Project Summary

The SPOON Foundation identified a gap in proper modification of food textures

for children with disabilities around the world. Our goal was to address both texture and
nutrition by developing recipes that served both needs. The project addressed modified
textures for children with dysphagia who are at risk for nutritional deficiencies in twelve
countries: Bhutan, Bulgaria, China, Ethiopia, India, Kazakhstan, Mongolia, Russia,
Tajikistan, United States of America, Vietnam, and Zambia. Our objective included
researching common deficiencies and local foods in each country and developing
culturally appropriate, nutrient-rich recipes. Recipes were altered to accommodate
texture/consistency needs and evaluated for nutritional adequacy using the USDA foods
database. Our recipes focused on the nutritional deficiencies that were common in a
majority of the countries. These included total calories, protein, iron, calcium, vitamin A,
and vitamin C. We worked with the SPOON Foundations team to evaluate the recipes
for texture and cultural appropriateness. The recipes will be compiled into books for each
country and used by the SPOON Foundations staff for training and education during
interventions in each country. The projected impact of our contribution to the SPOON
Foundations educational materials is to increase the nutritional status of children with
dysphagia in each of the countries. These recipes and materials will also serve as
resources and references for caregivers.
Project Revisions and Group Assessment
Our initial project design was to create recipes for seven days of breakfast, lunch,
dinner, and snacks for each of the twelve countries. These culturally appropriate recipes
would address nutrition deficiencies found in the literature review, identify thickening
agents for dysphagia diet, have instructions for texture modifications, and include
nutrition analysis. During the development process, the project was revised to focus on
five snack-sized recipes for each of the three texture categories: smoothie,

pudding/yogurt/custard, and soft/bite-sized (fifteen total recipes). Our goal is to increase

the nutrient density of snack meals by focusing on protein, iron, vitamin A, calcium, and
vitamin C.
Revising our project allowed us to focus on the quality of the recipes. Scaling
back the project was necessary due to the timeframe of the project and the degree of
involvement needed for each recipe. Creating recipes for each country was more difficult
than originally expected for several reasons. First, it was difficult to find recipes that
addressed all five nutrients of special concern. For example, more mountainous and
remote regions do not routinely have access to fresh citrus fruits, which are an excellent
source of vitamin C. Second, it was challenging to find recipes that were fully adaptable
from puree to table ready foods. Third, we also found it difficult to propose recipes
without knowing the equipment of each of the facility kitchens and availability of
appropriate thickeners. In addition, we had feelings of intruding on their culture; it felt
awkward to suggest recipes that might be obvious to them and that might already be a
part of their menu. This project would be much more effective by involving dietitians,
speech language pathologists, or other medical professionals from each country. Using
professionals from each country would eliminate assumptions about recipes or
availability of ingredients. The project would also benefit from an inventory of kitchen
equipment and food preparation skills available at each facility.
What worked well in our project was our planning and communication. The
challenge of this project was to coordinate the central goal across twelve very
geographically and culturally diverse countries. We were able to communicate and
coordinate as a group with each other and with staff at the SPOON Foundation. We
were able to problem solve significant challenges respectfully. It would have been easy
to say that we did not possess all the qualifications and background for this project. But

our positive attitude towards tackling a task of this magnitude contributed significantly to
the progress we have made towards addressing malnutrition in this population.
Recipe Feedback
Positive
Great in depth research on nutritional
needs for each country
Cultural appropriateness of recipes.

Nutrient analysis

Needs more work

Consistency with sentence highlighting the
recipes value. Some focused on nutrition,
some did not.
Serving size- it would be optimal to have
serving size listed in addition to number of
servings.
Unit conversion: Vitamin A in mcg to IU.
Consistency with grams, kcals, and mL
needs to be consistent throughout the
group and or appropriate for the country.
Consistency of ingredient descriptors in
both the ingredient list and in the
directions.

Implementation and Next Steps

The SPOON Foundation is the organization responsible for the implementation of
the training and education using our recipe booklets. The SPOON Foundations staff will
travel to each country and train local staff on texture modification and feeding methods
for children with dysphagia. We are hopeful that our recipes can be incorporated into a
regular menu and will give local staff more options for children with disabilities.
Evaluation and critique of our recipes will be an outcome of these training sessions. The
SPOON Foundation can work to modify the recipes based on this feedback.
The proposed next steps are to further develop the recipes through recipe testing
and standardization. This would include weighing each ingredient, quantifying the recipe
volume, and standardizing portion size. The standardization process would need to be
repeated for each texture modification. This standardization is important for both
communicating the recipe to other languages and evaluating the nutrition outcomes
based on nutrient analysis.

Our contribution to the SPOON Foundations mission shows how important it is

to maximize nutrition at each meal. Children with dysphagia and disabilities related to
feeding are at high risk for malnutrition complicated by limited resources of their
environment. This project was initiated by the SPOON Foundation because it was
identified as a high need for the populations they serve. In this first phase of the project,
we collected culturally appropriate recipes that help to increase the nutritional status of
these children. We hope that these recipes can be carried forward and that the intent of
our efforts will be expanded upon as the SPOON Foundation increases its teaching and
influence.