Transcript Dietetics and Dysphagia - Ageing, Disability and Home Care

Dietetics and Dysphagia
Karen Davison Dietitian
Practice Development Team - Illawarra and Shoalhaven
How can we meet the nutritional needs of people with dysphagia ?
How can we meet the nutritional needs of people with dysphagia?
To meet nutritional needs takes so much more than just nutrition
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What does food mean to the person- how has the change affected them?
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How does the modification of texture affect the nutrition in foods?
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What should we think about when it comes to presentation – the dietetic
perspective?
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What else should be consider when working with disability?
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How can we improve the knowledge and skills of people we work with? –
description of menu planning project
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What clinical conditions and challenges affect nutrition ? – case study
What does food mean to us?
“………because eating is the only thing we do that involves all the senses. We
eat with our eyes and our ears and our noses. You think about some of the
most memorable meals you’ve ever had, the food will be good but it will often
be about locating a mental memory and taste is linked to all the other
senses…..”
Heston Blumenthal
The psychological effect of eating and drinking with dysphagia
Some perspectives on modified consistency diets……..
“I’m picking my foods differently because some are harder to chew. So I’m
eliminating some that I should be eating”
“But every once in a while it would hit me and I’d start to choke…I’d get
sneezing attacks therefore would get the food out of my nose. Its kind of
embarrassing. I don’t like to go out to dinner”
“How would you know what to give to keep strength if it got to the point they
couldn’t manage solids”
“You can last without food for a while but coughing and choking is right then –
you can’t breathe, its certainly not the way I want to die. That’s awful”
Martino R, Beaton D et al
More perspectives on modified consistency diets……
“ horrified, frustrated, angry, upset, sad, depressed, down in the dumps, confronting, loss”
“….he loved his food and one day choked on a bit of chicken and was downgraded to minced moist.
He became very sad and depressed because he felt like his was his right to eat normal food and this
was taken away from him. He was really really down in the dumps” (care worker)
“I eat it because I don’t want to lose any more weight. I eat it because I have to but I’m not enjoying
eating this…..”
“ and said…..oh she’s minced moist. I was very upset about it and asked why”
“I’ve seen a couple of people go from the normal food to the modified, there is no slow change to it, its
just boom one day its normal and the next day they’re like ‘where’s my food” (care worker)
“I put a lot of pepper and salt, tomato sauce or anything I can find to disguise or give it taste because
its got no taste”
Ullrich S Crichton J 2015
Factors to consider
Smell
Visuals
Texture
Colour
Taste
Environment
Utensils
Temperature
Nutritional considerations
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What is the recommended intake for nutrients? – Nutrient reference values,
Australian Guide to Healthy Eating
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What happens to nutrition as a diet is modified?
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Which nutrients change or become depleted as the texture and food choice
changes?
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What are the consequences of this?
Normal consistency
Breakfast
Branflakes, milk, glass orange juice, cup of tea
Morning tea
Coffee made with milk, oatmeal biscuit
Lunch
Tuna and salad sandwich on granary bread, apple, yoghurt
Afternoon tea
Cup of tea, handful of almonds, banana
Dinner
Grilled steak, baked potatoes, steamed carrot, broccoli and corn
Before Bed
Milky drink
Normal consistency
Energy
135% DEER
Protein
231%
Thiamin
166%
Riboflavin
Niacin.Eq
Vitamin C
Vit.B6
147%
Vit.B12
Folate-DFE
213%
Tot.Vit.A.Eq
122%
Magnesium
163%
Calcium
111%
Phosphorus
191%
Iron
104%
Zinc
205%
Selenium
167%
Iodine
0%
122%
40%
80%
120%
160%
200%
Soft
Breakfast
2 weetbix with milk, small glass orange juice, cup of tea
Morning tea
Coffee made with milk, soft cookie
Lunch
Tuna mayo sandwich, plain yoghurt with mango
Afternoon tea
Cup of tea, soft banana
Dinner
Shepherds pie, mashed carrot and broccoli florets with gravy
Custard and diced peaches
Before Bed
Milky drink
Soft
Energy
103% DEER
Protein
129%
Thiamin
151%
Riboflavin
185%
Niacin.Eq
Vitamin C
112%
Vit.B6
89%
Vit.B12
101%
Folate-DFE
125%
Tot.Vit.A.Eq
140%
Magnesium
107%
Calcium
75%
Phosphorus
117%
Iron
57%
Zinc
101%
Selenium
152%
Iodine
0%
96%
40%
80%
120%
160%
200%
Minced and moist
Breakfast
Porridge, small glass orange juice, cup of tea
Morning tea
Milky coffee, crème caramel
Lunch
Lentil and tomato soup, creamed rice pudding with puree apple
Afternoon tea
Cup of tea, mashed banana
Dinner
Shepherds pie, mashed carrot and broccoli florets with gravy
Custard and mashed, diced peaches
Before Bed
Milky drink
Minced and moist
Energy
81% DEER
Protein
120%
Thiamin
71%
Riboflavin
191%
Niacin.Eq
158%
Vitamin C
71%
Vit.B6
60%
Vit.B12
117%
Folate-DFE
50%
Tot.Vit.A.Eq
128%
Magnesium
88%
Calcium
122%
Phosphorus
Iron
136%
28%
Zinc
87%
Selenium
57%
Iodine
0%
102%
40%
80%
120%
160%
200%
Smooth puree
Breakfast
Porridge, small glass orange juice, cup of tea
Morning tea
Milky coffee, plain yoghurt with puree mango
Lunch
Creamed chicken soup – small bowl, puree rice pudding and apple
Afternoon tea
Cup of tea, puree banana
Dinner
Puree shepherds pie, puree carrot, puree broccoli floret with gravy
Custard and puree peaches
Before Bed
Milky drink
Smooth puree
Energy
73% DEER
Protein
96%
Thiamin
80%
Riboflavin
161%
Niacin.Eq
130%
Vitamin C
56%
Vit.B6
46%
Vit.B12
101%
Folate-DFE
43%
Tot.Vit.A.Eq
89%
Magnesium
74%
Calcium
90%
Phosphorus
Iron
105%
25%
Zinc
76%
Selenium
47%
Iodine
0%
88%
40%
80%
120%
160%
200%
Smooth puree fortified
Breakfast
Porridge - fortified small glass orange juice, cup of tea
Morning tea
Milky coffee, plain yoghurt, puree banana
Lunch
Creamed chicken soup - fortified– small bowl, puree rice pudding and
apple
Afternoon tea
Cup of tea, plain cake and custard puree
Dinner
Puree shepherds pie with extra butter and cheese, puree carrot, puree
broccoli floret with gravy
Custard with puree peaches
Before Bed
Milky drink
Smooth puree fortified
Energy
147% DEER
Protein
151%
Thiamin
91%
Riboflavin
262%
Niacin.Eq
Vitamin C
174%
40%
Vit.B6
53%
Vit.B12
183%
Folate-DFE
46%
Tot.Vit.A.Eq
159%
Magnesium
79%
Calcium
157%
Phosphorus
Iron
171%
32%
Zinc
Selenium
118%
78%
Iodine
0%
139%
100%
200%
300%
Dietary modifications
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The higher the texture modifications the more likely the diet is to be deficient
in nutrients.
Some people will have to make more significant changes than others.
Key nutrients are energy, protein, iron, folate, magnesium, zinc vitamin C
and some B vitamins.
Diets also tend to be low in fibre.
Fluid intake can be problematic especially if on modified fluids.
This is due to the dilution of foods, smaller portions of meat, fish and poultry
and the elimination of green vegetables especially and some fruits.
Nutrient content of the diets will also be altered by longer cooking times
especially for water soluble vitamins such as vitamin C.
Nutrition should be monitored and assessed for everyone requiring a
modified consistency diet.
Effects of poor nutrition
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Poor general health in an already compromised population
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Respiratory illness and longer recovery time
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Hospital admissions increased and length of stay increased
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More likely to miss school/work
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Decreased quality of life
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Delayed healing and pressure areas
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Poor immune function
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Linear growth failure
Additional challenges in dysphagia when working with disability
Cognitive
function
Mealtime
support
Nutritional
status
Client
Medical
Communication
conditions
Behaviour
Drugs
Nutritional intervention
Nutritional status – assessment and ongoing review
Nutritional requirements met – NRV’s
Is fluid intake adequate – especially if modified?
Is food fortification appropriate?
Nutritional supplements
Multivitamins and minerals
How do we achieve good nutrition and safe diets for dysphagia within
disability services?
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Multidisciplinary approach
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Never assume carers’ knowledge of modified consistency diets
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Carers have the responsibility to ensure the correct diet and consistency for
the person they are caring for
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There may have multiple diets to cater for at once
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There will be a wide range of cooking skills and nutritional knowledge
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Education and training ongoing
Modified consistency project within group homes
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Nutrition project developed in 2013 after dietetic review and menu analysis
of group home menus and in conjunction with Mealtime Management Plan
project.
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Indication that there was lack of consistent dietetic input to the group homes
– particularly for modified consistency diets
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Many of our group homes have people who need modified consistency diets
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The project aimed to provide dietetic support and training for staff to ensure
practical, appealing and nutritionally complete food choices for people
requiring modified consistency diets
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Resources and training was provided and help was given with menu
planning
Training requirements within the project
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Group homes were prioritised for intervention as part of the Mealtime
Management project
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Dietitian and speech pathologist met with the group homes identified to
establish issues with mealtime management plans, dietary intervention,
barriers to managing the diets
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Training and education took place re modified consistency with dietitian and
speech pathologist
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Dietitian helped each group home to develop menu plans
Example
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Group home has 4 clients
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1 minced moist diet
1 soft diet
1 person has diabetes (controlled with diet)
1 person has coeliac disease – gluten free diet
3 of the clients were of normal weight but the person with diabetes had a tendency to gain
weight
Examples of issues and barriers
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Group home staff had varied cooking skills from the keen cook to little skills or interest
Difficult to cook for lots of different diets, likes and dislikes
Time issues
Different feelings about why people have to follow this in the first place
Lack of understanding regarding the different categories of modified consistency and food
choice within these
Lack of ideas
Incomplete menu plans so hard to work out if the diets were able to meet nutritional needs
Sample menu
Mon
Tues
Chicken
Cottage
curry and pie
rice
Veg
Veg
(Corn flour
in sauce)
Wed
Thurs
Fri
Sat
Sun
Chicken
schnitzel
Veg
Zucchini
slice
Fish and
chips or
take
away
Sweet
and sour
pork
Rice
noodles
Baked
dinner
Issues addressed
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Updated Mealtime Management Plans
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What were the dietary restrictions and nutritional status of clients?
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Are we being person centered?
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What were the clients likes and dislikes, food preferences?
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House routines with regard to shopping, times to eat, weekend routines?
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Staff cooking skills, recipe books
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Eating out – restrictions and practice?
Improved menu
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Chicken curry
(pumpkin and
zucchini in curry –
see recipe) and
rice
Cottage pie
peas, carrots,
broccoli
Chicken Schnitzel
Potato wedges
Corn, green beans
Carrot and zucchini
slice
mixed salad
Fish and chips
Mixed salad
Sweet and sour
pork with rice
noodles
Roast lamb and
gravy with carrots,
broccoli and
pumpkin
roast potatoes
Minced & moist
Ensure all the food
is tender and rice is
soft – serve with
plenty of sauce
- May need to
pulse separately
Minced & moist
No peas
Mashed carrots,
mashed tender
broccoli in gravy
(florets only)
Minced & moist
Chicken casserole
with carrot and
pumpkin (from
freezer)
Mashed potatoes
Creamed corn
May need to pulse
separately
Minced & moist
Serve with plenty
of extra sauce and
ensure no crunchy
toppings.
Minced & moist
Fish baked in
tomato sauce (see
recipe)
mashed potatoes
with cheese
Soft broccoli florets
in sauce.
Minced & moist
Pork casserole with
pumpkin and sweet
potato
Soft pasta with
sauce
Ensure meat is
tender may need to
pulse separately
Minced & moist
Ensure meat and
veg are tender with
plenty of gravy and
mashed potatoes
instead of roast
Soft
Ensure all the food
is tender and rice is
soft– serve with
plenty of sauce
Soft
No peas
Mashed carrots,
mashed tender
broccoli in gravy
(florets only)
Soft
Chicken casserole
with carrot and
pumpkin (from
freezer)
Mashed potatoes
Creamed corn
Soft
Serve with plenty
of extra sauce and
ensure no crunchy
toppings.
Soft
Fish in tomato
sauce
mashed potatoes
with cheese
Soft broccoli florets
in sauce
Soft
Pork casserole with
pumpkin and sweet
potato
Soft pasta with
gravy
Soft
Ensure meat and
veg are tender with
plenty of gravy and
mashed potatoes
instead of roast
Gluten free
Diabetic
Gluten free
Diabetic
Gluten free
Diabetic
Gluten free
Diabetic
Gluten free
Diabetic
Gluten free
Diabetic
Gluten free
Diabetic
Soft diets – ensure all vegetables and meats are tender and no bigger than 1.5cm, meals should be mashable with a fork
Minced and Moist diet – food is soft and moist and should form into a ball requiring little chewing. Pieces no larger then 0.5cm
Additional information and education
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Information was also given from Australian Standards for Texture Modified
Foods and Fluids with expanded food lists
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Information was given re suitable foods for breakfasts lunches and snacks
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Modified fluid information was given
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Recipe book was produced with a range of recipes which could be used for
modified consistency diets – these had eg crunchy vegetables removed and
replaced, additional fluid added to recipes and guidelines on how to adapt
for each diet added as a reference for staff
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Staff were encouraged to make food decisions “squish test”
Sample recipe
Chicken and Pumpkin Curry
Serves 4 -5
Ingredients
4 tsp korma curry paste
8 skinless and boneless chicken thighs (check
no bones or gristle)
200g pumpkin peeled and cubed
4tbsp red lentils
1 carrot peeled and sliced
300mls chicken stock
400mls coconut milk
½ cup low fat natural yoghurt
Heat the oil in a large saucepan, stir in the curry paste and fry for 1 minute.
Add the chicken, pumpkin, carrot and lentils and stir to coat in the paste, and then pour in the stock and coconut milk.
Bring to the boil, and then simmer for 30 minutes, covered until the chicken and vegetables are very tender. If the sauce
is a little thin take the lid off and reduce for a few minutes. If too thick add some more stock.
Add some natural low fat yoghurt to serve.
Modify for
Soft diet – ensure the chicken and vegetables are tender and can be easily broken up with a fork. Serve with plenty of
sauce . Pieces should be no bigger than 1.5cm
Minced and Moist – may need to be lightly pulsed in a blender with plenty of sauce, pieces should be no bigger than
0.5cm
Smooth Puree – puree until smooth in a blender – serve with sweet potato instead of rice
Case study
Introduction
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Client has cerebral palsy, epilepsy, GORD, constipation, classification 5 on GMFCS scale
22 year old female and has lived in a group home since the age of 18
Dependent on others for eating and drinking
Issues
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Ongoing feeding issues weight loss and lengthening time to eat and drink
Weight loss in past 2 years
Ongoing issues with scoliosis and positioning
At risk of pressure injury
Increasing chest infections and periods of illness
Determined to enjoy food and finish at mealtimes although very slow
Previous joint dietetic and speech pathology visits
Weight loss and poor fluid intake
Dietetic assessment
Weight history
45 kg, estimated height 1.47m BMI 20.28 kg/m² - borderline underweight
53kg 6 months previously, 57kg at age 18 yrs ~ 15% weight loss in 6 months, over 20% in past 2 years.
Diet history mildly thick fluids and puree diet
Breakfast
Porridge – ½ bowl
Thickened orange juice – mildly thick – 150ml
Thickened tea – 150ml
Snacks
Yoghurt/ custard pot/ thickened drinks – cordial 200mls
Lunch
Soups/ puree from night before, yoghurt – few spoonfuls taken at day placement
Less than 100mls fluid
Dinner
Puree diet eg shepherds pie small bowl– usually eats well full portion
Custard or yoghurt, thickened drinks – 150mls
Dietetic assessment cont.
Requirements
~1550kcal (6510kJ), 50g protein, 1700mls fluid
micronutrients to Nutrient Reference Values
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Not meeting requirements for energy, protein or micronutrients at this intake
Diet low in most micronutrients including iron, vit C, magnesium, folate
Fluid intake poor less than 1000mls
Moderately malnourished
At risk of becoming severely malnourished and dehydrated
Action
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Joint feeding assessment dietetics, speech pathologist key worker and
manager from group home
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Speech pathology recommendations made and Mealtime Management Plan
revised
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Smooth puree diet
level 400 moderately thick fluids
Also advice re spoon size, timings, length of mealtime and reminder re good positioning
Dietetic recommendations
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Nutritional supplements trialed and type of supplement decided (Flavour creations range)
Given recommendations on number and usage to meet recommended intakes
Regular monitoring of weight and food record charts
Food fortification advice given
Encouraging with foods which have a high fluid content
Timings of meals and supplements also important to prevent overfilling and further aspiration
Action cont.
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Mealtime Management Plan and dietetic recommendations implemented by
group home
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Staff meeting attended
Recommendations discussed
Physio and OT referral
General medical review
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Joint recommendations also made for gastro appointment for consideration
of alternative form of feeding e.g. gastrostomy as concerns re deterioration
in swallow and difficulty in maintaining nutrition
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Parents contacted for consent.
Outcome
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After 3 months, with monthly joint reviews, the client had gained weight now 48kg and
intake improved with implementation of joint advice – although fluid intake continued
to be poor.
Respiratory and general health had improved.
Decision made by gastroenterology after multidisciplinary assessment to assess for
PEG as a back up in times of illness or poor nutrition.
Plans made for PEG insertion.
Gastro unable to insert PEG planned surgical gastrostomy insertion planned instead
Surgical insertion done 6 months later – liaison with hospital dietetic and speech
pathology departments.
Gastrostomy is used as a back up for days when intake and fluid intake poor –
although difficult to determine on a plan. Care is required not to over feed as client did
experience one episode of reflux with the gastrostomy bolus feed.
Client preference for diet which she continues to enjoy and thickened fluids despite
poor fluid intake.
Summary of case study
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Joint multidisciplinary assessment and intervention is essential for a good
outcome
Staff from group homes need to be involved at all stages in assessment and
planning
Clear concise plans and education with regular follow up – keeping
everyone informed
Nutritional supplements have an important role in boosting nutrition but
should be used with clear guidelines
Recommendations for gastrostomy placement should be multidisciplinary
and done in conjunction with the treating hospital team. Also need to
consider practicalities of gastrostomy care and the implications for the
person
People who have a gastrostomy are still at risk of aspiration and meeting
nutritional requirements may continue to be challenging in some cases
In conclusion………..
To meet nutritional needs takes so much more than just nutrition
•
What does food mean to the person- how has the change affected them? 
•
How does the modification of texture affect the nutrition in foods? 
•
What should we think about when it comes to presentation – the dietetic
perspective? 
•
What else should be consider when working with disability? 
•
How can we improve the knowledge and skills of people we work with? 
•
What clinical conditions and challenges affect nutrition ? 
References
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Atherton, M., Bellis-Smith, N., Chichero, J. &Suter, M. (2007) Texture –
Modified foods and thickened fluids as used for individuals with dysphagia:
Australian standardised labels and definitions, Nutrition and Dietetics, 2007,
64, 2 Supp.:s53-s76
Keller H, Chambers L et al, Issues associated with the use of modified
texture foods, JNHA: Nutrition, 2012, Vol16, No 3
Martino R, Beaton D et al, Perceptions of psychological issues related to
dysphagia differ in acute and chronic patients, Dysphagia, 2010 25:26 – 34
Ullrich S, Crichton J Older people with dysphagia transitioning to texture
modified food, British Journal of Nursing, 2015, Vol 24, No13
Bell K, Samson – Fang, Nutritional management of children with cerebral
palsy, European Journal of Clinical Nutrition, 2013, 67: ppS5-8