Innovations and Improvements in Food Production and Preparation for Dysphagic Patients

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

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

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.  

Conclusion

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.

References

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