[1]
Dysphagia is a term that means difficulty swallowing food and/or liquids properly. The diet for dysphagia involves five various levels of difficulty in swallowing, which we will detail below. It is crucial to know the process of swallowing to understand dysphagia. First and foremost, it is important for all individuals to chew food slowly and thoroughly. Once this process is completed, the food is moved to the back of the mouth by stretching of the cheek muscles and pressing the tongue against the roof of the mouth. From this moment on, the process of swallowing becomes spontaneous and reflexive. [2]
When the esophagus is relaxed, the airway is automatically closed by the soft palate, preventing food from entering the lungs. As food and liquid enter, the muscular esophagus contracts in the form of waves, which sweeps the food along and down into the stomach.
Hence, any blockage or malfunction in this function results in dysphagia.
Types of Dysphagia
There are two types of dysphagia.
- Esophageal Dysphagia
- Oropharyngeal Dysphagia
Esophageal Dysphagia
Esophageal dysphagia occurs when food or liquid stops in the esophagus during swallowing.
Esophageal dysphagia occurs in several ways. Sometimes, stomach acid can reflux into the esophagus, which causes inflammation. A hiatal hernia can increase the occurrence of acid reflux as well. Over time, inflammation from reflux can lead to narrowing of the esophagus. As a result, food and even liquids can cause a sticking sensation in the middle and lower chest. Individuals might feel discomfort and even pain in the chest. Fortunately, the narrowed region can be dilated during endoscopy with a balloon-guided technique. Other, less frequent causes of esophageal dysphagia are cancer and muscle disorders.
Oropharyngeal Dysphagia
The difficulty in moving food to the back of the mouth and swallowing it is called oropharyngeal dysphagia. This type of condition is a result of various nerve or brain disorders, including stroke, cerebral palsy, multiple sclerosis, Parkinson’s and Alzheimer’s diseases, throat or neck cancer, and even dental disorders.
The main symptoms of oropharyngeal dysphagia include drooling, choking, coughing after or during meals, impaired voice quality, chronic respiratory infections, or weight loss. Liquids are more problematic than solids in oropharyngeal dysphagia. Esophageal dysphagia typically involves solids being more problematic.
The treatment of oropharyngeal dysphagia requires a proper diagnosis involving a medical history and several tests to determine the cause of dysphagia. GI providers often direct the strategy for treatment, and will involve dietitians, psychologists, speech pathologists, and occupational therapists as necessary to collaborate and design the best program tailored for individual needs [3].
The most crucial part of treatment involves helping the patient with adequate nutrition and protecting against complications, including pneumonia from solid food or liquids getting into the lungs. This treatment requires a special diet of five levels, from level 1 (pureed food) to level 5 (regular, modified food). The levels of this diet vary in texture and consistency, and are made to suit each individual patient [4].
Special Considerations for Dysphagia Patients
We suggest the following guidelines for the safe swallowing when a patient has dysphagia. [5]
- Maintain an upright position (near 90 degrees as possible) whenever eating or drinking.
- Take small bites — only 1/2 to 1 teaspoon at a time.
- Eat slowly. It may also help to eat only one food at a time.
- Avoid talking while eating.
- When one side of the mouth is weak, place food into the stronger side of the mouth. At the end of the meal, check inside the cheek for any food that may become pocketed.
- Try turning the head down, tucking the chin to the chest, and bending the body forward when swallowing. It often provides greater swallowing ease and helps prevent food from entering the airway.
- Do not mix solid foods and liquids in the same mouthful, and do not “wash foods down” with liquids unless instructed by the therapist.
- Eat in a relaxed atmosphere, with no distractions.
- Sit in an upright position (90-degree angle) for 30 to 45 minutes following each meal.
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Level 1 Puréed Foods |
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|---|---|
CAUTION:If any food does not purée into a smooth consistency, eating or swallowing may be more difficult. For example, zucchini seeds sometimes do not blend well. |
|
| Puréed meats, poultry, & fish | Puréed cottage cheese |
| Puréed tuna, ham, & chicken salad | Puréed fruit |
| Pureed scrambled eggs & cheese | Thickened juices & nectars |
| Baby cereals | Thickened milk or eggnog |
| Thinned cooked cereals (no lumps) | Malts |
| Puréed French toast or pancakes | Thick milkshakes |
| Mashed potatoes | Ice cream |
| Puréed parsley, au gratin, scalloped potatoes, candied sweet potatoes | Fruit or Italian ice, sherbet |
| Puréed buttered or Alfredo noodles | Plain yogurt |
| Puréed vegetables (no corn or peas) | Smooth & drinkable yogurt |
| Puréed soups & creamed soups | Smooth pudding, mousse, custard |
| Puréed scalloped apples | Whipped gelatin |
| Gravies | Sugar, syrup, honey, jelly |
| Sauces: cheese, tomato, barbecue, white, cream | Cream |
| Decaffeinated coffee or tea | Non-dairy creamer |
| Margarine | |
| Mayonnaise | |
| Ketchup, mustard | |
|
Level 2 Minced Foods |
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|---|---|
|
|
|
| Minced meat, fish, poultry | Cottage cheese |
| Minced stuffed fish | Junior baby fruit |
| Flaked fish | Semi-thickened juices |
| Junior baby meats | Nectars |
| Minced soft-cooked, scrambled, poached eggs | Ripe mashed bananas |
| Minced soufflé & omelets | Minced canned fruit |
| Minced soft French toast | Pineapple sauce |
| Minced soft pancakes | Milk |
| Cooked cereals | Milkshakes |
| Minced potatoes | Custard |
| Minced buttered or Alfredo noodles | Puddings, including rice & tapioca |
| Minced vegetables | Yogurt |
| Creamed soups | Fruit ice, Italian ice, sherbet |
| Puréed vegetables soup or alphabet soup | Whipped gelatin |
| Minced scalloped apples | Junior baby desserts |
| Gravy | Sugar, syrup, honey, jelly |
| Sauces: cheese, creamed, barbecue, tomato, white | Cream |
| Decaffeinated coffee or tea | Margarine |
|
Level 3 Ground Foods |
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|---|---|
|
|
|
| Ground meat, fish, poultry | Cottage cheese |
| Ground meat salads (no raw eggs) | Smooth fruited yogurt |
| Ground Swedish meatballs | Fruit juices or nectars |
| Scrambled eggs or soufflés | Ground canned fruit |
| Ground poached eggs | Crushed pineapple |
| Cooked cereals | Ripe bananas |
| Ground soft French toast | Lemonade/Limeade (no pulp) |
| Ground potatoes | Milk |
| Ground noodles | Ice cream |
| Ground baked potato (no skin) | Custard |
| Ground well-cooked frozen vegetables (no corn, peas, or mixed vegetables) | Puddings or mousse |
| Ground canned vegetable | Fruit ice, Italian ice, sherbet |
| Creamed soups | Cream |
| Puréed vegetables soup or alphabet soup | Non-dairy creamer |
| Ground scalloped apples | Margarine |
| Gravies | Mayonnaise |
| Sauces: cheese, creamed, barbecue, tomato, white | Ketchup |
| Decaffeinated tea or coffee | Mustard |
|
Level 4 Chopped Foods |
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|---|---|
|
|
|
| Chopped meat or poultry | Cottage cheese |
| Chopped Swedish meatballs | Yogurt |
| Meat salads (ground or flaked meat) | Milk |
| Flaked fish | Milkshakes |
| Poached or scrambled eggs | Soft, cold, dry cereal |
| Soufflés and omelets | Soft bread (if approved by speech or occupational therapy) |
| Cooked cereals | Fruit juice or nectars |
| Chopped French toast or pancakes | Chopped canned fruit |
| Chopped noodles or pasta (no rice) | Canned fruit cocktail |
| Chopped cooked vegetables (no frozen peas, corn, or mixed vegetables) | Pudding, mousse, custard |
| Chopped canned small sweet peas | Ice cream |
| Creamed soup or vegetable soup | Fruit ice, Italian ice, sherbet |
| Canned chicken noodle soup | Cream cheese |
| Chopped potatoes (all kinds) | Whipped topping |
| Gravy | Whipped gelatin |
| Bacon dressing | Sugar, syrup, honey, jam, jelly |
| Sauces: cheese, creamed, barbecue, tomato, white | |
| Decaffeinated tea or coffee | |
|
Level 5 Modified Regular Foods |
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|---|---|
|
|
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| Soft, moist meat, fish, poultry | Soft cheeses |
| Baked fish | Cottage cheese |
| Meat Salads | Cream cheese |
| Soufflés and omelets | Yogurt |
| Eggs | Milk |
| Stuffed shells | Milkshakes |
| Spaghetti with meat sauce | Cold, dry cereals (no nuts, dried fruit, coconut) |
| Cooked cereal | Crackers |
| French toast or pancakes | Soft bread (no hard rolls) |
| Toast | Fruit juices or nectars |
| Noodles or pasta (no rice) | Canned fruit |
| Potatoes (all types) | Ripe bananas |
| Soft, cooked vegetables (no corn, lima, or baked beans) | Peeled, ripe, fresh fruit |
| Creamed soups or vegetable soup | Cakes (no nuts, dried fruit, coconut) |
| Canned chicken noodle soup | Plain doughnuts |
| Gravies | Ice cream |
| Bacon dressing | Pudding, mousse, custard |
| Sauces: cheese, creamed, barbecue, tomato, white | Fruit ice, Italian ice, sherbet |
| Decaffeinated tea or coffee | Whipped gelatin |
| Regular gelatin | |
| Canned fruited gelatin molds | |
| Sugar, syrup, honey, jam, jelly | |
| Cream | |
| Non-dairy creamer | |
| Margarine | |
| Oil | |
| Mayonnaise | |
| Ketchup | |
| Mustard | |
References
[1] “Person Mixing Cereal, Milk, and Strawberry Jam on White Ceramic Bowl · Free Stock Photo.” https://www.pexels.com/photo/person-mixing-cereal-milk-and-strawberry-jam-on-white-ceramic-bowl-704971/ (accessed Mar. 28, 2022).
[2] S. T. O’Keeffe, “Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?,” BMC Geriatr, vol. 18, no. 1, Jul. 2018, doi: 10.1186/S12877-018-0839-7.
[3] Y. Chen, M. Zong, S. Li, L. Tang, Y. Feng, and J. Sun, “Nutritional diet plan for patients with dysphagia,” Asia Pac J Clin Nutr, vol. 30, no. 2, pp. 238–244, 2021, doi: 10.6133/APJCN.202106_30(2).0008.
[4] J. M. Garcia and E. Chambers, “Managing dysphagia through diet modifications,” Am J Nurs, vol. 110, no. 11, pp. 26–33, Nov. 2010, doi: 10.1097/01.NAJ.0000390519.83887.02.
[5] I. Germain, T. Dufresne, and K. Gray-Donald, “A novel dysphagia diet improves the nutrient intake of institutionalized elders,” J Am Diet Assoc, vol. 106, no. 10, pp. 1614–1623, Oct. 2006, doi: 10.1016/J.JADA.2006.07.008.
