Transcript Mechanically Altered Diets

Dysphagia Diets and Appropriate Diet Consistencies
Dietary Managers Association
Thursday February 4, 2016
Presented by : Jeanine O’Toole RD
( Corporate Dietitian Brandywine Senior Living)
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What is Dysphagia?
It is defined as a difficulty or discomfort in swallowing.
This condition can range from mild discomfort such as a feeling that there
is a lump in your throat, to severe inability to control the muscles needed
for chewing and swallowing.
Dysphagia is medically described as a lack of pharyngeal sensation, causing
difficulty for solids and fluids to be passed from the mouth to the stomach.
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How does swallowing occur?
Food must be chewed thoroughly, then it is moved to the back of the mouth by
tightening the cheek muscles and pressing the tongue against the roof of the mouth.
From this point the process should be automatic. The food enters the pharynx and into
the esophagus, while the body automatically closes the epiglottis.
If this process fails and the foods and fluids switch direction and go through the trachea
into the lungs, side effects are choking and pulmonary aspiration.
The human body has an automatic response when eating and swallowing, it will temporally
close the epiglottis as swallowing is occurring.
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Signs and Symptoms of Dysphagia:
Some people have limited awareness of their dysphagia, if it goes undiagnosed
untreated patients are at increased risk of pulmonary aspiration, weight loss,
malnutrition and dehydration.
Symptoms:
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Food and drink leaking from mouth
Gurgling voice after eating and drinking
Coughing during or after eating
Extra effort or time needed to complete meals
Frequent pneumonia
Weight loss
Dehydration
Repetive swallowing or progressive need to clear throat
Clear liquid discharge from nose
Weakness or lack of control of head or neck muscles
Fullness or tightness in throat
Pressure or pain in the chest
Frequent heart burn
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What can cause Dysphagia?
There are numerous underlying causes which include, stroke, neurological
conditions such as Multiple Sclerosis, Parkinson's Disease, ALS, Alzheimer's, Dementia.
Dysphagia can also be the result of localized trauma or muscle damage to the
esophagus muscle,a tumor or swelling that can partially obstruct
the passage of food.
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Types of Dysphagia:
Esophageal Dysphagia : caused by an abnormality in the esophagus.
The muscles malfunction and can not push the food properly down into the stomach
Oropharyngeal Dysphagia : caused by difficulty in initiating the swallowing process.
This makes it difficult for solids and liquids too move out of the mouth
properly into the throat.
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Consequences of Dysphagia
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Malnutrition
Dehydration
Embarrassment
Social Isolation
Decreased enjoyment from eating
Anger/ Agitation
Lung Infections
Urinary Tract Infections
Slower wound Healing
Depression
Weight Loss
Increase risk for skin wounds
Decline in ADL functioning
Increase risk of death
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Dysphagia Diagnosis
Evaluation and testing is performed by a licensed speech language
Pathologist (SLP), or physician with specialty in Ear Nose and Throat or
Gastroenterologist.
Evaluations can start tableside as patient is monitored and evaluated eating and
drinking different food textures and liquid consistencies. If dysphagia diagnosis is
suspected, often additional formal swallowing tests are performed in a hospital
called a Modified Barium Swallow test, a patient is observed with an x-ray
as they chew and swallow different foods and fluid consistencies that are coated with
a barium substance that can be seen on the x-ray clearly, to evaluate if swallowing
or aspiration difficulty is noted.
Upon diagnosis an appropriate safe food and fluid consistency will be recommended
per the SLP or MD.
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Dysphagia treatment:
Treatment generally requires the involvement of the speech pathologist to provide
treatment and strategies to help maintain safe swallowing practices and minimize the
risk of aspiration or choking.
Dysphagia can seriously compromise the nutritional status of a patient or resident.
Temporary measures such as tube feedings or TPN (feeding a person intravenously),
can be utilized to immediately remedy the problem.
Long term goals are rehabilitation, which focuses on helping the patient or resident recover
the ability to swallow sufficient amounts of food and drink to assure adequate nutrition.
There are different stages of swallowing. Each patient case is particular and an appropriate
diet consistency is extremely important.
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What is a Mechanically Altered Diet?
They consist of foods and fluids that can be safely and successfully swallowed.
Foods are altered by whipping, blending, cutting, chopping, grinding or mashing, so they
are easy to chew and swallow.
The National Dysphagia Diet Guidelines are categorized on a level system,
for food consistencies as well as liquids.
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Levels of Dysphagia
National Dysphagia Level 1 : Pureed Nutrition Therapy
Moist puree foods, presented as a pudding like consistency without pulp or
small particles. NO CHEWING is required. All bread items should be pureed or
slurred.
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National Dysphagia Level 2 : Mechanically Altered Nutrition Therapy
This diet is a transition from pureed textures to more solid textures. Chewing ability is required
Foods are moist, soft and easily formed into a bolus.
• Meats are ground or minced with additional moisture from gravy and sauces provided.
Meat pieces should not exceed ¼ inch cube and need to be tender. Dry tough meats
such as bacon, sausage and hot dogs should be eliminated. Protein salads such as tuna, chicken
and egg salad should be without large chunks and moist. AVOID casseroles that contain rice.
• Canned fruits and ripe banana are allowed. Eliminate all fresh and frozen fruits, unless
pureed. (omit pineapple canned or fresh)
• Vegetables are cooked well and cut into ¼ diced pieces. Fibrous vegetables are omitted or served
puree. (corn, peas, broccoli, cauliflower, asparagus, Brussel sprouts). Omit all raw vegetables.
• Bread products need to be pureed or slurried. Soft pancakes well moistened with syrup are allowed.
Cooked cereals should have little texture. Some dry cereals are allowed as long as they are well
moistened and with little texture. (Rice Krispy, corn flakes, bran flakes) NO dried fruits, coconut,
or nuts to be added to hot or cold cereal.
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National Dysphagia Level 3 Advanced Nutrition Therapy
This diet is a transition to a regular diet. Cohesive, moist semisolid food which requires
some chewing. Foods are nearly regular textures with the exception of a very hard, sticky
or crunchy foods. Menu items still need to be moist and should be bite size pieces at the
oral phase of swallowing.
• Meats are typically cut up, ground or shaved.
• Fruits and vegetables are fork tender and mashable
• Bread items are allowed (no toast, dry crackers or tough crusty breads)
items such as pancakes, waffles, biscuits should be well moistened with syrup and butter
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Thickened Liquids
Dysphagia may not only affect ability to eat, but often can effect an individuals
ability to drink.
Often straws or carbonated beverages are avoided to ease swallowing, however at times
changes to the liquids consistency is necessary for safe swallowing.
Fluids can be served in 4 different consistencies.
1. Thin Liquids-
No restrictions all beverages are served as usual.
Water, milk, juice, tea, coffee, ice cream
sherbet, broth based soups.
2. Nectar Liquids-
Liquids must be thickened to nectar consistency, such as
maple syrup, peach or apricot nectar, eggnog, buttermilk
tomato or cream soup consistency. Well chilled supplements
such as Ensure or Mightyshakes are nectar thick. All nectar
liquids should be able to drink through a straw.
3. Honey Liquids-
Liquids are honey consistency, and should NOT be able to be sipped
through a straw.
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4. Pudding Liquids-
Liquids are pudding thick, and must be taken with a spoon.
Anything that is liquid at room temperature is considered a liquid.
This includes (ice cream, ice cubes, sherbet, popsicles, water ices,
cream ices, soups and broths.
Thickening can be done using commercial thickeners,
Nectar = 1 ½ teaspoons thickener per 4 oz. thin liquids
Honey = 1 ½ Tablespoons thickener per 4 oz. thin liquids
Pudding = 2 Tablespoons thickener per 4 oz. thin liquids
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• Generally most thickening agents need to sit at least 2-3 minutes to
set to appropriate thickness.
• If liquid becomes too thick, thin liquids can be added to reduce to a
thinner consistency
• Hot beverages tend to get thicker once it cools off.
• Carbonated drinks can be thickened but will generally lose it
carbonation through the stirring process.
Common Thickeners
-Banana Flakes
-Cooked cereal (cream of wheat, rice)
-Cornstarch
-Gravy
-Instant Potato Flakes
-Mashed Potatoes
-Unflavored Gelatin powder
-Pureed fruits and Vegetables
-Pureed Meats
Commercial Thickening Agents, can often change consistency once
refrigerated, and taste can sometimes be altered.
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Basic Guidelines for People using Thickeners
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All liquids must be thickened. Avoid thin liquids
Do not serve anything that melts, such as ice cream, sherbet, ice cubes,
Encourage fluids due to high risk for dehydration. Goal 6-8 cups daily
Allow extended time to complete meals
Encourage eating and drinking in an upright position.
Avoid moist and juicy foods. (watermelon, oranges, grapes, canned fruit, jello)
Straws should not be used, increased risk of aspiration
Monitor weight and intake. Poor intake can lead to malnutrition and dehydration
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References
1. National Dysphagia Diet Task Force (2002)
National Dysphagia diet standardization for optimal care. Chicago Illinois
American Dietetic Association
2. Goulding R. and Bathetic AM (2000)
Evaluations of Monitoring Fluid Thickeners in the dietary management
of Dysphagia stroke patients
3. McCallum . SL (2003)
The National Dysphagia Diet : Implementation at a regional rehabilitation
center and hospital system.
Journal of American Dietetic Association
4. Sayadi R and Herskowitz J. (2010)
Swallow safely : How swallowing problems threaten the elderly and
others. A care givers guide to recognition, treatment and prevention
( 1st edition )
5. Elaine N. Marieb (2015)(Ele
Essentials of Human Anatomy and Physiology (Eleventh Edition)
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