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Thick, cheap and easy: fortifying texture-modified meals with infant cereal.


Patients requiring texture-modified meals, particularly those with dysphagia, were identified as being at high risk of malnutrition and aspiration. The innovative use of a common infant cereal as an iron-fortified thickening agent significantly improved food texture and increased iron content of pureed and minced meals by 57%, without any discernible change in flavour. These results are currently benefiting up to 33% of patients and can be directly applied to all areas where consumers require thickened, iron-rich texture-modified meals with minimal additional cost.

Key words: dysphagia, fortification, infant cereal, iron, malnutrition, texture modified.


To increase iron content and improve texture of modified meals for patients with dysphagia, in the most cost-effective manner. Our specific goals were to increase iron content by at least 50% and to thicken these foods to facilitate safer swallowing.


Malnutrition in hospitals remains an issue in Australia and other developed countries. (1-3) The costs associated with such malnutrition are significant and are borne by both the patient and health services. (1,4-7) Patients requiring texture-modified meals, especially the elderly and those with dysphagia, are at particular risk of malnutrition and aspiration. (8-13) With its role in oxygen transportation and antibody production, (14) iron is a mineral that plays a critical role in recovery and yet is one of the most difficult to ensure an adequate intake in hospitalised patients. (15,16) Iron has been highlighted as one of the affected key nutrients for the elderly, (16) particularly those with lower food intakes, (17) and for patients receiving texture-modified diets when actual consumption is considered. (18)

Routine monitoring of patient plate waste at Royal Prince Alfred Hospital (RPAH) and interviews with patients at Concord Repatriation General Hospital (CRGH) (19) (A. Singh, unpublished plate wastage survey at Concord Hospital, 2003) indicated that dysphagic patients typically have poor appetites and consequently lower nutrient intakes. Feedback from speech pathologists indicated that there were multiple issues regarding food textures affecting dysphagia management, which needed addressing to minimise the risk of aspiration in susceptible patients. These included inconsistent bolus formation, lack of bolus cohesion throughout the oral swallowing phase and lack of texture consistency across the entire diet range (see Table 1).


Several products were trialled for their ability to thicken and/or fortify texture-modified foods. These included skim milk powder and albumen (egg white powder) to increase protein, commercial fortified thickeners to increase micronutrients, waxy maize starch and xanthum gum to improve texture. Trial products were incorporated into the existing standardised recipes and trialled by staff in Food Services and Nutrition and Dietetics. Nutritional analysis was performed using 'FoodWorks Nutrition Labelling, Version 3, 2002, Xyris Software, Brisbane, Queesland'.

Problems identified in the initial trials included:

* The quantity of skim milk powder necessary for fortification displaced large quantities of food and other nutrients and altered the taste of the foods being fortified

* Albumen powder left a 'metallic' aftertaste, even when used in small quantities

* Waxy maize starch and xanthum gum could only be used to certain levels, after which they left a 'gluey' mouthfeel and affected food flavour

* Commercial fortified thickeners were based on egg, milk, wheat or a combination of these, significantly limiting the variety of texture-modified products suitable for allergic patients

A common rice-based infant cereal (Heinz Baby's First Rice Cereal, Heinz Watties Ltd, Hawthorn East, Victoria, Australia) was then trialled and found to offer the following benefits: high iron content, good thickening ability without affecting flavour, low allergen profile (egg-, dairy-, yeast- and gluten-free) and was cost-effective.

Existing standardised recipes were modified to include addition of the infant rice cereal in the cooking process. Initially, RPAH Food Services Department developed recipes for 28 pureed and minced meat dishes and nine varieties of pureed vegetables between March and July 2003. These were progressively evaluated by Food Services staff and the Speech Pathology and Nutrition and Dietetics Departments and were first introduced on the patient menu in August 2003. Further recipes have been developed and incorporated into the texture-modified menu since that time.


Iron content

Each meal analysed contained one serve of fortified minced or pureed main dish and two fortified pureed vegetables. Average iron content available from these meals increased by 57% for pureed and minced meals after fortification (Figure 1). This represents contributions of 2.69 mg of iron per meal before fortification and 4.22 mg of iron per meal after fortification for puree meals, and 2.62 mg of iron per meal before fortification and 4.11 mg of iron per meal after fortification for minced meals. If two hot meals are offered per day these would contribute 5.38 mg of iron per day for pureed meals without fortification and 8.44 mg of iron per day with fortification. For minced meals this would equate to 5.24 mg of iron per day without fortification and 8.22 mg of iron per day with fortification. Therefore, for both puree and minced diets, 100% of the recommended dietary intake for iron for both men and women over the ages of 51 years (20) can be offered with two hot meals when fortified with a common infant rice cereal.

The average amount of infant cereal added to the menu items to achieve these results were--2.3 g for minced main dishes (per 150 g serve size), 2.4 g for puree main dishes (per 150 g serve size) and 2.8 g for puree vegetables (per 60 g serve size).


Specific evaluation of texture changes was conducted by speech pathologists between March and August 2003. Nutrition and Dietetics and Food Services staff evaluated the foods for general acceptance criteria. Table 1 shows the results of this evaluation. Criteria evaluated included consistency of bolus formation, bolus cohesion throughout the oral swallowing phase and food texture consistency across the entire diet range. Figure 2 shows the visual texture difference of vegetables after thickening with infant rice cereal.

Consumer evaluation and implication for iron intake

The consumers in the present study were dysphagic patients. Routine monitoring of patient plate waste was undertaken in January and March 2004 (K.L. Ek and S. Zhang, unpublished student project: plate waste in texture-modified diets, 2004). When compared with earlier plate waste results, there was a slight but not significant, reduction in plate waste noted after fortification. This indicates that, although patient intake remained relatively constant, the iron intake would have increased because of the increased nutrient density of the fortified foods.


A number of dysphagic patients were also interviewed in 2004 and 2005 to evaluate the quality of the new textured meals. Given the very frail status of these patients, only 27 could be successfully interviewed between CRGH and RPAH. Of these patients, 74% stated they had poor appetites or required assistance with feeding. A summary of the feedback appears as follows and suggests overall satisfaction with the new meals considering the challenges posed in the management of patients requiring texture-modified meals:

* Seventy per cent stated that the meals would look better in smaller serve sizes whereas 22% felt nothing was needed to improve the look of the foods

* Seventy per cent stated they were able to eat all or some of the meals provided

* Fifty-two per cent stated that the texture was good and did not need further improvement

* Forty-eight per cent found the hot meals easier than, or the same as, the thickened drinks to swallow

* Of those patients who found the thickened fluids easier to swallow, half indicated that the 'dryness' of texture-modified meals was an issue in the management of their diet


Table 2 shows how the common infant cereal is 6.9 times more cost-effective when compared against the most readily available commercial fortified thickener in Australia.


Dysphagic patients generally have poor appetites, significant swallowing problems and are at high risk of malnutrition during hospitalisation. Therefore, the fortification and thickening of texture-modified foods is particularly appropriate. The use of a flavourless thickening agent has helped to achieve a texture that minimises the risk of aspiration for dysphagic patients. Most unfortified commercial thickeners displace vital nutrients and those commercial thickeners that are fortified pose the risk of excluding allergic patients from safely accessing texture-modified meals. Rice cereal is a low allergen product, and therefore has maintained the suitability of these meals for patients with allergies. Using a thickening agent that is also fortified is effective and efficient, achieving both fortification and a suitably thickened texture in a single processing step.

The new fortified recipes have been standardised and incorporated into the patient menu. All patients on soft, 'easy chew', minced and pureed diets across RPAH, CRGH and Canterbury Hospitals now receive meat and/or vegetables that have been thickened and fortified with infant cereal. Daily monitoring of food quality by senior RPAH Food Services staff indicates that these dishes have maintained their texture and appeal. Further positive feedback from patients and Speech Pathology staff, who observe the meals while assessing patients with dysphagia, supports this observation.

The infant cereal used is a readily available commercial product. Other papers have noted the use of unfortified rice cereal as a thickener (21,22) and infant cereal for thickening and fortifying fluids only. (9) However, it does not appear to have been previously considered for use as a thickener or fortification agent for adult food, as no documented record of such use in Australia or overseas could be found. As a result of this innovation, the iron content of these meals is now higher (per gram) than standard, unmodified meals and thus represents a new benchmark in nutritional best practice.

It is interesting to note the number of dysphagic patients who perceived the 'dryness' of their texture-modified meals as an issue. Several patients requested gravy to 'pour over' their meals, although using such large amounts of gravy was contraindicated by their dysphagia as this had the potential to 'thin down' the meal and create a swallowing risk. Speech pathologists within our Area Health Service permit the use of small (50 mL) amounts of gravy for patients with dysphagia, but do not permit patients to receive jugs, cups or bowls of gravy to pour over their meals if they are on thickened fluids. While appropriately thickened fluids are supplied with all meals, these results indicate a need for further research in the management of adequate hydration in diets for patients with dysphagia. Some hospitals are currently investigating the need to routinely provide patients with dysphagia with alternative means of hydration, such as intravenous fluids.


As the population continues to age, the incidence of dysphagia in Australia will also increase. As a result, more people will require foods that are nutritionally dense and texture-appropriate. At any one time, up to 7% of our hospital patients have dysphagia and up to 33% of total patients require texture-modified diets for a variety of reasons. Most of these patients are also at high risk of malnutrition and require considerable nutrition support. This innovation is therefore benefiting up to 33% of current patients and can be directly applied to all areas where consumers require thickened, iron-rich texture-modified meals with minimal additional cost. This includes:

* Health care, nursing homes, rehabilitation centres

* Meals on wheels, free-living individuals with similar dietary requirements, boarding hostels for disabled and mentally ill

* Child-care centres


The advice, assistance and cooperation of the following departments in this project were greatly appreciated: Food Services Department, Nutrition and Dietetics and Speech Pathology Services at RPAH and Concord Hospitals. We would also like to thank Peter Williams, Jenny Ravens and Nicole Gately for their assistance in the preparation of this paper.


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2 Middleton MH, Nazarenko G, Nivison-Smith J, Smerdley P. Prevalence of malnutrition and 12 month incident of mortality in two Sydney teaching hospitals. Intern Med J 2001; 31: 455-61.

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5 Chima CS, Barco K, Dewill MLA, Maeda M, Teran JC, Mullen KD. Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service. J Am Diet Assoc 1997; 97: 975-8.

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9 Phillip KEA, Greenwood CE. Nutrient contribution of infant cereals used as fluid thickening agents in diets to feed the elderly. J Am Diet Assoc 2000; 100: 549-54.

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11 Position of the American Dietetic Association. Nutrition, aging and the continuum of care. J Am Diet Assoc 1996; 96: 1048-52.

12 Wright L, Cotter D, Hickson M, Frost G. Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. J Hum Nutr Diet 2005; 18: 213-19.

13 Nowson CA, Sherwin AJ, McPhee JG, Ward JD, Flicker LF. Energy, protein, calcium, vitamin D and fibre intakes from meals in residential care establishments in Australia. Asia Pac J Clin Nutr 2003; 12: 172-7.

14 Drummond KE. Water and minerals. In: Nutrition for the Foodservice Professional, 2nd edn. New York: Nostrand Reinhold, 1994; 149.

15 Todd EA, Hunt P, Crowe PJ, Royal GT. What do patients eat in hospital? Hum Nutr Appl Nutr 1984; 38: 294-7.

16 Thomas AJ, Bunker VW, Brennan E, Clayton BE. The trace element content of hospital meals and potential low intake by elderly patients. Hum Nutr Appl Nutr 1986; 40: 440-46.

17 Drewnowski A, Shultz JM. Impact of aging on eating behaviors, food choices, nutrition and health status. J Nutr Health Aging 2001; 5: 75-9.

18 Johnson RM, Smiciklas-Wright H, Soucy IM, Rizzo JA. Nutrient intake of nursing-home residents receiving pureed foods or a regular diet. J Am Geriatr Soc 1995; 43: 344-8.

19 Williams P, Kokkinakos M, Walton K. Definition and causes of hospital food waste. Food Serv Technol 2003; 3: 37-9.

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21 Cassens D, Johnson E, Keelan S. Enhancing taste, texture, appearance, and presentation of pureed foods improved resident quality of life and weight status. Nutr Rev 1996; 54: S51-4.

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Suzanne KENNEWELL (1) and Maria KOKKINAKOS (2)

(1) Food Safety, QI and Training Unit, SSWAHS (East), Royal Prince Alfred Hospital Food Services Department, and (2) Sydney South West Area Health Service, Camperdown, New South Wales, Australia

S. Kennewell, MND, APD, Manager Food Safety & QI Unit

M. Kokkinakos, DipNutrDiet, APD, Director Area Food Services

Correspondence: S. Kennewell, Food Safety, QI and Training Unit, SSWAHS (East), Royal Prince Alfred Hospital Food Services Department, Missenden Road, Camperdown, NSW 2050, Australia. Email:

Heinz Wattie's Limited, maker of Heinz Baby's First Rice Cereal, has not been involved in any aspect of this project. All supplies of this product have been purchased independently by RPAH Food Services through-State Government Contract suppliers.
Table 1 Evaluation of texture changes after thickening with infant

 Before thickening After thickening with
 with infant cereal infant cereal

Criteria for suitability for
 dysphagic patients
 Single texture within each No Yes
 food at all times (no
 separation on standing)
 Bolus formation consistent No Yes
 Bolus cohesion maintained No Yes
 through oral swallowing
 Food texture consistency No Yes
 across each diet range
General criteria
 Visual presentation Runny, mixed Smooth texture, firmer
 textures appearance
 Flavour Baseline standard No discernible change
 Colour Baseline standard No visible change

 Iron content (mg)
 Before After
 fortification fortification

Puree meals 2.69 4.22
Minced meals 2.62 4.11

Figure 1 Changes in average iron content per meal after fortification.

Note: Table made from bar graph.

Table 2 Relative cost-effectiveness of infant cereal as an iron-
fortified thickening agent

Indicator Infant cereal (a) thickener (b)

Average additional cost/day $0.235 $1.61
Average additional iron/day 3.02 mg 2.52 mg
Allergen status Egg-free, milk-free, Contains egg, milk,
 gluten-free, yeast- wheat, yeast

Indicator Difference

Average additional cost/day Infant cereal is 6.9 times cheaper
Average additional iron/day Infant cereal provides 20% more iron
Allergen status Infant cereal is less allergenic

(a) Heinz Rice Cereal.
(b) Puree Appeal (Novartis Nutrition, Minneapolis, MN, USA).
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Title Annotation:INSIGHT
Author:Kokkinakos, Maria
Publication:Nutrition & Dietetics: The Journal of the Dietitians Association of Australia
Date:Jun 1, 2007
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