Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents

Abstract

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident’s daily nutritional intake and body weight. As part of a large, multisite clinical trial (N?=?786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals?+?snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.     

Accuracy of minimum data set in identifying residents at risk for undernutrition: oral intake and food complaints

OBJECTIVE: to evaluate the accuracy of nursing home (NH) staff in documenting two Minimum Data Set (MDS) items that are used to identify residents at risk for undernutrition, low oral intake and food complaints, using standardized observation and interview assessment protocols implemented by research staff. DESIGN AND METHODS: MDS information related to low oral intake (item K4c: <75% of most meals) and complaints about the taste of food (item K4a) was compared to independent evaluations of low oral intake and food complaints for a random sample of 75 residents in two proprietary NHs within the same month that a complete MDS assessment was due for each participant. Direct observations were conducted by research staff during nine mealtime periods for 3 consecutive days according to a standardized mealtime observational protocol to estimate low oral intake; and, two one-on-one interviews with residents were conducted on two consecutive days using standardized questions to assess the stability of food complaints. RESULTS: Research staff documentation based on direct observation and resident interviews showed a significantly larger number of residents being identified as potentially at risk for undernutrition due to low oral intake (73%) and/or stable complaints about the taste of food (32%) as compared with NH staff documentation of MDS items K4c (44%) and K4a (0%), respectively, within the same month. A total of 47% of the participants expressed stable complaints about some aspect of the NH food service (eg, variety, appearance, temperature). CONCLUSION: The documentation of low oral intake and food complaints on the MDS was inaccurate and resulted in a significant underestimate of residents with either of these risk factors for undernutrition.     

Impact of protected mealtimes on ward mealtime environment,patient experience and nutrient intake in hospitalised patients

Background: Malnutrition is a common problem in hospitalised inpatients, resulting in a range of negative clinical, patient‐centred and economic sequelae. Protected mealtimes (PM) aim to enhance the quality of the mealtime experience and maximise nutrient intake in hospitalised patients. The present study aimed to measure mealtime environment, patient experience and nutrient intake before and after the implementation of PM. Methods: PM were implemented in a large teaching hospital through a range of different approaches. Direct observations were used to assess ward‐level mealtime environment (e.g. dining room use, removal of distractions) (40 versus 34 wards) and individual patient experience (e.g. assistance with eating, visitors present) (253 versus 237 patients), and nutrient intake was assessed with a weighed food intake at lunch (39 versus 60 patients) at baseline and after the implementation of PM, respectively. Results: Mealtime experience showed improvements in three objectives: more patients were monitored using food/fluid charts (32% versus 43%, P = 0.02), more were offered the opportunity to wash hands (30% versus 40%, P = 0.03) and more were served meals at uncluttered tables (54% versus 64%, P = 0.04). There was no difference in the number of patients experiencing mealtime interruptions (32% versus 25%, P = 0.14). There was no difference in energy intake (1088 versus 837 kJ, P = 0.25) and a decrease in protein intake (14.0 versus 7.5 g, P = 0.04) after PM. Conclusions: Only minor improvements in mealtime experience were made after the implementation of PM and so it is not unexpected that macronutrient intake did not improve. The implementation of PM needs to be evaluated to ensure improvements in mealtime experience are made such that measurable improvements in nutritional and clinical outcomes ensue.     

The impact of trained volunteer mealtime assistants on the dietary intake of older female in-patients: The Southampton Mealtime Assistance Study

Objective

Malnutrition among older hospital inpatients is common and is associated with poor clinical outcomes. Time-pressured staff may struggle to provide mealtime assistance. This study aimed to evaluate the impact of trained volunteer mealtime assistants on the dietary intake of older inpatients.

Design

Quasi-experimental two year pre and post- test study of the introduction of volunteer mealtime assistants to one acute medical female ward, with contemporaneous comparison with a control ward.

Setting

Two acute medical female wards in a university hospital in England.

Participants

Female acute medical inpatients aged 70 years and over who were not tube fed, nil by mouth, terminally ill or being nursed in a side room.

Intervention

The introduction of volunteer mealtime assistants to one ward to help patients during weekday lunchtimes in the intervention year.

Measurements

Patients’ background and clinical characteristics were assessed; 24-hour records were completed for individual patients to document dietary intake in both years on the two wards.

Results

A total of 407 patients, mean (SD) age 87.5 (5.4) years, were studied over the two-year period; the majority (57%) needed mealtime assistance and up to 50% were confused. Patients’ clinical characteristics did not differ between wards in the observational or intervention years. Throughout the intervention year volunteers provided mealtime assistance on weekday lunchtimes on the intervention ward only. Daily energy (median 1039 kcal; IQR 709, 1414) and protein (median 38.9 g: IQR 26.6, 54.0) intakes were very low (n=407). No differences in dietary intake were found between the wards in the observational or intervention years, or in a pre-post-test comparison of patients on the intervention ward. Data were therefore combined for further analysis to explore influences on dietary intake. In a multivariate model, the only independent predictor of energy intake was the feeding assistance required by patients; greater need for help was associated with lower energy intake (P<0.001). Independent predictors of protein intake were the feeding assistance given (P<0.001) and use of sip feeds; sip feed users had slightly higher protein intakes (P=0.014).

Conclusions

Trained volunteers were able to deliver mealtime assistance on a large scale in an effective and sustainable manner, with the potential to release time for nursing staff to complete other clinical tasks. The study participants had a low median intake of energy and protein highlighting the importance of patient factors associated with acute illness; a stratified approach including oral and parenteral nutritional supplementation may be required for some acutely unwell patients. The level of mealtime assistance required was the factor most strongly associated with patients’ poor intake of energy and protein and may be a useful simple indicator of patients at risk of poor nutrition.

     

A Quality Improvement System to Manage Feeding Assistance Care in Assisted-Living

Purpose

To describe a feasible quality improvement system to manage feeding assistance care processes in an assisted living facility (ALF) that provides dementia care and the use of these data to maintain the quality of daily care provision and prevent unintentional weight loss.

Visual contrast enhances food and liquid intake in advanced Alzheimer's disease

BACKGROUND & AIMS: Patients with severe Alzheimer's disease (AD) in long-term care have deficient contrast sensitivity and poor food and liquid intake. The present study examined how contrast manipulations affect these intake levels. METHODS: Participants were nine men with advanced AD. Independent variables were meal type (lunch and supper) and condition (baseline, intervention, and post-intervention). Dependent variables were amount of food (grams) and liquid (ounces). Data were collected for 30 days (10 days per condition) for two meals per day. White tableware was used for the baseline and post-intervention conditions, and high-contrast red tableware for the intervention condition. In a follow-up study 1 year later, other contrast conditions were examined (high-contrast blue, low-contrast red and low-contrast blue). RESULTS: Mean percent increase was 25% for food and 84% for liquid for the high-contrast intervention (red) versus baseline (white) condition, with 8 of 9 participants exhibiting increased intake. In the follow-up study, the high-contrast intervention (blue) resulted in significant increases in food and liquid intake; the low-contrast red and low-contrast blue interventions were ineffectual. CONCLUSIONS: Simple environmental manipulations, such as contrast enhancement, can significantly increase food and liquid intake in frail demented patients with AD.     

Dietary,Food Service,and Mealtime Interventions to Promote Food Intake in Acute Care Adult Patients

Malnutrition is common in acute care hospitals. During hospitalization, poor appetite, medical interventions, and food access issues can impair food intake leading to iatrogenic malnutrition. Nutritional support is a common intervention with demonstrated effectiveness. “Food first” approaches have also been developed and evaluated. This scoping review identified and summarized 35 studies (41 citations) that described and/or evaluated dietary, foodservice, or mealtime interventions with a food first focus. There were few randomized control trials. Individualized dietary treatment leads to improved food intake and other positive outcomes. Foodservices that promote point-of-care food selection are promising, but further research with food intake and nutritional outcomes is needed. Protected mealtimes have had insufficient implementation, leading to mixed results, while mealtime assistance, particularly provided by volunteers or dietary staff, appears to promote food intake. A few innovative strategies were identified but further research to develop and evaluate food first approaches is needed.     

Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents’ nutrition and well-being is required.     

Parent-reported feeding and feeding problems in a sample of Dutch toddlers

Little is known about the feeding behaviors and problems with feeding in toddlers. In the present questionnaire study, data were collected on the feeding behaviors and feeding problems in a relatively large (n = 422) sample of Dutch healthy toddlers (i.e. 18-36 months old) who lived at home with their parents. Results show that three meals a day was standard and the mean mealtime duration was 22 minutes. Most children eat independently and sit in a high chair. All of the generally recommended foods were consumed with a decreasing tendency across age groups. Of the total sample, 65% had at least one type of feeding problem. In seven percent of the cases feeding problems were moderate to severe and significantly related to parental concern. However, few had sought professional help. Two dimensions of feeding problems (i.e. pickiness and disturbing mealtime behavior) and three dimensions of parental management techniques could be identified. Several significant associations were found. For example, associations were found between pickiness and variables such as parental concerns, difficulties in learning to eat solid foods, and several food items. No associations were found between pickiness and mealtime duration. In conclusion, implications of the findings are discussed in relation to the treatment of severe feeding problems in toddlers with developmental disabilities.     

Person-centered feeding care: A protocol to re-introduce oral feeding for nursing home patients with tube feeding

Background

Although the literature on nursing home (NH) patients with tube feeding (TF) has focused primarily on the continuation vs. discontinuation of TF, the reassessment of these patients for oral feeding has been understudied. Re-assessing patients for oral feeding may be better received by families and NH staff than approaches focused on stopping TF, and may provide an opportunity to address TF in less cognitively impaired patients as well as those with end-stage conditions. However, the literature contains little guidance on a systematic interdisciplinary team approach to the oral feeding reassessment of patients with TF, who are admitted to NHs.

Methods

This project had two parts that were conducted in one 170-bed intermediate/skilled, Medicare-certified NH in Honolulu, Hawai‘i. Part 1 consisted of a retrospective observational study of characteristics of TF patients versus non-tube fed patients at NH admission (2003-2006) and longitudinal follow-up (through death or 6/30/2011) with usual care of the TF patients for outcomes of: feeding and swallowing reassessment, goals of care reassessment, feeding status (TF and/or per oral (PO) feedings), and hospice status. Part 2 involved the development of an interdisciplinary TF reassessment protocol through working group discussions and a pilot test of the protocol on a new set of patients admitted with TF from 2011-2014.

Results

Part 1: Of 238 admitted patients, 13.4% (32/238) had TF. Prior stroke and lack of DNR status was associated with increased likelihood of TF. Of the 32 patients with TF at NH admission, 15 could communicate and interact (mild, moderate or no cognitive impairment with prior stroke or pneumonia); while 17 were nonverbal and/or bedbound patients (advanced cognitive impairment or terminal disease). In the more cognitively intact group, 9/15 (60%) were never reassessed for tolerance of oral diets and 10/15 (66.7%) remained with TF without any oral feeding until death. Of the end-stage group, 13/17 (76.5%) did not have goals of care reassessed and remained with TF without oral feeding until death. Part 2: The protocol pilot project included all TF patients admitted to the facility in 2011-2014 (N=33). Of those who were more cognitively intact (n=22), 21/22 (95.5%) had swallowing reassessed, 11/22 (50%) resumed oral feedings but 11 (50%) failed reassessment and continued exclusive TF. Of those with end-stage disease (n=11), 100% had goals of care reassessed and 9 (81.8%) families elected individualized oral feeding (with or without TF).

Conclusion

Using findings from our retrospective study of usual care, our NH’s interdisciplinary team developed and pilot-tested a protocol that successfully reintroduced oral feedings to tube-fed NH patients who previously would not have resumed oral feeding.

     

Improving opportunities for food service and dietetics practice in hospitals and residential aged care facilities

Aim: Food is a phenomenon that everyone has an opinion on because eating is a frequent, often social occurrence, and as such the importance of mealtimes can be undervalued in healthcare settings. Some staff may not share our concerns about suboptimal dietary intakes as they assume that nutritional status will improve as people feel better. However, the provision and consumption of an appealing and adequate diet is a critical aspect of holistic health care. This review examines the role of dietitians in food services to improve the situation. Methods: A narrative review was formed with reference to the literature. Results: Labelling food service departments as a ‘hotel service’ or a ‘non‐clinical service’ does little to assist the perception of these services by others; to enhance the knowledge and skills needed by others about optimising dietary intake opportunities by the sick and elderly; or to enhance the communication that is needed between stakeholders about food and mealtimes. The issue of addressing malnutrition, reviewing and improving menus, mealtime environments, feeding assistance, communication between staff, and acknowledgement of the important care role of food service providers becomes even more relevant as the population ages and the demand for health care grows. Conclusion: This narrative highlights that the importance of dietitians building links with food services, leading high‐quality research, and improving the profile and recognition of food and mealtimes as integral to care, has never been greater.     

Mealtimes in nursing homes: striving for person-centered care

Malnutrition is a common and serious problem in nursing homes. Dietary strategies need to be augmented by person-centered mealtime care practices to address this complex issue. This review will focus on literature from the past two decades on mealtime experiences and feeding assistance in nursing homes. The purpose is to examine how mealtime care practices can be made more person-centered. It will first look at several issues that appear to underlie quality of care at mealtimes. Then four themes or elements related to person-centered care principles that emerge within the mealtime literature will be considered: providing choices and preferences, supporting independence, showing respect, and promoting social interactions. A few examples of multifaceted mealtime interventions that illustrate person-centered approaches will be described. Finally, ways to support nursing home staff to provide person-centered mealtime care will be discussed. Education and training interventions for direct care workers should be developed and evaluated to improve implementation of person-centered mealtime care practices. Appropriate staffing levels and supervision are also needed to support staff, and this may require creative solutions in the face of current constraints in health care.     

Incidence and nature of feeding problems in young children referred to a paediatric HIV service in London: FEAD screening

A detailed screening assessment was carried out on two matched groups of young children; one group was HIV-infected and the other was not. Screening included assessments of growth, development and food intake. Parents were also interviewed about their child's feeding and mealtime behaviours. Half of the HIV-infected children were reported with serious feeding problems; significantly higher than in the uninfected group. More of the children in the HIV-infected group were found to have poorer growth and developmental weaknesses than in the uninfected group. A combination of physical and psychological factors are suggested as contributing to these feeding difficulties. Early monitoring of feeding behaviours, daily routines and food intake, together with systematic growth and developmental measures are suggested as important components in the care and management of HIV-infected children.     

Mealtimes in Nursing Homes: Striving for Person-Centered Care

Malnutrition is a common and serious problem in nursing homes. Dietary strategies need to be augmented by person-centered mealtime care practices to address this complex issue. This review will focus on literature from the past two decades on mealtime experiences and feeding assistance in nursing homes. The purpose is to examine how mealtime care practices can be made more person-centered. It will first look at several issues that appear to underlie quality of care at mealtimes. Then four themes or elements related to person-centered care principles that emerge within the mealtime literature will be considered: providing choices and preferences, supporting independence, showing respect, and promoting social interactions. A few examples of multifaceted mealtime interventions that illustrate person-centered approaches will be described. Finally, ways to support nursing home staff to provide person-centered mealtime care will be discussed. Education and training interventions for direct care workers should be developed and evaluated to improve implementation of person-centered mealtime care practices. Appropriate staffing levels and supervision are also needed to support staff, and this may require creative solutions in the face of current constraints in health care.     

A new dental approach for reducing food intake

OBJECTIVE: A behavioral recommendation for weight loss is reduction of size of bites of food. This "proof of concept" study tested the efficacy of a new, patented, dental approach, the DDS System, for reducing food intake. This removable tool is inserted into the upper palate of the mouth, reducing the size of the oral cavity, thereby potentially reducing bite size. RESEARCH METHODS AND PROCEDURES: Thirty-two adults (18 to 65 years) with BMI between 27 and 40 were randomly assigned to the control or experimental conditions. Participants ate all meals and stayed between meals at a research center. Day 1 served as baseline for both groups. On Day 2, experimental participants utilized the tool during meals. Changes in subjective ratings of hunger and satiety were measured using visual analog scales before and after each meal. RESULTS: Food intake difference scores were calculated for each participant (Day 2 - Day 1). Analysis of covariance on difference scores, using baseline as a covariate, showed that the experimental group ate significantly less (p < 0.05) on the second day (M = -659.2 kcal/d) compared with the control group (M = -125.9 kcal/d). Analysis of covariance, with ratings on Day 1 as a covariate, revealed that the experimental and control group did not differ on visual analog scale difference scores (premeal - postmeal) from Day 1 to Day 2. DISCUSSION: These findings suggest that use of this tool during meals significantly reduced food intake. This reduction of food intake was not associated with changes in ratings of hunger or satiety.     

The effect of intensified diet counseling on the diet of hypertensive subjects in primary health care: a 2-year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland

BACKGROUND: Diet is an essential part of the nonpharmacological management of hypertension. The aim of this study was to investigate in a primary health care setting the effect of intensified diet counseling on the diet of hypertensive subjects. METHODS: A total of 715 free-living subjects, ages 25-74 years, with systolic blood pressure 140-179 mm Hg and/or diastolic blood pressure 90-109 mm Hg and/or drug treatment for hypertension participated in an open randomized trial with a 2-year follow-up at health centers in eastern Finland. The intervention group (n = 360) was advised to reduce their total fat, saturated fat, and salt intake and to increase monounsaturated and polyunsaturated fat intake as well as to reduce weight and to use alcohol in moderation if at all. The usual care group (n = 355) continued with their usual primary health care. The subjects filled out a 4-day food record, and 24-h urine samples were collected at baseline and at 1- and 2-year examinations. RESULTS: The 2-year net changes (change in intervention minus change occurring in usual care group) in total fat intake [-2.7 E% (95% CI -4.0, -1.6; P < 0.0005)], in saturated fatty acid intake [-1.7 E% (95% CI -2.3, -1.1; P < 0.0005)], and in body weight [-1.4 kg (95% CI -2.0, -0.8; P < 0.0005)] were significant. Furthermore, the 2-year net change in daily sodium intake was significant, -9 mmol (95% CI -17, -2; P = 0.021), but the 24-h urinary sodium excretion showed no difference between the study groups. CONCLUSION: The intensified diet counseling in primary health care resulted in dietary changes interpreted as being of benefit in the long-term treatment of hypertension and prevention of atherosclerotic vascular diseases.     

Final results of the Maryland WIC Food for Life Program

BACKGROUND: The few randomized community trials in middle-income populations that tried to modify multiple dietary risk factors for cancer only demonstrated small changes. This trial sought to decrease the percent of calories derived from fat and to increase fruit, vegetable, and fiber intake among low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Maryland. METHODS: We conducted six-month intervention programs for 1055 women at ten WIC sites; 1011 women served as controls. Intervention participants were invited to five interactive nutrition sessions and were sent written materials. Controls received usual care. Women were surveyed at baseline, two months post intervention, and one year later. All analyses conducted used an intention-to-treat paradigm. RESULTS: Mean differences (intervention-control) in change from baseline were for percent calories from fat -1.62 +/- 0.33% (P < 0.0001), for consumption of fruits and vegetables 0.40 +/- 0.11 servings (P = 0.0003), and for fiber intake 1.01 +/- 0.31 grams (P = 0.001). These differences in change were related in a dose-response relationship to the number of sessions women attended and remained significant one year post-intervention for the first two outcomes. CONCLUSIONS: Multiple dietary improvements can be achieved in a low-income population with an effective, multi-faceted intervention program. The changes in this trial exceeded those in previous community trials conducted in higher SES populations.     

Current dietary zinc intake has a greater effect on fractional zinc absorption than does longer term zinc consumption in healthy adult men

BACKGROUND: No studies have examined the independent effects of current and longer-term dietary zinc intakes on zinc absorption. OBJECTIVE: We determined the effects of current compared with longer-term zinc intake on fractional zinc absorption (FZA). DESIGN: We studied 9 men whose usual zinc intakes were >11 mg/d. FZA was measured at baseline, depletion (0.6 mg Zn/d for 1 wk and 4 mg Zn/d for 5 wk), and repletion (11 mg Zn/d for 4 wk with 20 mg supplemental Zn/d for first 7 d). During 2 successive days after each dietary period, subjects consumed either adequate-zinc meals (11 mg Zn/d) with a zinc stable isotope tracer for 1 d, followed by low-zinc meals (4 mg Zn/d) with zinc tracer, or vice versa. Five days after oral dosing, a zinc tracer was infused intravenously. FZA was measured with the use of a modified double isotope tracer ratio method with urine samples collected on days 5-7 and 10-12 of absorption studies. RESULTS: Plasma and urinary zinc did not vary by dietary period. Mean FZA was greater from low-zinc meals than from adequate-zinc meals (60.9% +/- 13.8% compared with 36.1% +/- 8.9%; P < 0.0001), whereas mean total absorbed zinc was greater from adequate-zinc meals than from low-zinc meals (3.60 +/- 0.91 compared with 2.48 +/- 0.56; P < 0.0001), regardless of the longer-term dietary period. CONCLUSIONS: FZA was inversely related to current zinc intake, but there was no detectable effect of longer-term dietary zinc. If longer- term zinc intake does modify FZA, such changes are smaller than those caused by current zinc intake, or they occur only after more severe zinc depletion.     

The prevalence and impact of 'atypical' days in 4-day food records

OBJECTIVE: To understand how days with atypical food intake affect estimates of usual nutrient intake from 4-day food records. PARTICIPANTS/SETTING: Secondary analyses of 4-day food records (4DFRs) (n = 2,560) collected from 1,090 women, aged 50 to 79 years, who participated in the Women's Trial Feasibility Study in Minority Populations, a randomized dietary intervention trial. DESIGN: Food records were classified as atypical if participants marked one or more day's food intake as "more than usual" or "less than usual." Total amounts and nutrient densities (percent of energy or grams per 1,000 kcal) were examined for all macronutrients, fiber, vitamin C, beta carotene, and calcium. STATISTICAL ANALYSIS: Contingency tables were used to examine associations of demographic characteristics with the likelihood of completing a 4DFR with atypical intake days. Analysis of variance was used to test whether nutrient intake differed among records with and without atypical days. Student t tests were used to identify any differences in total energy and percent energy from fat among typical and atypical intake days. RESULTS: Approximately 16% of records included at least 1 atypical day. Reporting less-than-usual intake was associated with younger age, higher income, and higher body mass index. Black women were less likely to report more-than-usual intake than whites and Hispanics. Records with less-than-usual intake had lower intakes of all nutrients analyzed except alcohol; however, there were no differences in nutrient densities. Records with more-than-usual intake had higher intakes of alcohol and all nutrients except beta carotene and vitamin C, with higher nutrient density measures of alcohol and decreased nutrient density measures of protein, vitamin C, and fiber. CONCLUSIONS: Atypical intake days are common in 4DFRs and they have a large effect on mean total intakes of most nutrients. APPLICATIONS: It is important for researchers to collect information on atypical intake days included in a 4-day food record. Strategies are needed to incorporate information on atypical intake days when analyzing and interpreting research results.