The number of elderly individuals is increasing. By the year 2025, there are expected to be more than one billion persons over the age of 60 years and most will have some sensory loss, including impairment in taste and smell perception.
A study done at the Jewish Home Lifecare, Bronx, New York, showed improvement in overall resident satisfaction with meals when provided with flavor enhancement.
Other studies have found that there is a progressive decline in taste and smell functioning that begins around 60 years of age and becomes more severe in persons more than 70 years of age. Taste and smell losses occur in the elderly and may influence their enjoyment of food and affect nutritional intake. Previous studies have found that the burn from hot pepper and the pungency of mustard are the result of stimulation of the trigeminal nerve. Adding a combination of MSG and flavorants increased enjoyment of foods served at Jewish Home Lifecare compared to unenhanced foods. Flavor enhancement was more effective than flavor amplification.
Risk for malnutrition
Residents with reduced oral intake are at risk for developing malnutrition, which contributes to impaired health status. Inadequate oral intake can lead to weight loss, hospitalization, and even death. Federal guidelines specify that a patient is potentially at risk for malnutrition if daily oral food and fluid intake is less than 75% of meals.
The diet of the elderly tends to be less varied than that of younger adults. Reduced variety itself poses a possible problem, as well as eating and dining environments with decreased social facilitation. Elderly food habits differ from those of younger adults in that elderly eat less and consume small meals. They eat slower with fewer snacks between meals and fewer cravings. As people age, there are both physiological and cognitive changes that affect meals and meal intake. All of the above factors need to be considered with the aging population.
Jewish Home study
A study was conducted by the Speech-Language and Swallowing Disorders Department at Jewish Home Lifecare to determine the effect of flavor-enhanced (spice) lunch meals on body weight and meal satisfaction. Results of this intervention showed improvement in overall resident satisfaction with meals when provided with flavor enhancement. No significant changes in body weight were observed, which was probably due to the short intervention of eight weeks and the provision of flavor enhancers at only one meal (lunch) five days a week.
Methods and participants
Sixty residents were enrolled in the Jewish Home Lifecare study. An eight-week intervention consisted of providing a choice of four spices (flavor enhancers) added by sprinkling over the cooked lunch meal to an experimental group (n = 30) and not over the meal of the control group (n = 30). The spices included red pepper flakes, adobo [a Latino spice mixture], Italian mixed seasoning, and a no-salt mixed seasoning. Lunch was chosen because at Jewish Home Lifecare, it was the meal with the lowest percentage of meal completion. Criteria for inclusion in the study consisted of the resident's ability to respond to a satisfaction questionnaire, the ability to eat by mouth, and the ability to choose a spice. The four spices were selected based on resident preference and cultural backgrounds, as well as the ability to complement food choices provided at the lunch meal.
Measurements for intake of a cooked meal (meal consumption), for weight of the individual, and satisfaction with meals were taken before and after the eight-week intervention. Additional demographic information was obtained for residents in both the experimental and control group and included age, diet consistency, and level of feeding assistance required. Residents were randomly selected and 30 assigned to the experimental group (with choice of spice) and 30 randomly assigned to the control group (no choice of spice given). Pre- and post-satisfaction scales were completed, as well as weights before and after for all patients enrolled in the study.
A Meal Satisfaction Questionnaire (MSQ) was created. It included a five-point severity scale that assessed five specific items:
A. I like spices offered at lunch meals.
B. I am given a choice of spices.
C. I am satisfied with the choice of spices.
D. The food tastes good.
E. I look forward to my lunch meal.
Residents rated each item “A” through “E” on a scale of 1 through 5, with 1 = never satisfied, 2 = unsatisfied, 3 = neither satisfied nor unsatisfied, 4 = satisfied, and 5 = always satisfied.
Residents in the experimental group were asked to choose what spice they wanted sprinkled over their food. Most often, residents chose one spice, but on occasion, some chose two. The speech-language pathologist sprinkled the powdered spices over the food once the plated meal was served.
Data was analyzed following the eight-week intervention. The mean age of participants in the experimental group was 86.9 years of age with ages ranging from 66 to 101 years. The mean age of the control group was 79.6 years of age with ages ranging from 58 to 101 years. Diet consistency varied across both the experimental and control groups. Fifty-seven percent of the participants in the experimental group received a regular consistency diet during the eight-week intervention, 37% received a soft consistency diet, 3% received a ground consistency diet, and 3% received a pureé consistency diet. The breakdown of diet consistencies in the control group consisted of 23% (regular consistency diet), 50% (a soft consistency diet), 3% (a ground consistency diet), and 23% (a pureé consistency diet).
An average lunch meal intake was obtained for both the experimental and control groups. The experimental group average lunch intake was 71.6% with the control group average lunch meal intake 72.5%. Twenty-three participants (76.6%) in the experimental group consistently requested spices on their cooked lunch meals. The adobo spice was the most popular spice, with 48% of participants requesting it. Red pepper flakes were the second most requested spice at 30%, and the no-salt mix spice was requested 22% of the time. The Italian spice mix was not requested by participants in the experimental group. Resident weights were obtained pre- and post-intervention participation. For those residents receiving weekly weights, an average was obtained using all available weights. Analysis of significant weight change (greater than 6 pounds) revealed a 3% weight loss in the experimental group and a 6% weight loss in the control group; overall no significant weight change occurred.
Participant satisfaction was assessed using a five-question, five-point severity scale rating. Satisfaction ratings were obtained from both the experimental and control groups. Meal satisfaction was obtained by averaging the responses provided to each survey question. Both the experimental and control groups scored the survey question “I look forward to my lunch meal” (question E) with the highest rating. The experimental group rated it with an average score of three and the control group scored with an average of four.
The experimental group was unsatisfied and for all other questions asked in the survey, a score of two was given. The control group ratings were higher, with a score of “unsatisfied” for questions A and B and they were “neither satisfied nor unsatisfied” for questions C and D. Total meal satisfaction scored a two for the experimental group, and a three for the control group. Pre-intervention satisfaction for questions A, C, D, and E ranged from a score of one to four and question B scores ranged from one to two. The control group scores ranges from one to four for questions A, B, and E. Question C's scores ranged from two to five and question D from two to four. Changes in participant satisfaction were noted in the experimental group following the eight-week intervention. Individual scores for questions A and B ranged from a two to five, question D's range improved to scores of three to four, and questions C and E scores ranged from three to five. All areas assessed, questions A through E and the average meal satisfaction, received a mean score of four, while the control group responses did not change.
The addition of flavor enhancers to a cooked lunch meal was effective in improving resident satisfaction with the meal, but did not improve body weight. The use of flavor enhancement has been suggested to compensate for the diminished chemosensory function that is a contributing factor to impaired appetite and decreased intake in the elderly. Other factors to be considered in future studies should include the relationship between possible diagnostic factors, disease, pharmacological factors, surgical intervention, and environmental issues including texture and appearance of food. Long-term care communities should consider providing or offering flavor/spices to meals to improve resident satisfaction and quality of life.
Faerella Boczko, MS, CCC-SLP, BRS-S, a Board-Recognized Specialist in swallowing and swallowing disorders, is Chief of the Department of Speech-Language and Swallowing Disorders at Jewish Home Lifecare, New York. Ms. Boczko has authored book chapters and published research articles. She has more than 30 years of experience working with the adult and geriatric population. Ms. Boczko can be reached at firstname.lastname@example.org, (718) 410-1605 or (212)870-5026.
Siobhan McKeon, MS, CCC-SLP, is Assistant Director of the Department of Speech-Language and Swallowing Disorders, at Jewish Home Lifecare, New York. She has more than six years of experience working with the adult and geriatric population and can be reached at email@example.com. Long-Term Living 2010 September;59(9):38-40