LIKE FALLING OVER, choking in public is always a little embarrassing. When it happens, people feel the need to apologise once the episode is over, as if it were a sign of weakness or social gaucheness instead of an involuntary malfunction.
It is a sad fact that as we age, eating becomes more hazardous. A person older than sixty-five is seven times more likely to choke on their food than an infant. My elderly mother-in-law always loved to chat while enjoying one of the feather-light scones that were her trademark. Inevitably, crumbs caused a sudden coughing episode as she struggled to clear her passageways, inducing heightened anxiety because of her chronic asthma and weakened lung capacity.
At ninety-one my mother, a robust eater, increasingly finds that even a sip of tea can take the wrong route, provoking a sudden attack of choking. In neither case is diminished cognition or degenerative disease to blame.
Swallowing is something we take for granted as much as breathing. We do it unconsciously between five and seven hundred times a day, even when we are not eating or drinking. We can’t swallow and breathe at the same time. The brain takes care of the choreography of how the two alternate in perfect co-ordination. Which means that if something happens to the brain – a stroke, say, or a tumour or degenerative disease such as Alzheimer’s – it impacts one of the most taken-for-granted but essential functions of the body. The result is a condition called dysphagia – difficulty in swallowing, including problems with sucking, drinking, chewing and an increased risk of choking. It is estimated that 60 per cent of those in aged care experience some variety of the problem. It is the second-highest preventable cause of death after falling.
ALL OF THIS came as news to Maggie Beer when she chose to spearhead an unfashionable crusade to improve the quality of food served in the nation’s aged-care dining rooms.
Her campaign began in 2010, following her award as Senior Australian of the Year. Later, she conducted a speaking tour during which she addressed one thousand CEOs of aged-care facilities – and told them that her firsthand observation of the state of aged-care catering had revealed to her that it was pitiably inadequate in terms of nutritional value and flavour, and in need of urgent reform.
‘My speech was not well received. I was naive, thinking they would be encouraged to improve, and that the government would fix the situation – but it ended up being up to me to do that. Not because I am a grand crusader but because it’s my arena and my passion. I’d seen what Stephanie Alexander [a fellow member of the foodie establishment] had achieved with her kitchen-garden scheme in schools, and that was my template.’
Four years later she launched the Maggie Beer Foundation with a mission to improve the food experiences of older Australians, particularly those living in aged care. The foundation’s logo features a cut pomegranate and the slogan ‘Creating an appetite for life’. It is, to her knowledge, the only organisation of its kind in the world.
Since then, she has testified before the Royal Commission into Aged Care, learnt all about the complexities of large-scale institutional food preparation, and digested the protocols around health and safety – and the often-frustrating inconsistencies in state-by-state variations in food-safety rules: New South Wales, for instance, requires red meat to be on the menu every day.
Eggs might seem like a less controversial, and cheaper, source of protein: poached or soft boiled they are a popular request among seniors – but they can present problems because of the risk of salmonella. Yolks have no antimicrobial properties and eggs that are not cooked for long enough can be a source of infection. In NSW, the rules are fairly relaxed; you can have a runny yolk as long as it is setting and the white is firm. In Victoria, the rules are stricter and eggs have to be cooked until they are hardboiled. Queensland Health goes further, recommending pasteurised egg or egg products.
Anyone who insists on being served an egg with a runny yolk has to sign a waiver – in all states.
Then there is the whole complex landscape of food preparation either on site by a team of cooks and serving staff or by off-site external contractors who prepare food and cool it in a blast chiller before it is delivered to a facility where meals may be ‘finished’ on site in kitchens or smaller cooking stations and served by poorly paid staff who have had little or no involvement in its preparation.
Undaunted by the enormity of her task, Beer maintains her near-religious belief that everything can be improved by adding more butter – a mantra she repeats throughout the intensive two-day workshops she runs with enviable stamina, training aged-care cooks in how to prepare food that is nutritious, appealing and tasty to a modest budget.
‘Without flavour and pleasure, food is just fuel,’ she says. She has banned the word ‘facility’ from her vocabulary. ‘I prefer to use the word home,’ she says, reinforcing the personalised domestic familiarity she aspires to.
Invited to observe a workshop in action, I find myself among forty-three cooks from all over the country at Sydney’s Fish Market cooking school, sponsored by their employers, including one from Blue Care in Queensland, which features a facility for up to fifty First Nations elders on Thursday Island, where the kitchen opens out onto the sea.
To date, nearly 500 cooks have attended these workshops, which are not accredited. Aware that not everyone can afford the time and money, Beer and her team of consultants have filmed a program of online modules thanks to a grant of half a million dollars from the government.
AS WELL AS coaching on the benefits of using cheap cuts of meat and fish, Beer calls on outside expertise from nutritionists and food technologists, introducing participants to innovative techniques that can be used to enhance even the most distasteful of prescribed diets requiring textured modified food for those with severe swallowing difficulties.
Before things get underway, Beer goes round the room, asking each chef what their budget is. ‘If it’s $7 a day or less, I can’t help you,’ she says. Most are working to costs of between $8 to $10 per person per day, although one, from the Marco Polo home in Woonona in NSW, which caters for a predominantly Italian community, says: ‘I don’t have a budget, my boss says spend whatever it takes.’ There are sighs of envy all round.
Food scientist Peter Kenny draws attention to an overlooked but crucial part of the eating experience: saliva. It’s the magic juice in the swallowing story. The average person produces between one-and-a-half to two litres of the stuff a day, until around the age of eighty, when that can drop by up to 50 per cent. Its role is crucial in lubricating the oropharyngeal passages and activating our taste buds, another element of our eating experience that we take for granted. We have around 8,000 of them for most of our lives, and they replace themselves every ten days or so. But the number halves as we get older, blunting our sensation of flavour, which explains why so many older citizens sprinkle liberal amounts of salt on their food before they’ve even tasted it.
A common side effect of being on several medications – as many elderly people are – is dry mouth, or xerostomia. Symptoms can be alleviated with saliva substitutes – including sprays, gels, lubricating toothpastes and lozenges.
The good news is that in a healthy older person, saliva production can be increased through other sensory stimuli – including looking at cookbooks, watching food shows, or just being around a kitchen while food is being prepared so the aroma can prompt anticipation and appetite. As my mother says, referring to her favourite TV chef: ‘When I see Jamie, I salivate alright.’
Smell can be as potent as music as a mood lifter, according to Peter Kenny. ‘It can herd residents into the dining room, even those suffering from dementia. Don’t underestimate this element of sensory pleasure. That’s why baking or toasting bread, roasting coffee or nuts, or a barbecue can be so stimulating.’
OUR MOUTHS DULY lubricated, it’s time to learn new techniques and recipes that will restore the pleasure and benefit of food, even for those who are cognitively impaired. The challenges are complex: research shows that those who require assistance with feeding lose weight more than those who can handle cutlery, and that we produce less saliva when being fed by someone else than when we feed ourselves. Dementia affects the palate, making food taste as if it’s gone off. Free of social inhibitions, sufferers often spit it out.
Those with dementia may also be incapable of processing the fact that food is even present, so strategies that encourage awareness are vital. Together with Peter Morgan-Jones, executive chef for HammondCare, Beer has come up with an ingenious response: finger food that is easy to handle (sandwich fillings that are well bound and don’t fall apart) and can be consumed in two bites.
It’s a clever solution, underpinned by a strategy that emphasises grazing rather than traditional set mealtimes, but even such a seemingly innocuous idea faces resistance. Surprisingly, there has been pushback from families, who complain that they find it distressing to see relatives eating this way.
Morgan-Jones, whose career highlights have included stints in palace kitchens for the British Royal Family and at the Bennelong restaurant in the Sydney Opera House, is a rarity among his peers, moving from the high-status end of the industry to the institutional sector where prestige, budgets and wages are low. But his foresight is shrewd: ‘70 per cent of the food workforce will be in healthcare in the next decade. It’s rewarding to cook for vulnerable people. You go home with a smile on your face.’
At the pass in the demonstration kitchen, he asks for volunteers to help prepare recipes that are ‘easy to eat, attractive and more-ish’ in order to meet the foundation’s nutritional targets. His snacks get the thumbs up until, inspired by his idol Heston Blumenthal, he goes a little overboard with effects involving nitrogen capsules and cocktail shakers.
MORE POPULAR AND achievable are the brightly coloured piped purees presented by Perth-based Amanda Orchard, founder of Texture Modified Food Solutions.
Until now, texture-modified food has mostly been a ghastly mush – often just the standard meal of meat and veg put through a blender to become a bland puree, to which a thickening agent is added. But texture-modified food is of poor nutritional value, and many residents find it shameful to eat it in front of others because they feel a loss of dignity in being served a substance associated with baby food.
As in the story of Goldilocks and the Three Bears, aiming for a happy medium is key. Food must be neither too thick nor too thin, and definitely not lumpy. Ingredients need to be either hand-diced or processor-chopped, depending on the required texture, with thickener added for smoothness. Traditional thickeners are usually made from modified maize starch or natural gums such as xanthan, but their flavour can be so overpowering as to compromise the taste of food, making them unpleasant.
Echoing Morgan-Jones’ emphasis on colour and presentation, Orchard says ‘we eat first with our eyes’. Her secret weapon to making veggies more appealing? The humble piping bag.
Demonstrating basic dexterity with various nozzle attachments, she creates decorative flowers of beetroot, carrot and pumpkin. By the time she’s finished, her plate looks like a pretty bouquet styled for a high-end glossy magazine. Given a chance to experiment and practise, everyone in the class steps forward eagerly: this is a method they can master – and with added flavourings such as balsamic vinegar and herbs, purees take on complex flavours that get unanimous approval, especially as they are easy to make in advance and freeze.
Workshop participant Julie McMahon, chef manager at Bodington, a home at Wentworth Falls in NSW, oversees the menus and food preparation for 120 residents. She says it is common for a majority of residents to sign a waiver to say they would rather eat real food – while fully aware of the increased risk of choking – than endure a diet of goop.
‘I suspect that number will only increase with the Baby Boomer generation, who are going to be more demanding,’ she says, echoing an oft-voiced apprehension across the care sector. ‘Just think of how much fussier our generation is as eaters, and all the food intolerances people have.’
Since 2019, texture-modified food has been standardised globally through a system known as the International Dysphagia Diet Standardisation Initiative (IDDSI) – a mouthful in itself. According to its board co-Chair Dr Julie Cichero (who is also a consultant to the Maggie Beer Foundation), the impetus for creating IDDSI arose partly from coronial inquiries revealing that inconsistency in hospital records relating to the definition of what constituted ‘soft food’ had, in several instances, led to fatal choking.
Researchers in Australia and Canada established IDDSI to codify terminology and definitions for modified foods. To date, the adoption of IDDSI is discretionary everywhere except in Israel, where it is enshrined in law.
Months later, I check in with McMahon about the lasting impact of attending the workshop. ‘The finger food was appealing but hard to organise as staff have limited hours and you can’t leave food sitting uncovered indefinitely,’ she says. ‘Boosting the flavour and colour of our purees with herbs is something we’ve adopted. We are also putting more focus on enriching all our foods for improved nutrition, adding cheese to mashed potato for more protein, or nuts to steamed veggies.’
McMahon also benefited personally from being part of the foundation cohort. ‘Too often, if you are a cook in aged care you are made to feel like a failure because you are not considered good enough to be a restaurant chef. The workshop made me feel like we were being recognised for doing a really important job in the community.’
Like many others in this sector, McMahon anticipates that Boomers may take a different approach when it is their turn, relying on delivery services for their favourite foods, as is already occurring in hospitals. But not everyone will be able to afford such convenience.
Tireless and optimistic, Beer too is thinking long term: as soon as she has residential dining rooms sorted, she is keen to turn her attention to another service ripe for an overhaul: Meals on Wheels. But not just yet. No point biting off more than she can chew. It only makes it hard to swallow.
The author would like to thank Sascha Middlemiss, speech pathologist at St Vincent’s Hospital, Sydney, for her advice in the writing of this piece.