Sue Baic MSC RD Consultant Dietitian to apetito and Wiltshire Farm Foods.
Texture-modification of diet is an important part of the medical management of patients with dysphagia. In a normal swallow, the action of food hitting the back of the mouth stimulates the swallow centre in the brainstem. This triggers a swallow reflex which temporarily seals off the airway preventing food and fluid from entering the lungs. However, if this process is disrupted there is a risk of aspiration and associated bronchopulmonary infections (1-3).
Specialist assessment of the dysphagic patient can establish whether oral feeding is safe, and which consistency will best allow the patient to control the rate food passes through their mouth and into the pharynx (4-5).There are national descriptors recognised for texture-modification of food and fluids for adults and details are available at http://www.bda.uk.com/publications/statements. These reflect a common language and consensus between dietitians and speech and language therapists which have been helpful in defining the appropriate texture needed for an individual (6-7).
Unfortunately texture-modified food can be unappealing - especially where the constituent parts of a meal are not identifiable. This may be alarming or confusing to consumers, especially those with a degree of cognitive impairment. Texture-modified food may also be low in nutrient density if liquidised with water. These factors are problematic if eating is tiring or stressful for the patient or if they are also experiencing a range of physical, psychological and social problems affecting their appetite and nutritional status. Food surveys of individuals on texture-modified diets have frequently found lower intakes of energy and protein than those consuming a normal diet (8-11).
Malnutrition resulting from dysphagia is associated with delayed recovery and excess morbidity (12-13). The cost to the NHS of caring for these patients will be higher because of increased dependency, more complications and medication, and a longer stay in hospital.
In recent years guidelines have been drawn up to enhance the provision of texture-modified meals (14-15). These require that food should be served and flavoured attractively with recognisable individual components , thereby allowing a dignified and more socially acceptable dining experience.
Dysphagic patients should be offered a choice of savoury main courses and sweet desserts including those suitable for special dietary needs. Variety is positively associated with a good intake of nutrients (16) and taste and temperature are important for eliciting the residual swallow reflex (17).
Texture-modified diets can be prepared in patient’s homes, care homes and hospitals 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 achieve the correct texture - all of which may add stress for a patient or carer in an already difficult situation.
“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 and the meal looks attractive even after cooking
and warm holding.
These meals have a long shelf life and make the feeding of dysphagia patients whether at home, in care homes or in hospital much easier and more convenient. Some are even fortified to meet nutrition standards in line with those for other community or hospital meals (18-19).
Conclusion
Nutritionally dense, palatable and attractive looking texture-modified diets where meals are 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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incidence, natural history, and repercussions on the nutritional status, morbidity, and mortality. Rev Neurol 27 :759-66.
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A national clinical guideline. SIGN 119 . http://www.sign.ac.uk/pdf/sign119.pdf Accessed June 28 2010
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http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4135403.pdf . Accessed
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19. Department of Health (1995) . Nutrition Guidelines for Hospital Catering. The Health of the Nation. Nutrition Task Force DH, Wetherby.