Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

Combating Malnutrition among Children with Disabilities in 12 Countries:

Development of Culturally Appropriate, Texture-Modified Recipes
Improper feeding practices around the world have been linked to poor growth and
developmental outcomes in children. The SPOON Foundation has found a gap in proper
modification food textures for children with disabilities. Our overall project goal is to address
this issue by researching local foods in 12 different countries and create recipes for texturemodified meals and snacks that are nutritionally rich and balanced. These recipes will include
seven different breakfasts, lunches, and dinners along with fourteen different snacks. Finding
locally appropriate thickening agents that are affordable for use by caregivers in various
countries must also be taken into consideration when choosing recipes. Once the group has
compiled a recipe book for each country, we must then develop culturally appropriate training
curriculum including handouts and pamphlets. A timeline will be made to outline how long it
will take to educate caregivers in the particular country about the recipes and texture
modifications once SPOON is onsite. Literary reviews on food textures and their association
with gastrointestinal issues, respiratory issues, feeding skills, available methods, current
equipment and systems will also be done. It is SPOONs goal to fully integrate this project in
their nutrition and feeding interventions abroad.
Literature Review
Dysphagia, or difficulty chewing and swallowing, is common among children and
individuals with developmental disorders and is often associated with malnutrition. Children
with disabilities have a high prevalence of malnutrition and are at an increased risk of aspiration
and other health-related complications (Stalling, et al, 1995; Redstone & West, 2004). Estimating

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

nutritional needs for a child with impairments is not straightforward and no commonly accepted
method for estimating energy needs in children and adolescents exists. Caloric energy needs can
be influenced by physical activity, gross motor skills, and metabolic raterelated to reduced lean
body mass, tone and adaption to poor nutrition (Bell & Samson-Fang, 2013).
Although the caloric needs of children with disabilities are varied, the protein
requirement remains the same for children regardless if they have a disorder. Adequate protein
intake is essential to build and repair tissue, for adequate growth and development, and to
promote lean tissue gain (Bell & Samson-Fang, 2013). Limited evidence exists to support the
nutritional equality between regular unmodified food products and their modified texture food
counterparts (Keller, Chambers, Niezgoda, & Duizer, 2012). In fact, lack of consistency in
terminology has led to confusion and diversity of modified texture foods prescriptions for those
with dysphagia. This variability for interpretation of soft-chopped, ground, or pureed, may
contribute to nutritionally inferior food quantities being served to individuals with dysphagia and
have the potential to lead to malnutrition.
Additionally, modified food textures may play a role in the high prevalence of chronic
constipation in children with disorders and dysphagia. Constant constipation has also been found
to be associated with malnutrition among children with disabilities. This could be due to
insufficient fiber in the diet or may be due to normal fluid losses during texture modification for
chopped, minced, ground, or blended foods, thus further contributing to dehydration and
constipation in these individuals (Camponozzi, et al, 2007; Keller, Chambers, Niezgoda, &
Duizer, 2012). Individuals with disabilities partially rely on the moisture content of their foods
for hydration, due to their increased risk of aspirating on liquids. It is important to add a
thickener to modified foods in order to limit fluid loss, which is inevitable with texture

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

modification. Depending on the type of fluid added (e.g water, broth, milk, thin gravy/sauces),
nutritional density of the food can be diluted, requiring a larger amount to receive the same
amount of nutrients compared to the unmodified version of the food.
Protein-calorie malnutrition complications associated with dysphagia include decreased
respiratory function, cardiac capacity, immune function, cognitive development, exploratory
activity, and wound healing. Malnutrition is also associated with an increase in gastroesophageal
reflux (GERD), with evidence suggesting that GERD may contribute to malnutrition in children
with cerebral palsy rather than being a consequence of malnutrition (Kuperminc & Stevenson,
2008; Camponazzi, et al 2007).
Malnutrition may be prevented in children with disabilities and dysphagia by
implementation of proper feeding techniques. It is well documented that the childs head position
influences the swallow during feeding and reduces the risk of aspiration. Head position is
dependent on trunk control and a proper head position is necessary for the entire process of
swallowingfine movements of jaw and tongue. Due to the high incidence of dysphagia in this
population of children with disabilities in orphanages and community settings, modifying
textures is often necessary.
The countries in which we hope to create resources to treat or prevent malnutrition in
children with disabilities are: Bhutan, Bulgaria, China, Ethiopia, India, Kazakhstan, Mongolia,
Russia, Tajikistan, the United States, Vietnam, and Zambia. The malnutrition and micronutrient
deficiencies among these countries share commonalities. For example, signs of malnutrition such
as stunting, wasting, and children below their normal weight range is apparent in all twelve
countries except Kazakhstan. Severe acute malnutrition is highly prevalent in Vietnam (Nga, et
al, 2013) and protein-energy malnutrition and chronic malnutrition are apparent in China,

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

Ethiopia, India, Tajikistan, and the United States (Li, Guo, Shi, Anme, & Ushijima, 1999; Asfaw,
Wondaferash, Taha, & Dube, 2015; Kumar, 2015;(FAO, n/a); 2015; Johns Hopkins, n/a). Among
the countries with the highest prevalence of malnutrition, food insecurity is especially
widespread in Ethiopia, Tajikistan, and the United States. Food insecurity is hypothesized to be
associated with gender inequality and low SES (Fanta Project, 2014).
There is a high prevalence of anemia in Bhutan, Ethiopia, Kazakhstan, Mongolia,
Tajikistan, and Zambia but iron deficiency appears to only be highly prevalent in India, Russia,
Tajikistan, Vietnam, and Zambia. This may be due to other nutritional deficiencies, such as,
malaria, intestinal worms, infections, lack of clean water, in addition to feeding difficulties
(Asfaw, Wondaferash, Taha, & Dube, 2015; Alaofe, Kohler, Taren, Mofu, Chileshe, &
Kalungwana, 2014; US Aid, 2015). Among all micronutrient deficiencies, vitamin A, vitamin D,
vitamin C, Iodine, and Zinc appear to be the most common deficiencies among the twelve
countries. It is interesting to note that in the malnutrition in the United States is most often due
to dietary imbalances of nutrients rather than a deficiency of nutrients (Johns Hopkins, n/a). This
may be due to higher intakes of sugar, sodium, saturated fat, and processed foods and a lower
intake of nutrient-rich fruits and vegetables.
Apart from micronutrient deficiencies, lack of dietary variety was observed in countries
such as Bhutan, Ethiopia, India, Russia, Tajikistan, and Zambia (Zangmo, de Onis, & Dorji,
2011; Herrador, et al, 2014; Deka, 2015; US Aid, 2015; Alaofe, Kohler, Taren, Mofu, Chileshe,
& Kalungwana, 2014). These countries reported low consumption of animal products such as
meat, fish, milk, eggs, and dairy. Among the many similarities and differences between the
twelve countries that being analyzed, signs of malnutrition, micronutrient deficiencies, and poor

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

diversity in diet appear to have the strongest influence on nutritional inadequacy among these
countries.
Table 1. Nutritional Deficiencies & Issues by Country of Interest
Sources:

Country

Common
Deficiencies

Common Issues

(Zangmo, 2012;
Bilukha, Howard,
Wilkinson, Bamrah,
Husain, 2011;
Zangmo, de Onis, &
Dorji, 2011)

Bhutan

Vitamin B12

Stunting
Underweight
Anemia
Low consumption of meat, eggs,
and dairy products (Vitamin B12
sources)

(UNICEF, 2004;
GNR-B, 2014)

Bulgaria

Iodine

Stunting
Wasting

(Zheng, et al, 2014;

China
Li, Guo, Shi, Anme,
& Ushijima, 1999; Li,
et al, 2007)

Thiamine

Protein-Energy Malnutrition
(PEM)
Low intake of calories
Overnutrition
Stunting
Wasting
Underweight
Lack of knowledge by doctors to
treat causes of malnutrition and
local culture food taboos

(Petrou & Stavros,

2010; Herrador, et al,
2014; Asfaw,
Wondaferash, Taha,
& Dube, 2015)

Ethiopia

Vitamin A
Zinc
Vitamin D
Folate

Undernutrition
Stunting
Wasting
Underweight
Diarrheal morbidity related to
infections
Protein Energy Malnutrition (PEM)
Anemia
Low consumption of meat, fish,
and dairy products
Low diet diversity: diet composed
of mostly legumes, oils, and pulses.
Food insecurity

(Deka, 2015; Kumar,

2015; Petrou &

India

Iron
Vitamin A

Wasting
Low intake of calories

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

Stavros, 2010)

Vitamin C

Low intake of protein

Low intake of fat
Poor consumption of milk, liver,
and leafy vegetables in diet.
Protein Energy Malnutrition (PEM)

(GNR-K, 2014;
Hashizume, et al ,
2003)

Kazakhstan

Vitamin A
Iodine

Anemia

(UNICEF, 2008;
UNICEF, 2009;
Uush, 2013)

Mongolia

Vitamin A
Vitamin D
(rickets)
Iodine

Low intake of calories

Underweight
Stunting
Anemia
High prevalence of disabled
children

(Adoption
Nutrition/SPOON
Foundation,n/a;
WHO Russian
Federation, n/a)

Russia

Iodine
Iron
Manganese
Riboflavin
Selenium
Zinc
Vitamin A
Vitamin C
Vitamin D

Underweight
Stunting
Diet high in saturated fat and
sodium
Diet low in fruits and vegetables,
apart from cold damp produce (e.g
cabbage, potatoes, beets, onion)

(US Aid, 2015; Fanta

Project, 2014; FAO,
n/a)

Tajikistan

Iodine
Vitamin A
Iron

Malnutrition
Stunting
Wasting
Anemia
Underweight
Undernutrition
Low dietary diversity
Lack of clean water
Food insecurity
Gender inequality (affecting food
insecurity and malnutrition)
Lack of parental knowledge of
infant/child feeding practices
Diet high in sugar and saturated fat
Diet poor in mineral-rich fruits and
vegetables

(Coleman-Jensen, et

United States Dietary

imbalances rather

Food insecurity
Underweight

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

al, 2015; Johns
Hopkins, n/a; Fryar &
Ogden, 2012)

than deficiencies

Chronic malnutrition

(Ta, Nguyen,
Kawakami, Kawase,
& Nguyen, 2003;
Khan, Tuyen, Ngoc,
Duong, & Khoi,
2007; Nga, et al,
2013)

Vietnam

Iron
Calcium
Phosphorous
Potassium
Beta-carotene
(severe)
Vitamin Etocopherol
(severe)
Magnesium
Vitamin A
Vitamin C

Severe acute malnutrition (SEM)

Malnutrition and stunting (has
declined but still prevalent)

(Gibson, et al, 2011;

Alaofe, Kohler,
Taren, Mofu,
Chileshe, &
Kalungwana, 2014)

Zambia

Vitamin A
Zinc
Selenium
Vitamin B12
Folate
Iron
Calcium

Undernutrition
Stunting
Wasting
Underweight
Overweight
Anemia
Night-blindness
Diet rich in maize-based foods,
which contain high phytate content
that inhibits mineral absorption.
Low consumption of animal and
animal products (meat, fish, milk,
dairy
High prevalence of malaria and
intestinal worms contributing to
anemia and malnutrition

Significance
The nutrition of children with disabilities should not be overlooked as it impacts the
childrens growth and development. Often times, children with disabilities are at an increased
risk for malnutrition due to improper feeding practices and improper foods. SPOONs field
assessments found a significant gap in solutions to the feeding needs of children with disabilities:

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

modification of food textures. As dysphagia is often prevalent in children with disabilities the
types of food the child can consume is limited, which may lead to malnutrition. Modifying food
allows children to eat safely, comfortably and more efficiently. However, caregivers often lack
the knowledge and skills to prepare proper texture-modified foods. Thus our goal is to address
the source of the problem by providing education and culturally appropriate recipe books to
create proper feeding techniques using modified texture foods. The recipe books developed will
take into account each countrys cultural diet and the foods available in each local area.
Methods & Design
The recipes and education will be to the caregivers who are responsible for feeding
children with disabilities. The training curriculum and guidelines will be targeted towards those
providing the cook books and education to the caregiver. In order to attain the finalized product
the following timeline will be followed:

Table 2. Proposed Project Timeline

Step

Description

To Be Completed By

1. Literature Review

Each team member will research her

assigned country to determine
common nutrient deficiencies and
causes of malnutrition.
This part of the literature review will
focus on food textures and their
associations with health issues,
feeding skills, available methods,
current equipment, and systems.

October 31st 2015

2. Identify local resources

Find locally appropriate thickening

agents accessible for caregivers
within each given country

December 2015

3. Create Nutrition Standards

Create nutrition standards based on

the research that will be applied to

December 2015

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

the recipes created in step 5.
4. Identify local foods and
culturally appropriate recipes

Research the local cuisine of each

country of interest. Find appropriate
recipes that can be modified to
provide varying textures.

December 2015

5. Create recipes for each

country of interest

Create 7 breakfast, lunch, and dinner

recipes and 14 snack recipes.
Recipes will address the common
deficiencies found in step 1.
Nutrition analysis will be done to
ensure that the recipes meet nutrient
needs.

February 2016

6. Develop Adapting Food

Textures for Children with
Disabilities training

Create a recipe book for each

country of interest with the recipes
from step 4.

March 2016

The effectiveness of Modifying Food Textures for Children with Disabilities will be
evaluated by SPOON in accordance with its procedures. The evaluation will ensure that the
recipes include appropriate thickening agents that are both accessible and affordable by
caregivers in each country of interest. Throughout the writing and creating process two
employees of SPOON, Maureen Dykinga, MS, CCC/SLP and Zeina Makhoul, PhD, RD will
serve as mentors and guides to help ensure that proper steps are being taken. The collection of
culturally-tailored recipes will be evaluated for nutritional quality via comparison to nutrition
standards set by the group and texture modifications will be monitored to ensure safety. The
nutrition quality will be determined via use of Food Processor.
Each project component will be integrated into SPOONS nutrition and feeding
interventions. The cookbook will be provided to families and caregivers in need by employees or
partners of SPOON at facilities set up by SPOON or its partners within each country of interest.

Attema, Glasser, Hamilton, Meyer, Somohano, & Wittenberg, 2015

One or two facilitators will be required to provide the instructional material to caregivers and
instruct caregivers on use of the material.
Budget
Estimated Cost

Item

$6,792

Cookbook - printing 100 copies for each

country (12)

References will be cited in AJCN format after our initial draft is approved.

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