight variation 1.0+/-7.2%,
short-form MNA® 9.3+/-2.8 and global MNA® 18.4+/-3.8.
Each criterion was obtained for all residents, except for weight
variation (n=80) and global MNA® (n=51). Weight variation
was 5.5+/-5.7% for malnourished residents and -3.4+/-6.5% for
obese residents. 56.3% of the residents consumed a normal
texture food, 13.8% had a chopped texture and 29.9% a mixed
one. Only nine residents (29.0% of obese patients) were
presumed to receive a low-calorie diet because of excessive
weight gain, and consequently the other ones were presumed to
receive a diet with normal calorie intake, or high-calorie food
for the malnourished residents. Levels of food consumption
were obtained in 43.7% of cases by weighing technique and in
other cases by food grids, for practical reasons. 25.3% of
residents were malnourished, 35.6% were obese. Only one
resident with BMI > 30 was considered malnourished because
he experienced a recent excessive weight loss. There was no
relationship between the texture of the food consumed and the
nutritional status of the residents (p=0.30, table 1). Food
consumption results are presented in table 2. There was no
difference (p=0.86) beyond texture groups as regards the
caloric intake relative to weight. However, there were
significant differences beyond texture groups for protein
intakes: mixed meals protein intakes were higher than those of
normal meals (in g/kg/d, p=0.03; in % of the total energy
contribution p<0.0005). There was also a significant difference
according to the texture group for daily fat intake as a
percentage, which were lower for the mixed flows versus
normal intakes (p<0.05).
Concerning intakes according to the nutritional status (Table
2) the more the residents were overweight, the more the inputs
were low for both energy (p<0.0001) and protein intakes
(p<0.0001). The comparisons two by two showed a higher
energy intake (kcal/kg/d) in malnourished than normally-
nourished and obese residents (p=0.001 and p<0.0001
193
respectively), a higher protein intake (g/kg/d) in malnourished
than obese residents (p<0.0001) and higher energy and protein
intakes in normally-nourished than obese residents (p<0.007
and p=0.011 respectively). Energy consumption and protein
intakes of obese residents, after exclusion of the nine residents
with therapeutic hypocaloric diet, were close to the global
results (21.4+/-3.9 kcal/kg/d and 0.8+/-0.1 g/kg/d respectively),
without any change in statistical comparisons.
Table 1
Nutritional status of residents according to the texture of food.
The relationship is not significant
Normal texture Chopped texture Mixed texture
(number; %) (number; %) (number; %)
Malnutrition 15; 68.2% 1; 4.5% 6; 27.3%
Normality 15; 44.1% 6; 17.6% 13; 38.3%
Obesity 19; 61.3% 5; 16.1% 7; 22.6%
An additional analysis was made by comparing the
populations according to the manner of dietary intake collection
(weighed food versus food survey by the care staff). There was
no significant difference for the age, gender, weight, BMI and
short-form MNA, nor for the main criteria of food consumption
(caloric intake and protein intake per kg per day, respectively
p=0.56 and p=0.67). However there were differences for the
raw values, which were higher when weighing the food for total
calories (p=0.01), total protein (p=0.03), fat percentage
(p<0.0001) and lower for carbohydrate percentage (p<0.0001).
Discussion
This study is related to nutritional value of texture-modified
food, frequent in clinical practice, with potentially large
consequences on elderly nutritional status, but rarely studied in
Europe. In the nursing homes explored, texture-modified food
was frequently used since 43.7% of the residents were receiving
it. Mixed food was used in ≈30% of cases. Surveyed residents
were old (85.8+/-9.3 years) and mainly women (76%), in
accordance with a study performed in 2007 on 1550 residents in
67 elderly nursing homes from various regions of France
(population 86+/-8 years old, 76% women) (7), and with a 2005
study in 36 elderly nursing homes in the French region of
Aquitaine (age 85+/-9 y, 75% women) (8). As regards
nutritional status, the present study has an over-representation
of undernourished patients compared to the Aquitaine study
(15% of malnutrition with the MNA) (8), but is very near from
the 67 nursing homes study (27%, using the BMI and weight
loss) (7). The difference with the Aquitaine study may be
explained by both the method of recruiting the residents of the
current study, favouring residents with nutritional disorders,
and the different nutritional tools used. Indeed, Crogan and
Pastvogel showed in 2003 a malnutrition prevalence of 39% in
a population of 311 elderly nursing home residents in USA (9),
and even higher percentages have been reported, until 85%,
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FOOD CONSUMPTION AND TEXTURE IN NURSING HOMES

Table 2
Levels of food consumption for residents depending on the texture of food and nutritional status. For texture, there is no difference
as regards the caloric intake, but significant differences for protein intakes: mixed meals protein intakes are higher than normal
meals (in g/kg/d, §p=0.03; in % §§p<0.0005), and for daily fat intake as a percentage, which are lower for the mixed than for
normal meals (§§§p<0.05). For nutritional status, the more the residents were overweight, the more the inputs were low for both
energy (in kcal/kg/d; p<0.0001) and protein intakes (in g/kg/d; p<0.0001) (global comparisons)

Energy intake Energy intake Protein intake Protein intake Protein intake Fat intake (%) Carbohydrate
(kcal/d) (kcal/kg/d) (g/d) (g/kg/d) (%) (%) intake (%)

Total of residents 1607.8 +/- 396.0 25.7 +/- 8.7 65.1 +/- 15.9 1.0 +/- 0.4 16.6 +/- 3.3 36.2 +/- 6.6 46.2 +/- 6.5
Normal texture; n=49 1627.0 +/- 447.1 25.4 +/- 8.3 62.4 +/- 16.8 1.0 +/- 0.3 15.5 +/- 2.5 37.8 +/- 6.9 45.5 +/- 7.2
Chopped texture; n=12 1764.3 +/- 283.2 25.0 +/- 10.9 69.7 +/- 10.2 1.0 +/- 0.4 16.9 +/- 3.5 33.8 +/- 6.1 48.0 +/- 5.5
Mixed texture; n=26 1499.2 +/- 308.8 26.4 +/- 8.5 68.0 +/- 15.7 1.2 +/- 0.4§ 18.4 +/- 3.5§§ 34.3 +/- 5.4§§§ 46.7 +/- 5.2
Malnouri-shed residents 1426.2 +/- 375.2 33.1 +/-10.4 54.2+/-16.2 1.3+/-0.5 15.5+/-3.2 35.8+/-7.0 48.3+/-66
n=22
Normo-nourished 1645.0 +/- 366.4 25.8 +/- 6.7 67.6+/-15.8 1.1+/-0.3 16.6+/-2.9 35.9+/-6.6 46.1+/-6.6
residents n=34
Obese Residents n=31 1697.4 +/- 413.0 20.3 +/- 4.3 70.1+/-11.9 0.8+/-0.2 17.3+/-3.6 36.9+/-6.3 44.8+/-5.9

depending on chosen evaluation methods and on the study
centre (10, 11). Over-representation of obese patients (35.6%
versus 16% in the 67 nursing homes study (7)) can be linked to
the recruitment method, but it is known that the prevalence of
obesity residents in elderly nursing homes in USA is likely to
exceed 20% (12, 13), and that it increases significantly over
time (13). Consequently, our results suggest that the problem
could be similar in France, and that further studies on this topic
are necessary.
The percentages of residents with texture–modified food
(13.8% with chopped texture, 29.9% with mixed texture) were
close to percentages of the 67 nursing homes study, in which
17% of residents had chopped texture, and 23% mixed texture
(7), suggesting that results may reflect the general distribution
in French nursing homes and that texture–modified diet is
usually used.
The lack of relationship between food textures and residents
nutritional status is not in accordance with the 67 nursing
homes study, in which malnutrition risk is 1.7 times higher for
residents with mixed food relative to normal texture food (7).
However, the modified texture diets were not necessarily
enriched in this study, unlike the current one. Moreover,
the low number of residents in certain groups of our study
leads to a lack of potency of the statistical tests on this subject
(Table 1).
It is well known that the food consumption collection
method can lead to assessment errors (14), like an
overestimation of patients consumption by care staff (15). In
our study, the main criteria of population and calorie or protein
consumptions were not different depending on collection
methods, suggesting a good reliability of these criteria. The
best solution may have been weighing the total daily food
consumption for all residents, but it has not been done, for
dieticians’ availability reasons. For the whole population,
calorie consumptions were much lower (25.7+/-8.7 kcal/kg/d)
than 30-40 kcal/kg/d intakes recommended in 2009 by the
French Food Agency (FFA) (16). As shown by table 2, the
194
more the residents were overweight, the more energy and
protein intakes per kg per day were low, indicating that the
possible over-representation of undernourished residents did
not explain the low level of food consumption. An insufficient
energy consumption and/or a low protein consumption have
been reported several times on residents in nursing homes (10,
16-18). When consumptions are quantified, they are closed to
the current study ones: Bouchiche et al. noted among 195
residents of French nursing homes an energy intake of 27.0+/-
6.7 kcal/kg/d and a protein intake of 0.9+/-0.3 g/kg/d (18). As
shown in the FFA 2009 report on nutritional needs of older
persons (16), these low levels are more frequent than thought,
and may keep a balance weight to the elderly because they have
very reduced physical activity. However, it is likely to expose
many people to deficiencies, and therefore the
recommendations for the frail elderly remain in France between
30 and 40 kcal/kg/d for energy needs, and >=1 g/kg/d for
protein needs (6, 16, 19), in conformity with the 2005 advice of
the French Food Council on the elderly needs (20).
Despite protein intakes were at the lower limit
recommendation (1.0+/-0.4 g/kg/d), it seems that mixed
textures were protein enriched. The lower fat intake may be
explained by the abolition or reduction of some normal meal
components, as often suggested by daily practice in institutions.
However, this low fat intake is more in accordance with a
healthy balance of nutrients.
The very low consumption levels in obese population are not
explained by a therapeutic limitation of intakes, because
exclusion of residents with hypocaloric diet does not change
significantly the levels. This result, not been previously
described, underlines the malnutrition risk among overweight
elderly, whether as regards an insufficient protein-energy
intake or micronutrient deficiencies. It could participate to
create sarcopenic obesity, which seems to be more and more
present on the elderly, and would have detrimental effects in
these populations (21). However, without any consensus on the
food needs in relation to weight in obese elderly people,
The Journal of Nutrition, Health & Aging©
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JNHA: NUTRITION
interpretation of these results must remain modest. It would be
better to relate the food consumption to fat-free mass, but even
with the impedance measurements which have been proposed
(21), fat-free mass is difficult to assess in elderly nursing
homes.
In conclusions, the texture-modified diet was common in the
nursing homes studied. The residents’ nutritional status is not
related to the food texture type. Whatever the food texture,
energy consumption was lower than the recommendations and
protein consumption just enough. These abnormalities did not
appear related to the data collection method and drew attention
to the risk of inadequate dietary intake in French nursing
homes. The mixed texture had more protein than the normal
one and was better balanced regarding fat intake. Mixed texture
consumption limited the deficit of protein intake but had no
effect on energy deficit, suggesting that implementation of
modified textures should be considered carefully in nursing
homes. The more the residents were overweighed, the more
their energy and protein consumptions were low. This might
suggest that overweighed residents should be closely
monitored, with a necessary look at their nutritional needs.
Grants and conflict of interest: None.
Statement of authorship: All authors contributed to this article; AB, AM, LGP, CV, VJ
and JCD drafted the manuscript, HB, PMP and JCD participated to analysis and
interpretation of data, PMP, JLF and JCD participated in the manuscript revision. All
authors read and approved the final manuscript.
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