ABSTRACT
Introduction
Texture modified foods are recommended for people with dysphagia but the visual appeal and nutritional quality of the foods may be reduced through modification. Moulding pureed foods back into their original shape rather than serving as a scoop in a ramekin may improve the visual appeal of texture modified foods, and their intake. The current study describes the cost, nutritional composition, intakes and satisfaction of two methods for preparing and serving texture modified meals in hospital, one cooked‐fresh and scooped in ramekins and one commercially prepared and moulded.
Methods
Data on patient nutritional intakes and adequacy of energy and protein were collected retrospectively from two cohorts of patients receiving texture modified foods in hospital using data recorded in the electronic menu management system and compared to theoretical nutrition requirements calculated based on height and weight. The first cohort (n = 120) were served texture modified meals made on‐site, served in ramekins. The second cohort (n = 152) were served externally sourced commercially prepared, moulded food items.
Results
Overall, we found the externally sourced commercially‐prepared, moulded meals to be more nutrient dense and approximately 10% more expensive than cooked‐fresh, scooped meals, but there were no differences in nutritional intakes between the two cohorts (with patients meeting 43%–47% of energy requirements and 55%–59% of protein requirements). Patient satisfaction reports appeared to favour the commercially‐prepared meals.
Conclusion
Our findings suggest that for a 10% increase in cost, an externally sourced commercially prepared, moulded texture modified meal can deliver a more energy dense product though significant improvements in intakes of energy and protein were not achieved.
Keywords: food service, hospital, moulded, nutrition, protein, texture modified
Summary
Commercially prepared, moulded texture‐modified meals may improve energy and protein density and patient satisfaction compared with cooked‐fresh, scooped meals served in ramekins.
Increased nutrient density alone may not translate into improved energy and protein intake, with patients in both cohorts meeting less than half of estimated energy requirements and around half of protein requirements.
Food Services should consider appearance, nutritional composition, patient acceptability and cost together for texture modified food items, while continuing to use strategies beyond meal presentation to support adequate intake in hospital patients with dysphagia.
1. Introduction
Dysphagia is common among adults in both the community and in healthcare settings. Approximately 15% of older adults living in the community, 37% of adults in hospital, 43% of adults in rehabilitation centres and 50% of adults in aged care experience dysphagia [1, 2]. Dysphagia is a well‐recognised risk factor for malnutrition [3], with estimates that approximately 50% of hospital inpatients with dysphagia are malnourished [4]. Aged care residents with dysphagia eat less of their meals, are more likely to be underweight and are more likely to be dehydrated compared to their fellow residents who do not experience dysphagia [5].
Modifying the texture of the food is recommended for people with dysphagia to ease swallowing and prevent choking [6]. However, the nutritional quality of texture modified foods may be limited by the modification process and may be less acceptable to those requiring them [7]. An analysis of nutrient provision by diet type of meal tray in an aged care facility suggested that the pureed meal tray had approximately 500 fewer calories and 7 g fewer protein than the regular tray [8]. Moreover, those who require a texture modified diet waste a lot of their plate, with research suggesting that only half of residents requiring texture modified meals eat their entire meal [9]. In hospital settings, plate waste for texture modified meals has been documented to range from 56% to 65% for lunch and dinner depending on the level of modification [10], higher than the average of 30% in hospital settings more generally [11]. This may be due, in part, to the lack visual appeal of these meals. Modifications may result in a loss of vibrancy of colour and rendering the food unrecognisable once it has been mince/pureed [12].
Recent innovations in food science have resulted in novel methods for improving the visual appeal of texture modified foods. One such innovation involves moulding pureed foods back into their original shape rather than serving as a scoop in a ramekin. A pilot study trialling moulded texture modified meals in the hospital setting found that when served the meals in the moulded form, mean plate waste appeared lower for the moulded meals than the scooped meals, but due to the small sample sizes these findings did not reach statistical significance [13]. Similarly, residents eating enriched moulded texture modified foods in the aged care setting consumed more energy and protein than when eating their usual, pureed meals [14]. Though, because of the study design, it cannot be determined if the effects were attributable to the enrichment, the moulding of the foods, or both.
The current study adds to what is currently known about the potential for moulded, texture modified foods to enhance patient intakes and experience in the hospital setting. The current study describes the cost and nutritional composition of two methods for preparing and serving texture modified meals, one cooked‐fresh and scooped in ramekins and one commercially prepared and moulded. The current study will also compare patient intakes of energy and protein, plate waste and meal satisfaction when consuming the two meals.
2. Materials and Methods
The study took place at Mater Health, South Brisbane, a multi‐facility healthcare campus comprising approximately 800 hospital patient beds, both publicly and privately funded, in South Brisbane, Australia. Foodservices at this campus offer a cook‐fresh, room service model to all patients. Prior to April 2023, all texture modified meals were cooked‐ fresh. Meals at Level 4 and 5 (pureed and minced and moist) of the International Dysphagia Diet Standardisation Initiative (IDDSI) were modified with additional gravy or water to achieve correct texture and scooped and served in ramekins on the patient tray. No fortifiers were added. In April 2023, the facility initiated a trial, replacing the in‐house cooked‐fresh, scooped texture modified meals with an externally sourced commercially prepared, moulded product for the protein and vegetable components of the dish (https://smoothdining.com.au/) The meals are moulded into shapes resembling the foods they represent and do not contain any fortifiers. The protein components are made from 100% protein and the vegetables have vegetable gum added. Neither product requires any gravy or water to added to be processed to the correct consistency and therefore the nutritional content is not diluted. Photos of exemplar meals for both methods of preparation are available in Figure 1. The starch component (mashed potato or mashed sweet potato) continued to be made in‐house. No other changes were made to the menu during this transition.
Figure 1.
Photographs of example texture modified meals served. Left displays the meal that was cooked‐fresh and scooped in a ramekin. Right displays the externally sourced commercially‐prepared moulded meal. Both meals contain a meat, green vegetable, orange vegetable, starch and gravy.
Data for the current study were collected retrospectively from two cohorts of patients receiving one of the models of production of texture modified foods. The first cohort included all patients in hospital between January and March 2023 who had a diet code specifying Levels 4 or 5 (pureed or minced and moist); these patients were served texture modified meals made on‐site, served in ramekins. The second cohort of patients included all patients in hospital between February and April 2024, with the same diet codes; these patients were served the externally sourced, commercially prepared, moulded food items. These two cohort timelines allowed for comparisons at approximately similar times of the year and allowed for a settling in period for implementing the new texture modified food products. Patients from both cohorts were excluded if they had less than one complete day of intake data or if they were under 18 years old. The Mater Human Research Ethics Committee reviewed and approved the study protocol as low to no risk research. Patient consent was waived as the study is retrospective (dietary intake data), draws on routinely collected data (intake data and patient satisfaction with meals data) and poses no risk to patients.
All data were extracted from CBORD (Ithaca, NY), a foodservices application. CBORD includes data on patient characteristics including date of birth, gender, and admitted ward (used to determine clinical area) which it pulls from upstream patient administration systems, and height and weight which is manually added by dietetic assistants as part of routine malnutrition screening. It also contains the nutritional composition of all meals, meal cost, patient meal orders and proportion of meal consumed. The latter is assessed by foodservice assistants who, at the time of collecting patient trays, do a visual estimation of what proportion of each meal item has been consumed (0%, 25%, 50%, 75%, or 100%). This method has been validated against weighed food records for estimating energy and protein intakes [15]. Nutritional intake is calculated within CBORD by comparing the proportion of meal consumed to the nutritional content of the meal. Plate waste is calculated as 100% minus the proportion of the meal consumed, then averaged by patient. Up to three continuous days of intake were averaged to estimate energy intake (kJ) and protein intake (g) to give a better indication of overall intakes while in hospital. In addition, the intake of the protein and vegetable component of main meals were analysed separately as these were the key items that were changed.
Age was calculated using date of birth compared to date of data collection. Nutritional requirements for energy and protein were estimated by applying moderately hyper‐metabolic requirements for the population, with energy requirements of 125 kJ per kg of body weight and protein requirements of 1.2 g per kg [16]. The proportion of requirements met for energy and protein were calculated by dividing energy intake (kJ) or protein intake (g) by the respective requirement.
The labour cost of producing the cooked‐fresh, texture modified meal on site was estimated by calculating the time allocated to preparing texture modified foods in the allocated shift at the specified hourly rate, divided by the average number of texture modified meals ordered per day. This cost was then added to the food cost of the items in the recipe. All other labour costs associated with ordering, plating and delivering was not allocated to either product, as this is attributed to the usual running costs of the food service. The total food cost and labour cost of the in‐house, cooked‐fresh texture modified meal was compared to the purchase price of the commercially made, moulded meal.
Mealtime satisfaction was assessed using the Meal Assessment Tool [17], which assesses taste and flavour, appearance, and quality of three meal components (protein, carbohydrates, and vegetables). Response options included a 7‐point Likert scale ranging from “1 very poor” to “7 excellent”. For analyses, responses were dichotomised at above average (scores 5–7). The survey was completed by the patient using pen and paper or by interview with a dietitian where support was needed; data on patient characteristics (age, gender) is not routinely collected as part of this tool. Patients were not eligible for the meal satisfaction survey if they had significant cognitive decline as identified by nursing team, were on contact precautions, if they were palliative or if they did not speak English. The research team aimed to reach 60 patients in each cohort for the patient satisfaction survey, but this was not possible to achieve (surveying 30 in total across the two cohorts) as the number who were ineligible (n = 57) was higher than expected, two patients declined (n = 2) and due to time limitations the rest could not be reached.
2.1. Analyses
Data were analysed using Stata v16.1 (StataCorp, College Station, TX). Patients characteristics (age, gender, clinical area, and BMI) were analysed descriptively (percents and means). To determine if characteristics of patients differed between cohorts, Chi‐square tests (gender, age group, clinical area) and independent t‐tests (age and BMI) were calculated. Means and 95% confidence intervals were generated for energy intake, protein intake and for the percentage of requirements met for energy and protein. Last, multiple linear regression models were generated to determine if differences in nutritional intake differed between cohorts, while controlling for any patient characteristics that differed by cohort (age). All differences were considered statistically significant at p < 0.05. Mealtime satisfaction, nutritional composition of meals and cost data were analysed descriptively using Excel.
3. Results
Cost and nutritional composition of the two meals are described in Table 1. The externally sourced commercially‐prepared, moulded meals were approximately 10% more expensive per serve and 28% more expensive per 100 g than the cooked‐fresh meals. It appears that increased price per serve was largely driven by the vegetable components of the meal (18% more per serve with similar serve sizes). The protein components of the externally‐sourced moulded meals were more expensive per 100 g (30%–86% more), but the serve size was smaller than the cooked‐fresh meals (50 g less per serve). Overall, the energy content of the two meals per serve appeared similar (within 300 kJ of comparable meal), but the commercially‐prepared, moulded meal was nearly 20% more energy dense than the in‐house cooked‐fresh, scooped meal (534 kJ per 100 g vs. 452 kJ per 100 g, respectively). The protein components showed marked variability of energy density with the externally‐sourced moulded beef having nearly twice the energy per 100 g as the cooked‐fresh beef (1140 kJ vs. 572 kJ per 100 g, respectively) and the externally‐sourced moulded pork having approximately 10% less energy per 100 g than the cooked‐fresh pork. On average, both the cooked‐fresh meal and the externally‐sourced moulded meals provided approximately 30 g of protein per serve. The amount of protein provided per serve from pork and beef were similar in the two options, but the externally‐sourced moulded chicken provided 9.5 g less protein per serve than the cooked‐fresh meals.
Table 1.
Estimated cost and nutritional composition of cooked‐fresh, scooped and externally sourced commercially‐prepared, moulded texture modified meals.
| In‐house cooked‐fresh, scooped | Externally sourced commercially‐prepared, moulded | |||||
|---|---|---|---|---|---|---|
| Serving size (g) | per serve | per 100 g | size (g) | per serve | per 100 g | |
| Cost ($) | ||||||
| Total Meal1 | 350 | $4.82 | $1.38 | 300 | $5.28 (+9.5%) | $1.76 (+27.5%) |
| Protein component | ||||||
| Pork | 150 | $3.06 | $2.04 | 100 | $3.27 (+6.9%) | $3.27 (+60.3%) |
| Chicken | 150 | $2.77 | $1.85 | 100 | $2.40 (−13.4%) | $2.40 (+29.7%) |
| Beef | 150 | $3.11 | $2.07 | 100 | $3.85 (+23.8%) | $3.85 (+86.0%) |
| Starch component | 80 | $0.37 | $0.46 | 80 | $0.37 | $0.46 |
| Vegetable component | ||||||
| Orange vegetable | 60 | $0.69 | $1.15 | 70 | $0.81 (+17.4%) | $1.16(+0.9%) |
| Green vegetable | 60 | $0.78 | $1.30 | 60 | $0.93 (+19.2%) | $1.54 (+18.5%) |
| Energy (kJ) | ||||||
| Total meal | 350 | 1584 (1542–1636) | 452 | 300 | 1603 (1245–1938) | 534 |
| Protein component | ||||||
| Pork | 150 | 764 | 509 | 100 | 447 | 447 |
| Chicken | 150 | 795 | 530 | 100 | 831 | 831 |
| Beef | 150 | 858 | 572 | 100 | 1140 | 1140 |
| Starch component | 80 | 415 | 519 | 80 | 415 | 519 |
| Vegetable component | ||||||
| Orange vegetable | 60 | 104 | 173 | 70 | 121 | 173 |
| Green vegetable | 60 | 259 | 432 | 60 | 262 | 436 |
| Protein (g) | ||||||
| Total meal | 350 | 31.4 | 9.0 | 300 | 30.2 | 10.1 |
| Protein component | ||||||
| Pork | 150 | 19.7 | 13.2 | 100 | 19.6 | 19.6 |
| Chicken | 150 | 28.3 | 18.8 | 100 | 18.8 | 18.8 |
| Beef | 150 | 21.7 | 14.4 | 100 | 23.2 | 23.2 |
| Starch component | 80 | 1.9 | 2.4 | 80 | 1.9 | 2.4 |
| Vegetable component | 0.0 | 0.0 | ||||
| Orange vegetable | 60 | 1.1 | 1.8 | 70 | 1.9 | 2.7 |
| Green vegetable | 60 | 5.2 | 8.7 | 60 | 5.8 | 9.7 |
Meal Cost for the in‐house cooked‐fresh product is based on cost associated with the ingredients plus labour to produce the product. Meal Cost for the externally sourced, commercially prepared moulded food products is calculated on purchase price.
In total 120 patients met the inclusion criteria for the cohort served the in‐house cooked‐fresh, scooped texture modified meals and 152 in the cohort for the commercially‐prepared, moulded texture modified meals. Patient characteristics for both groups are presented in Table 2. Patient characteristics for both groups were similar for gender, clinical area, and BMI. Patients receiving the commercially‐prepared, moulded meals were older (77.9 years vs 74.2 years; p = 0.04) than those receiving the in‐house cooked‐fresh, scooped meals.
Table 2.
Characteristics of patients in each cohort.
| In‐house cooked‐fresh, scooped | Externally sourced commercially‐prepared, moulded | p value1 | |||
|---|---|---|---|---|---|
| n | % or mean | n | % or mean | ||
| Total | 120 | 152 | |||
| Gender | |||||
| Female | 58 | 48.3% | 87 | 57.2% | |
| Male | 62 | 51.7% | 65 | 42.8% | 0.14 |
| Clinical area | |||||
| Medical | 53 | 44.2% | 78 | 51.3% | |
| Oncology | 29 | 24.2% | 27 | 17.8% | |
| Surgical | 17 | 14.2% | 15 | 9.9% | |
| Other | 21 | 17.5% | 32 | 21.1% | 0.32 |
| Age Group | |||||
| < 50 years | 12 | 10.0% | 13 | 8.6% | |
| 51–70 years | 29 | 24.2% | 14 | 9.2% | |
| 71–90 years | 52 | 43.3% | 96 | 63.2% | |
| > 90 years | 27 | 22.5% | 29 | 19.1% | 0.002 |
| Age, mean (SD) | 120 | 74.2 (19.2) | 152 | 77.9 (16.1) | 0.043 |
| BMI, mean (SD) | 80 | 23.7 (5.2) | 95 | 24.8 (5.8) | 0.09 |
p values were calculated from Chi‐squre tests comparing proportions or t‐tests comparing means.
Nutritional intake data was available for 96 patients receiving the in‐house cook‐fresh, scooped meals and 114 patients receiving the commercially‐prepared, moulded meals (Table 3). Missing data is due to excluding patients that had less than one complete day of intake data. Of those with intake data, individual requirements for energy and protein could be estimated for 56 patients in the in‐house cooked‐fresh, scooped cohort and 54 patients in the commercially‐prepared, moulded cohort. Additional missing data is resulted from not having heights and weights recorded for these patients to calculate nutritional requirements. Total intakes of energy (kJ) and protein (g) were similar for both groups (3722 kJ, 46.2 g for cooked‐fresh and 3768 kJ, 46.3 g for commercial; p > 0.05). Likewise, intakes of energy and protein, as a proportion of requirements, were also similar in both groups (43% energy, 55% protein for cooked fresh, 47% energy, 59% protein for commercial; p > 0.05). The proportion of the meal component wasted for the meat (46% and 42%) and the vegetable (47% and 46%) were also comparable for both cohorts (p > 0.05). When all analyses were conducted as regression models to control for the patient characteristics that differed between the two groups (age), the overall findings were the same with no statistically significant differences between the two groups on any nutritional intake measure (data not shown).
Table 3.
Nutritional intakes of patients receiving two models of preparation of texture modified meals.
| In‐house cooked‐fresh, scooped | Externally sourced commercially‐prepared, moulded | p value1 | |||||
|---|---|---|---|---|---|---|---|
| n | Mean [95% CI] | Median [IQR] | n | Mean [95% CI] | Median [IQR] | ||
| Average energy consumption (kJ) | 96 | 3722 [3267, 4176] | 3450 [1850, 5428] | 114 | 3768 [1947, 3407] | 3549 [2341, 5169] | 0.44 |
| Energy consumed, % of requirement | 56 | 43.1 [34.0, 52.1] | 44.5 [15.0, 64.6] | 54 | 47.3 [39.5, 55.1] | 44.4 [28.1, 59.1] | 0.23 |
| Average protein consumed (g) | 96 | 46.2 [40.4, 52.0] | 43.2 [19.1, 67.7] | 114 | 46.3 [41.7, 50.9] | 45.2 [26.5, 62.7] | 0.48 |
| Protein consumed, % of requirement | 56 | 55.4 [43.3, 67.4] | 56.3 [16.0, 79.9] | 54 | 59.2 [49.2, 69.3] | 59.4 [35.4, 74.1] | 0.31 |
| % of plate wasted, meat | 100 | 45.8 [39.7, 52.0] | 46.4 [20.3, 75.0] | 133 | 41.7 [36.3, 47.1] | 39.6 [12.5, 64.4] | 0.16 |
| % of plate wasted, vegetable | 89 | 47.2 [40.2, 54.1] | 50.0 [19.9, 75.0] | 116 | 45.9 [39.8, 51.9] | 47.9 [16.1, 71.8] | 0.39 |
p value generated from linear regression model, controlling for age.
Mealtime satisfaction surveys were conducted with 20 patients receiving the in‐house cooked‐fresh, scooped meals and 10 patients receiving the commercially‐prepared, moulded meals (Table 4). The proportion of patients reporting aspects of the meal as better than average appeared to be higher in the commercially‐prepared, moulded cohort, across a range of items. For example, 80% of patients with the moulded meals rated the meal met expectations, compared to 55% of patients with the scooped meals. Given the low numbers of patients with mealtime satisfaction surveys, further statistical analyses were not conducted.
Table 4.
Patient reported meal satisfaction in the two cohorts of patients.
| % reporting above average | ||||
|---|---|---|---|---|
| In‐house cooked‐fresh, scooped | Externally sourced commercially‐prepared, moulded | |||
| n | % | n | % | |
| Meat, chicken, fish or alternative | ||||
| Flavour and taste | 17 | 41% | 8 | 63% |
| Appearance | 16 | 44% | 8 | 50% |
| Quality | 16 | 69% | 7 | 71% |
| Potato, rice, pasta | ||||
| Flavour & taste | 17 | 71% | 9 | 89% |
| Appearance | 16 | 56% | 9 | 89% |
| Quality | 16 | 63% | 9 | 78% |
| Other vegetables | ||||
| Flavour and taste | 13 | 62% | 8 | 88% |
| Appearance | 12 | 58% | 8 | 75% |
| Quality | 12 | 67% | 8 | 88% |
| % reporting good or very good | ||||
| Meal met expectations | 20 | 55% | 10 | 80% |
| Overall satisfaction with foodservice | 20 | 65% | 10 | 100% |
4. Discussion
The aim of the current study was to determine if how the preparation and plating of texture modified meals is associated with better nutritional intake, less plate waste and greater meal satisfaction of patients with swallowing difficulties in an acute hospital setting. The nutritional composition and costs of the two methods for providing texture modified foods was also compared. Overall, we found the externally sourced commercially‐prepared, moulded meals to be more energy dense (across all options) and approximately 10% more expensive per meal on average (ranging from −2% to +20%) than the in‐house cooked‐fresh, scooped meals, but there were no differences in nutritional intakes between the two cohorts. Patient satisfaction reports appeared to favour the commercially‐prepared meals.
It may be surprising that the nutritional intake between the two cohorts was similar. The meals in the two groups are nutritionally quite comparable, although differed in portion size. Some may expect the appearance to encourage increased intake in the moulded food group, as some studies suggest improved intake with moulded pureed foods in a hospital setting [13]. However, the previous study only included pureed meals and only lunch time data were assessed. Additionally, the cohort size was small and not able to test statistical significance. Other studies that demonstrate improved intake often also fortified their moulded food items, so it is difficult to ascertain the reason for the improvement [18]. Also, these studies were carried out in aged care settings and may not be comparable to patients in an acute care setting.
Patient satisfaction in the commercially‐prepared, moulded texture modified group appeared higher than the in‐house, cooked‐fresh scooped cohort. This finding somewhat incongruent with previous research. Small studies [19, 20] and studies with healthy participants [21] have suggested that moulded texture modified foods were not necessarily more acceptable than scooped based on subjective assessments. One possible explanation for this could be the different thickener used. The products used in the current study did not contain any thickener in their proteins and only used vegetable gum in their vegetables, which may have resulted in a more acceptable taste and texture compared to thickeners used in other studies. One study [22] did find that when presented with scooped texture modified meal and a moulded texture modified meal, participants preferred the taste of the moulded texture modified foods. However, a different thickener was used in scooped (potato starch) and moulded (modified corn maize) options which may help to explain the results. Additionally, it should be noted that only a small sample of participants were able to engage in the satisfaction surveys in the current study, so this data may not be representative of the cohort.
While it appeared that the commercially‐prepared, moulded meals resulted in less plate waste, these differences did not reach statistical significance. The plate waste for both the scooped and moulded IDDSI level 4 and level 5 texture modified meals was consistent with the findings from previous studies [9]. That said, it is worth noting that the overall portion sizes are smaller and more nutrient dense in the moulded texture modified product, due to the decreased need for added liquid during processing in this product. This may have clinical significance for patients with swallowing fatigue or poor appetite, making each mouthful count.
The commercially‐prepared moulded meals were approximately 10% more expensive than the in‐house cooked‐fresh, scooped meals. However, there are additional financial savings in using the commercially‐prepared moulded meals that were not captured in this study. Firstly, as the commercially‐prepared moulded meals are frozen and individually packaged, there is virtually no production waste as portions are only heated as required. In the cooked‐fresh scooped meals, the kitchen would prepare a set amount of the product each day with a 1‐day shelf life, and any unused product would need to be discarded at the end of the day. As such, there may be additional benefits, such as reduction in greenhouse gas emissions related to food waste, that we were unable to measure in the current study. Additionally, modifying meals to IDDSI levels 4 or 5 requires specialised equipment that may not be required for other production, as well as the time and cost of training staff members to process foods to the correct texture. The savings on these expenses could justify the slightly higher food cost of the commercially‐prepared moulded meals. Additionally, approximately 1 h per day was allocated to producing the cooked‐fresh scooped meals. While this did not translate to a reduction in labour hours or cost, this resource could be diverted to a more high value task.
There are limitations with the retrospective nature of this study and study design. It is possible that there were unmeasured characteristics of patients in the two cohorts that confound our findings. Intake data relies on the assessment by food service staff. While they are trained and audited in this task, there is potential error for both cohorts in estimating the amount consumed or if items were thrown out or consumed by someone other than the patient. For the cooked‐fresh, scooped cohort there may have been additional error in the portioned serving sizes, that were standardised for the commercially‐prepared moulded meals. While 120 patients were eligible for this study, the number eligible for analyses was drastically reduced due to missing data on heights and weights. Insufficient completion of patient weight records is a common issue amongst hospitals, and organisational change is required to support improved completion rates (source) [23, 24]. Additionally, a stronger study design where patients are randomised to meal production method would be needed to confirm our findings. Patient satisfaction data was very difficult to collect in this study population as many patients were too confused to be able to participate in a survey, and those that were able to engage found the Likert scale very difficult to respond to. Future work to identify how to collect this type of information from patients with swallowing difficulties is needed. There are other outcomes of interest that could not be measured in the current study. For example, meals made in‐house may be prone to inconsistencies in the level of modification that may result in choking incidents. These events are rare, and a much larger study would be needed to confirm these findings, though it is reasonable to assume that commercially modified foods may be more consistent. This study focused on the comparison of moulded versus unmoulded texture modified main meal items. Other strategies such as food fortification may improve nutritional intakes in this cohort, and further research is warranted to determine the most effective strategies for improving nutritional outcomes.
5. Conclusion
Our findings suggest that for a 10% increase in cost (accounting for food and labour only), an externally sourced commercially prepared, moulded texture modified meal can deliver a more energy and protein dense product (with the exception of the chicken, which had the same protein content per 100 g). Patients appear to like the product, though significant improvements in intakes of energy and protein were not achieved.
Author Contributions
Kaitlin Brennan, Jennifer Utter and Sally McCray designed the study. Kaitlin Brennan, Ruby‐Rose Carnes and Chantal Luxton collected data. Kaitlin Brennan, Ruby‐Rose Carnes, Chantal Luxton and Jennifer Utter analysed data. All authors contributed to the writing of the manuscript and approved the final draft.
Funding
The authors have nothing to report.
Ethics Statement
The Mater Human Research Ethics Committee reviewed and approved the study protocol as low to no risk research. Patient consent was waived as the study is retrospective, draws on routinely collected data and poses no risk to patients.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
Open access publishing facilitated by Bond University, as part of the Wiley ‐ Bond University agreement via the Council of Australasian University Librarians.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.