Sue Baic MSC RD Consultant Dietitian to apetito and Wiltshire Farm Foods.
Successful swallowing is a highly complex process. During the initial stages - the oral and oral preparation stages - the facial muscles, lips, tongue and jaw are involved in controlling food and fluid in the mouth, in chewing and in bolus formation. Under normal conditions the act of the food bolus or fluid hitting the back of the mouth stimulates the swallow centre in the brainstem triggering the swallow reflex. This stage is under involuntary control and allows food and liquids to be moved smoothly from the mouth through the pharynx and into the oesophagus. During this process, the airway is temporarily closed off as a result of elevation of the larynx and closure of the epiglottis, in order to prevent aspiration of food or fluid into the lungs.
However when any stage of this swallow process is disrupted as a result of mechanical or neurological damage to the head or neck, swallowing difficulties (dysphagia) can occur. Dysphagia can lead to problems with adequate food and fluid intake and a real risk of aspiration - the entry of these items in to the airway, which may lead in turn to bronchopulmonary infections including aspiration pneumonia (1-6).
Dysphagia can occur as a result of a wide range of medical problems (see Table 1). It may come on gradually, as is the case in many progressive neurological conditions. In addition to this, impairment in cognitive function influencing concentration and attention, or tongue and facial muscle strength, which may occur with ageing and in some progressive medical conditions, can affect exacerbating dysphagia (1) or more suddenly following physical insult or a brain lesion resulting from stroke. For example the presence of dysphagia has been detected in as many as 64-78% of cerebral and brain stem stroke patients in the acute phase (1). In this group swallowing problems may resolve within the first few weeks, but for a subgroup it persists for several months and is associated with at least a three fold increase pneumonia risk (1).
Table 1 Medical conditions which can lead to dysphagia
|Head and neck cancer
||Injury or surgery to the head or neck
|Motor neurone disease
|Stricture or spasm in oesophagus
Early assessment of the presence or extent of dysphagia in an individual by a speech and language therapist or other appropriately trained specialist health professional is important. The gold standard for detection of dysphagia is considered to be videofluoroscopy(3). This involves recording and observing the dynamic swallow under x-ray using radio opaque food and fluids. Assessment will establish whether oral feeding is still possible and safe for the patient. If so, the simplest, cheapest and most palatable way of meeting nutritional requirements will be by encouraging and enabling the patient to access nutritious food and drinks.
Dietetic Management of Dysphagia
Texture-modification of food and fluids in a form that can be swallowed without aspiration is an important part of the dietetic management of many patients with dysphagia. This allows food or fluid to be delivered to the individual patient in the consistency which best allows them control over the rate it passes through the pharynx (7-8). Patients may need different consistencies at different stages of their condition, for example, progressing stepwise to a more normal diet as dysphagia resolves during recovery from stroke or in the opposite direction for some progressive neurological conditions.
Some hard, dry, crumbly, fibrous foods or vegetable and fruit skins are particularly difficult to manage in the mouth, as are mixed consistency foods such as minced meat in thin gravy. As a result, it is advisable to avoid these in all patients with swallowing impairment (see table 2). There is now a set of standardised national descriptors available for texture modification of food (five categories) and thickened fluids (three categories) (9-10) which have been established in recent years. The descriptors have been agreed by a multi‐disciplinary working group of registered dietitians and speech and language therapists, and are intended as a reference point to enable professionals to use their clinical judgement with regard to modifying consistency for an individual client. The descriptors remain to a large extent descriptive, since there few reliable, easy to use and cheap objective methods of accurately measuring consistency and viscosity of food and fluids in common practice. Nevertheless, they reflect a common language and professional consensus which has been helpful in defining the appropriate texture needed for an individual.
Table 2: High Risk foods which should be avoided in patients with dysphagia
|Stringy, fibrous texture, e.g. pineapple, runner beans, celery, lettuce.
|Vegetable and fruit skins including beans, e.g. broad, baked, soya, black‐eye, peas, grapes.
|Mixed consistency foods e.g. cereals which do not blend with milk, e.g. muesli, mince with thin gravy, soup with lumps.
|Crunchy foods, e.g. toast, flaky pastry, dry biscuits, crisps.
|Crumbly items, e.g. bread crusts, pie crusts, crumble, dry biscuits.
|Hard foods, e.g. boiled and chewy sweets and toffees, nuts and seeds.
|Husks, e.g. sweetcorn and granary bread.
Problems associated with the intake of texture modified diets can arise. Worryingly the Commission for Patient and Public Involvement in Health (CPPIH), in a survey in 2006 of 2,200 patients in English hospitals, found that over a third of patients said they had left their hospital meal because it looked, tasted or smelled unappetising (11). Liquidised food and thickened drinks can be particularly unappealing to patients. This is especially true of meals where the constituent parts are not separated and are unidentifiable visually or by taste. Such meals may also be alarming or confusing to consumers especially those with some cognitive impairment.
Texture-modified food may also be lacking in nutrient density, especially if water is used to liquidise to achieve the correct texture. Unsurprisingly some food surveys of individuals in hospital on texture-modified diets have found lower intakes of energy and protein than those consuming a normal diet (12-13). Dysphagia has also been shown to be associated with malnutrition outside secondary care settings in both care homes and the community (14-15).
There are many reasons why poor nutritional intake may occur in dysphagic patients. Swallowing difficulties can make eating tiring or stressful, especially if the patient has had a previous bad experience with choking. Patients with many of the medical conditions associated with dysphagia may be suffering from depression, anxiety, loneliness, pain or a partial loss of taste or smell which can in turn impair appetite. They may be frail, confused, have poorly fitting dentures or be on medication which affects their appetite or nutritional status.
Malnourished patients take significantly longer to recover
Malnutrition in healthcare is a big problem. The number of people leaving hospital malnourished is increasing – 157,175 people left hospital malnourished in 2007–8. This figure increased to 185,446 in 2008–9 (16). A proportion of these patients will be those suffering from dysphagia who have received inappropriate or unappetising meals.
Malnutrition resulting from dysphagia is associated with excess morbidity and increased mortality rates, and good nutrition is a vital part of the management of many of the medical conditions associated with it (17). Malnutrition has been found in up to 30% of patients with stroke – the risk increasing with the length of stay (18 -19). Patients with acute stroke, who have the potential for meaningful recovery but are undernourished, take significantly longer to recover and have a worse outcome than those who are well nourished.
Poor nutrient intake may impair immuno-competence increasing the risk of respiratory, gut and genito- urinary infections. It can delay wound healing and increase the risk of pressure sores. Malnutrition also leads to muscle weakness and early muscle fatigue, which may already be impaired as a result of the coexisting medical condition. This can in turn lead to difficulty with rehabilitation, self care, decreased mobility and a higher risk of falls. Impaired muscle function may also impair the ability to cough and expectorate, adding to the risk of chest infections. Poor nutritional intake can also lead to other medical complications such as reduced bone mass and anaemia, as well as exacerbating any reduced cognitive function, apathy and depression. This may reduce further the will or ability of a patient to eat well, or comply with aspects of their rehabilitation or treatment to aid recovery (20-22).
In general, well hydrated and well nourished patients get better more quickly and have a more positive experience of care (23). The cost to the NHS of caring for malnourished patients, including those with dysphagia, is higher than for those adequately nourished. This might include increased dependency, more GP visits, more admissions to care homes and higher prescription costs in primary care. The length of stay for malnourished patients in secondary care settings is, on average, 1.4 days longer than those who are better nourished - they succumb to infection more often, have more readmissions and require longer term and more intensive nursing care (24-25).
In recent years, guidelines have been drawn up to enhance the provision of texture-modified meals (26). These require that food should be served and flavoured attractively with the individual components recognisable. This allows the food to be better enjoyed, even if there are changes in taste and smell related to age, or as a result of the cause of the dysphagia, which may limit the type and quantity of food eaten(27). It also allows a more dignified and acceptable dining experience and makes eating in social settings less problematic. This allows some of the important physical and social pleasures normally associated with food to be retained and enjoyed (28).
Food likes and dislikes do not change when suffering from dysphagia
Dysphagic patients should be offered a choice of savoury main courses and sweet desserts including those suitable for special dietary needs such as energy dense, vegetarian or gluten free diets. Familiar sounding dishes as wells as more unusual spicy main courses and desserts are all very popular with this client group. Variety is positively associated with a good intake of nutrients and variations in taste and temperature may be important for eliciting the residual swallow reflex (19,29).
Texture modified diets can be prepared using a blender and commercial thickening agents where necessary, but to prepare a visually appealing, flavourful meal can be time consuming, messy and wasteful. It can also be difficult to consistently achieve the correct texture required for the individual.
“Ready to use” texture modified main courses and desserts, both hot and cold, are commercially available, usually frozen, and can help overcome some of these issues. The meals conform precisely to particular texture categories. Some use state of the art moulding technology, whereby individual components can be recognised by shape and colour, thereby ensuring that the meal looks attractive even after cooking and warm holding. Some are even fortified to meet nutrition standards in line with those for other community or hospital meals (30-31). These meals have a long shelf life and make meeting the nutritional needs of dysphagic patients much easier and more convenient.
For many patients, hospital discharge to the home or residential care setting will be dependent on the support available (19, 31). One aspect of this is an adequate food provision and preparation to support quality of life, rehabilitation and/or recovery (32). Many of the ready to use texture-modified meals can continue to be provided for patients via home delivery if required. This can help alleviate the concerns of patients and their carers who need particular support as to how they will manage with meal provision in either the long or short term.
Also it can be especially reassuring for those for whom the prospect of blending their own meals to achieve the correct texture causes anxiety, all of which may add stress in what may be an already difficult situation. Importantly, it may mean that adequately supported discharge of patients to their homes can occur sooner.
Where lifestyle measures are considered advisable for secondary prevention for example, with hypertension and stroke (19), these meals can also be used to count towards targets such as moderate salt intakes or adequate fruit and vegetable guidelines.
Nutritionally dense, palatable and attractive looking texture-modified diets recognisable as food, are valuable in the dietetic management of patients with dysphagia. These should be of the appropriate texture, microbiologically safe and convenient where possible. To this end commercially available meals delivered frozen can be useful in a variety of home and healthcare settings.
- Martino R, Foley N, Bhogal S, Diamant N, Speechly M and Teasell R (2005). Dysphagia after stroke: Incidence, Diagnosis and Pulmonary Complications Stroke 36: 2756-63
- Smithard DG, O.Neill PA, England RE, Park CL, Wyatt R, Martin DF, et al (1997). The natural history of dysphagia following a stroke. Dysphagia 12: 188-93
- Mann G, Hankey GJ, Cameron D (1999). Swallowing function after stroke: prognosis and prognostic factors at 6 months. Stroke 30: 744-8
- Kidd D, Lawson J, Nesbitt R, MacMahon J (1995). The natural history and clinical consequences of aspiration in acute stroke. Q J Med 88: 409-13
- Sala R, Munto MJ, de la Calle J, Preciado I, Miralles T, Cortes A, et al (1998). Swallowing changes in cerebrovascular accidents: incidence, natural history, and repercussions on the nutritional status, morbidity, and mortality. Reviews in Neurology 27: 759-66
- Smithard DG, O.Neill PA, Parks C, Morris J (1998). Complications and outcome after acute stroke. Does dysphagia matter? Stroke 29: 1480-1
- Agency for Health Care Policy and Research (1999). Diagnosis and treatment of swallowing disorders (dysphagia) in acute-care stroke patients. Evidence Report/Technology Assessment 8
- Cook IJ, Kahrilas PJ (1999). AGA technical review on management of oropharyngeal dysphagia. Gastroenterology 116: 455-78
- British Dietetic Association and the Royal College of Speech and Language Therapists (2009). National Descriptors for Texture Modification in Adults. http://www.bda.uk.com/publications/statements/NationalDescriptorsTextureModificationAdults.pdf. Accessed July 28 2010
- NHS Quality Improvement Scotland (2003). Clinical Standards: food, fluid and nutritional care in hospitals. Edinburgh http://www.nhshealthquality.org/nhsqis/files/Food,%20Fluid%20Nutrition.pdf. Accessed July 28 2010
- Commission for Patient and Public Involvement in Health (2006). Hospital food could you stomach it? http://webarchive.nationalarchives.gov.uk/20061031182340/http://cppih.org/about_new.html. Accessed August 2010
- Wright L, Cotter D, Hickson M, Frost G (2005). Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition & Dietetics 18: 212-220
- Brynes AE., Stratton RJ, Wright L, Frost CG (1998). Energy intakes fail to meet requirements on texture modified diets. Proceedings of the Nutrition Society 57: 117A
- Finch S, Doyle W, Lowe C, Bates CJ, Prentice A, Smithers G, Clarke PC (1998). National Diet and Nutrition Survey People aged 65 years and Older. Vol 1. London TSO
- Perry L, Love CP (2001). Screening for dysphagia and aspiration in acute stroke: a systematic review. Dysphagia 16: 7-18.
- Age Concern (2010). Still hungry to be heard. http://www.ageuk.org.uk/get-involved/campaign/malnutrition-in-hospital-hungry-to-be-heard. Accessed August 2010.
- Finestone HM, Greene-Finestone LS, Wilson ES, Teasell RW (1996). Prolonged length of stay and reduced functional improvement rate in malnourished stroke rehabilitation patients. Arch Phys Med Rehabil 77: 340-5.
- Gariballa SE, Parker SG, Taub N, Castleden CM (1998). Influence of nutritional status on clinical outcome after acute stroke. American Journal of Clinical Nutrition 68: 275-81.
- Intercollegiate stroke working party (2008). National Clinical guideline for Stroke 3rd Edition. RCP.
- Scottish Intercollegiate Guidelines Network (2010). Management of patients with stroke: Identification and management of dysphagia. A national clinical guideline. SIGN 119. http://www.sign.ac.uk/pdf/sign119.pdf Accessed June 28 2010
- Donini LM, Savina C, Cannella C (2003). Eating habits and appetite control in the elderly: the anorexia of aging. Psychogeriatrics 15: 73-87
- Keys A, Brozek J, Henschel A (1950). The Biology of Human Starvation. Minneapolis, MN. University of Minnesota Press
- Ward L et al (2010). The high impact actions for nursing and midwifery1: keeping nourished - getting better. Nursing Times 106: 27 10-11.
- Brotherton A et al (2010). Malnutrition Matters: Meeting Quality Standards in Nutritional Care. Redditch: BAPEN.
- Department of Health (2003). Care Homes for Older People: National Minimum Standards. London: The Stationery Office. Available from: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4135403.pdf . Accessed July 28 2010
- Rolls BJ (1999). Do chemosensory changes influence food intake in the elderly? Physiology and Behaviour 66:193-7.
- Hollis JH, Henry CJK (2007). Dietary variety and its effect on food intake of elderly adults. Journal of Human Nutrition and Dietetics 20: 45-351
- Thomas B, Bishop J ( eds) (2007). Manual of Dietetic Practice. Fourth edition. Blackwell Publishing
- National Association of Care Catering (2003). A Recommended Standard for Community Meals. https://thenacc.org.uk/ . Accessed June 28 2010
- Department of Health (1995). Nutrition Guidelines for Hospital Catering. The Health of the Nation Nutrition Task Force. Wetherby DH
- Pennington CR (1998). Malnutrition in hospital: the case of the stroke patient. British Journal of Nutrition 79: 477-478
- Gariballa S ( 2003) Protein energy under nutrition and acute stroke outcome Stroke 34: 1455-56