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Flashcards in Diet Modification and Therapy Deck (27):
1

Diet Modifications

- #1 thing we do to help pt. is modify the diet

- Anytime you modify the diet it can be liquid or textures or NPO (nothing by mouth)

- Usually the last thing we should do is change the diet, but it is really one of the first things we do.

- Can involve food texture and/or liquid viscosity modifications.

- Can be extreme or minor

- May be temporary or permanent

- Has been suggested to be the last treatment option, owing to poor patient acceptance (Logemann, 1993)

*** We modify liquids and solids

[x] diet (solid) + [x] liquids

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Liquid modifications (4)

- Thin

- Nectar thick (slightly thick-V8 juice)

- Honey thick (honey consistency, flows more slowly, spoon should almost stand up)

- Pudding thick (really puree food, very thick)

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Solid modifications (6)

- Puree (thin and thicker)

- Dental soft- mechanical soft (chopped up meats and veggies that are fork mashable (soft carrots, chopped broccoli)

- No mixed consistency (cohesive- you can form the bolus and hold it together) (not foods that leak out liquid)

- Smooth

- Slick- extra moisture (if pt. has difficulty moving food through the esophagus)

- Regular

4

Dietary considerations (5)

Consistent Carbs
Calorie restriction
Fluid restriction
Healthy Heart
Others

5

Benefits of dietary modifications

- Can allow the continued pleasure of sharing a meal with friends and family.

- Can mark time in a day for confused patients.

- Withholding of food considered unacceptable in some religions (Shoemaker, 1997)

- Meals are social and cultural

- May improve quality of life due to avoidance of tube placement.

- Patients may accept modifications as they are rehabilitating their swallowing skills.

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Reasons for reduced acceptance (5)

- Poor texture

- Poor taste

- Poor appearance

- Cost

- Inconvenience

***These factors may lead to dehydration or malnutrition

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Terminology differences between SLPs and dietitians

- SLP’s – looking at mechanics of the swallow

- RD’s - looking at nutrient issues

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Terminology differences- Regular diet

- Dietitians: No nutrient restrictions

- SLP: No texture/viscosity restrictions because the strength of the swallow is WFL

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Terminology differences: Mechanical soft

- Dietitians: Elimination of foods difficult to digest in the GI tract

- SLP’s: Foods easily chewed into cohesive bolus.

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Terminology differences: Puree

- Dietitians: used with patients who do not have teeth.

- SLP’s: used with patients unable to process solid food due to oral and/or pharyngeal stage dysphagia.

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Terminology differences : Therapeutic diet

- Dietitians: nutrient modifications

- SLP’s: Specific texture/viscosity modifications and feeding techniques.

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Viscosity-thickness

- Defined as the resistance of a substance to flow under an applied force.

- Usually refers to liquids

- Affected by temperature, the concentration and molecular weight of a solute, and the amount of suspended matter in the fluid. (pulp in oj)

- Clinicians must learn to control and understand a liquid’s inherent chemical properties, temperature, mixing technique, standing time, and flavor.

- Ice cream is a thin liquid

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Understanding Viscosity

- Liquids are described in centipoise.

- Thin: 1 – 50 cP

- Nectar: 51 – 350 cP

- Honey: 351 – 1750 cP

- Solid & spoon thick: >1750 cP

- To determine thickness, you need a viscometer.

- A line spread test can also be used. (Draw concentric circles on plastic and put liquid in the middle and then you time it (how fast they move is how thin they are)

- Water is thinner than milk and oj with pulp is thicker than milk

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Thickeners

1. Starch based

2. Advantages of xanthan (gum)

Starch based or gum (xanthan)based commercial products.

1. Most prevalent in facilities

- Best when freshly mixed – not stable over time

- Tend to “lump up” when mixing

2. Stability over time

- Heat stable

- Can be frozen

- If aspirated, clears from the lungs more readily than starch.

- Due to cellulose backbone, passes through the body like fiber.

- Adds no calories.

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Other thickeners

- unflavored gelatin

- cornstarch

- instant potato flakes

- baby cereal

- cracker crumbs

- instant pudding in milk

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Texture

Defined by SLP’s according to a patient’s amount of difficulty in forming and propelling it as a cohesive bolus in a safe and timely fashion.

- Puree (thin and thicker)

- Dental soft

- No mixed consistency (cohesive)

- Smooth

- Slick

- Regular

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Puree

Puree- don’t have the strength for a more solid food, sometimes not heavy enough

- Smooth and pudding like.

- Used with patients having difficulty forming and propelling a cohesive bolus safely.

- May have inadequate taste, temperature, texture and pressure to elicit an adequate pharyngeal swallow.

- Has been criticized with regard to its ability to maintain adequate nutritional needs.

- Not well accepted by patients with good cognition.

- Pt. with dementia do well with puree because they don’t have the cognition to chew.

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Dental soft (Mechanical Soft)

- Often with ground meats, vegetables are able to be “fork mashed.”

- Uses less energy expenditure than regular diet.

- For patients who are able to chew/process food in a timely manner.

- Individuals will reject a food texture if they require more than 10 seconds to complete the oropharyngeal phases of the swallow

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No mixed consistencies

- Cohesive, dental soft foods

- The bolus should not “weep”

- Used when a patient cannot manage a mixture of consistencies due to oral stage difficulties

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Slick

- Just as it sounds.

- All foods are slick, allowing ease of passage through the pharynx and esophagus.

THIS DIET MAY BE NEEDED FOR PATIENTS WITH SEVERE DYSMOTILITY OR SPASMS OF THE ESOPHAGUS.

- ADDITIONALLY, THE PATIENT SHOULD TAKE A SOLID BITE FOLLOWED BY A LIQUID SWALLOW TO HELP “WASH” THE FOOD DOWN.
 
- WHEN THE PATIENT SELECTS THEIR FOOD ITEMS, THEY SHOULD ALWAYS SELECT THOSE THINGS THAT ARE WET, SLIPPERY, AND JUICY.
 
 
THEY SHOULD BE COVERED IN GRAVY, SAUCES, OLIVE OR VEGETABLE OIL, OR EVEN BUTTER. IF THEY ARE NOT, THEN ADD SOMETHING TO MAKE THEM SLIPPERY.
 
 
IF THE FOOD IS DRY, SUCH AS BREAD, TOAST, CRACKERS, NUTS, OVER COOKED CHICKEN OR TURKEY, ETC. THEN THE FOOD SHOULD BE AVOIDED. THICK VISCOSITY FOODS SUCH AS MASHED POTATOES, PUDDINGS, THICK COOKED CEREALS, ETC. SHOULD ALSO BE AVOIDED.
 
SLICK FOODS WOULD INCLUDE TOMATO OR PEA SOUP, THIN YOGURT, THINNED OATMEAL, PASTA WITH OLIVE OIL OR RED SAUCE, SOFT COOKED EGGS, MOUSSES, CHIPPED BEEF, POTATOES WITH LOTS OF BUTTER ON THEM, ETC.

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Standardized diets

National Dysphagia Diet (NDD)

1. NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).

2. NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).

3. NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
Regular (all foods allowed)

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How do you decide what consistency/viscosity to use?

1. Reduced range of tongue motion

2. Reduced tongue coordination

3. Reduced tongue strength

4. Delayed pharyngeal swallow

1. Thick liquid initially, then thin liquid.

2. Thick liquid (moves slower)

3. Thin liquid (less strength needed)

4. Thick liquids and thicker foods (gives them more time)

23

How do you decide what consistency/viscosity to use?

1. Reduced airway closure

2. Reduced laryngeal movement/cricopharyngeal dysfunction

3. Reduced pharyngeal wall contraction

4. Reduced tongue base posterior movement

1. Pudding and thick foods
(need to slow everything down)

2. Thin liquid (will flow through better)

3. Thin liquid

4. Thin liquid

24

To thicken or not to thicken

- Fluid thickening does not necessarily protect some patients against pulmonary aspiration.

- Why?
1. fatigue?

2. poor posture?

3. reflux?

- High fluid viscosity may aggravate the swallowing difficulties in some patients because it increases the force required by the tongue to move the bolus.

- There is an inverse relationship between the volume of fluid consumed by the patients and the viscosity of the thickened fluid. This may increase the risk of dehydration and reduced calorie intake.

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Protocol 201- to thicken or not to thicken

- Protocol 201 – randomized clinical trial

- Patients with dysphagia can suffer from adverse effects when consuming thickened liquids:

- Aspiration

- Dehydration

- Increased hospital stays

- Death

- There are adverse effects to thickened liquids

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Protocol 201 - 1

- The probability of development of pneumonia is significantly higher in those receiving HTL vs. NTL

- At 3 months, the cumulative incidence of pneumonia was about 10%(thin), 8%(NTL), 15%(HTL)

- Dehydration more common with thick than thin liquids.

- Try to stay away from honey thick liquids

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Protocol 201 - 2

- Participants drinking NTL had a lower incidence of PNA than those drinking HTL.

- NTL may be easier to clear from the airway than more viscous liquids.

- Patients on thickened liquids need to be monitored for complications.