Purees are a necessary but not glamorous part of senior dining, but it’s one of the areas where we’ve seen the greatest strides in making life better for residents through the know-how of chefs and dietitians. A signature component of Cura Hospitality’s Connections Memory Support Dining program, Puree Creations features research, training and a set of standards to make purees as picture-perfect as possible.
To understand why purees are so necessary, we must look at dysphagia, a common condition in the elderly that is tough to handle on its own, but often leads to other complications, like pneumonia.
What is dysphagia?
Dysphagia essentially means difficulty swallowing, but there is a lot more to it. According to the Mayo Clinic, dysphagia is a geriatric syndrome affecting 10% to 33% of older adults, and it’s often seen in addition to other conditions, like dementia, stroke, or Alzheimer's or Parkinson's diseases. To get an idea of what dysphagia actually feels like, consider the main warning signs: Coughing or choking when eating or drinking; bringing food back up, sometimes through the nose; a sensation that food is stuck in your throat or chest; persistent drooling. Not pleasant, to say the least! And, potentially dangerous, as it can lead to other issues.
Here are a few questions asked by doctors to determine if a patient has dysphagia: “What happens when you try to swallow? Do you have difficulty swallowing solids, liquids or both? What is the onset, duration and frequency?”
Once it’s determined a patient might have this disorder, healthcare providers can use a Videofluoroscopic Swallow Study (VSS) or other methods to see what is going on when the patient tries to swallow.
Purees to the rescue
Dietary modification is the key component in the general treatment program of dysphagia. A diet of pureed foods is recommended, and here is where skilled senior dining chefs come in clutch, trying new recipes and rejiggering ingredients again and again to get a product that’s so close to the real thing, sometimes you can’t tell them apart.
One of the chefs who has worked closely with Cura’s Puree Creations program is Corporate Executive Chef Jason Clark, who conducts training with different communities to boost the eating experience and nutrition for residents.
IDDSI changes the game
Clark says the biggest improvements to the puree diet have been due to a standardization called IDDSI (The International Dysphagia Diet Standardization Initiative), which is used around the world.
“IDDSI is used universally to understand the diet the resident or patient needs to be on,” Clark says. “In the past, [senior living chefs] would use ‘mechanical ground’ food, but when that resident went to the hospital for a procedure, the hospital would use the IDDSI diet. When the resident went back to the retirement community, the staff did not understand the diet because it didn’t match up with their terminology.”
A pureed waffle. | Photo courtesy: Cura.
The IDDSI set of standards isn’t mandated officially in senior dining, “but a lot of hospitals have already gone that way,” Clark says. “Retirement communities are struggling to go there; it’s a lot of work and the nurses and the dining team have to be on the same page, with a lot of behind-the-scenes work to be done. But I think eventually IDDSI will be everywhere.”
The IDDSI diet is a framework providing a common terminology for describing food textures and drink thicknesses to improve safety for individuals with swallowing difficulties, placing foods into categories from Regular to Easy to Chew to Soft and Bite-Sized to Minced and Moist to Pureed, then Liquidized, which has its own set of classifications, from Extremely Thick to Moderately Thick to Slightly Thick to Thin on the beverage side. To learn more about the framework, visit the IDDSI website.
It seems counterintuitive, but thin beverages or broths aren’t necessarily the best thing for those with dysphagia, Clark says, describing the sensation we’ve all had when a drink “goes down the wrong pipe” and you’re left gasping for air.
Training on purees
Using the IDDSI standards, senior dining chefs can test the consistency of each food item using a fork, evaluating how easy it is to push a food through the tines of a fork. “IDDSI is attached to specific names with visual testing, making training much easier,” Clark says.
Through lots of experimentation, Cura’s Puree Creations program began using a thickening agent, Simply Thick, to create what Clark sees as a food engineering feat: Pureed bread that can stand up to a sandwich.
“We used to make a slurry with bread (soaking bread in a liquid), and you could eat that. Now, with IDDSI, there are no more slurries,” Clark says. “Because of consistency issues, slurries have become almost an unsafe practice. The slurry had been the only methodology that was known for a long time. It worked. But when you dip a cookie in milk and you dip it not long enough, it’s too crunchy, and if you dip it too long, it just dissolves. Bread is the same. The standardization is more smooth, and safer to do.”
A pureed caprese salad. | Photo courtesy: Cura.
Now, with the method Clark and the team have created for bread—making a bread batter and cooking it off in a mold—not only are pureed sandwiches possible, but also pureed waffles, French toast and pancakes. Other menu items from Puree Creations include spaghetti and meatballs, and beef burgundy with braised beef, egg noodles and carrots (all pureed). The noodles are an improvement over traditional pureed noodles from a mix, Clark has found. Depending on which pasta shape is desired, chefs can use extruders and special pastry tips.
Puree menus can echo regular menus, with seasonal specials such as a caprese salad with pureed tomatoes, cheese and pesto. “Our key is, we look at [each senior dining location’s] current menu and whatever we can do to replicate that menu to the fullest extent,” Clark says. “We have to analyze from a staffing perspective and what kind of resources they have; it’s not a one-size-fits-all for everywhere. When I set it up, I work with a speech therapist, a dietitian, the foodservice director, the chef …they’re all highly involved in the menu process.”
One of the most important goals of a great pureed diet is to provide nutrition for residents and patients. “If they don’t get their nutritional needs met, I’ve seen people’s health decline very quickly,” Clark says. “If the food resembles ‘real food,’ they are more likely to eat it. We need to make sure these residents are at least maintaining their weight.”
For senior dining chefs looking to elevate their puree program, Clark says, “Sometimes it’s baby steps; maybe you can’t do the whole menu right away. There are a lot of moving parts to getting the program rolled out.”
He recommends breaking down purees into manageable steps, such as working with proteins first, then starches, then vegetables. “It’s not a program you want to rush or just throw at somebody, because it’s a safety concern.”