Unraveling the Mystery of Dysphagia Diets

Preparation of modified texture diets should be simple! The actual use of a food processor to grind or puree foods is not a difficult task, but the end results vary widely! Over the past 15 years, dietetic professionals, food service personnel, speech language pathologists and food manufacturers have been trying to solve the mystery of standardizing texture levels related to a puree and mechanical soft diet.

In 1989, a speech language pathologist (SLP), Jane Pope, MS, CCC, SLP, led a group of Pacific Northwest SLP’s and dietetic professionals in defining “dysphagia” and the implications of treatment related to a resident’s quality of life. The goal of this group was to develop standardization of textures between a basic pureed and mechanical soft diet allowing flexibility for advancement in diet textures. It was recognized that the established diets of the late ‘80’s were too confining for residents with swallowing problems and limited SLP’s the flexibility to advance a diet consistency as a resident’s swallowing improved. From this study, three textures were defined: Dysphagia Blenderized/Pureed, Dysphagia Mechanical & Dysphagia Advanced Mechanical. Liquid consistencies were defined as thin, nectar thick, honey thick and spoon or pudding thick.

However, 13 years later inconsistencies of diet and liquid terminology and respective interpretation still exist for the dysphagic residents. But today the solution to unraveling the mystery is available!

The Dietetics in Physical Medicine and Rehabilitation, a practice group of The American Dietetic Association, developed guidelines for the National Dysphagia diet. The standardization of diet textures was based on the initial work of the Pacific Northwest diet “group” in 1989 with additional testing and reviewing of over 200 diets by the established task force. The multi-disciplinary task force included food scientists, clinical and consulting dietitians, speech language pathologists and representatives of the food industry. The new publication, “The National Dysphagia Diet: Standardization for Optimal Care” is available from The American Dietetic Association as of mid-October 2002.

The standardized diet consistencies and general guidelines are:

Level I - Dysphagia Pureed

A. Guidelines:

    This diet consists of pureed, homogenous, and cohesive foods. Food should be:

  • "Pudding-like"
  • No coarse textures, raw fruits or vegetables
  • No oatmeal or unprocessed wheat bran stirred into cereals
  • Any foods that require bolus formation, controlled manipulation, or mastication are excluded.
    NOTE: Smooth chocolate candy (plain) is allowed if thin liquids allowed.

B. Purpose

    This diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities and reduced ability to protect their airway. Close or complete supervision and alternate feeding methods may be required.

Level II - Dysphagia Mechanically Altered

A. Guidelines:

    Consists of foods that are:

  • Moist, soft-textured, and easily formed into a bolus
  • Meats are ground or are minced no larger than onequarter-inch pieces; they are still moist, with some cohesion
  • All foods from NDD Level 1 are acceptable at this level.
  • Avoid rice, bacon, hard cooked eggs, potato chips/French fries, and fibrous cooked vegetables

B. Purpose

    This diet is a transition from the pureed textures to more solid textures. Some chewing ability is required. The textures on this level are appropriate for individuals with mild to moderate oral and/or pharyngeal dysphagia. Patients should be assessed for tolerance to mixed textures. It is expected that some mixed textures are tolerated on this diet.

Level III - Dysphagia Advanced

A. Guidelines consist of:

  • Food of nearly regular textures with the exception of very had, sticky, or crunchy foods. Avoid French bread, fresh apples, pears or grapes, and cooked corn.
  • Foods still need to be moist and should be in “bite-size” pieces at the oral phase of the swallow.

B. Purpose

    This diet is a transition to a regular diet. Adequate dentition and mastication are required. The textures of this diet are appropriate for individuals with mild oral and/or pharyngeal phase dysphagia. Patients should be assessed for tolerance of mixed textures. It is expected that mixed textures are tolerated on this diet.

Liquid Consistency Controversy

Liquid consistencies have also been defined in the National Dysphagia Diet publication. The terminology is standardized as thin, nectar, honey and spoon or pudding thick, but standardization on the exact viscosity range of each level still needs further research. Manufacturers producing prethickened liquids generally have similar viscosity for each of the thickened liquid levels, but additional testing is necessary. Controversy still exists on viscosity levels as related to temperature, shear rate and centipose criteria. Further research is expected in the near future.

The first step in unraveling the dysphagia diet textures mystery is accomplished. It’s now in the hands of each of us to adopt and implement these guidelines across the healthcare continuum. Texture modified diets must be consistent, appealing and nutritionally sound for all dysphagic residents. The mystery is solved – accept the challenge to implement the solution.

References

Felt, P., et al. National Dysphagia Task Force. “The National Dysphagia Diet: Standardization for Optimal Care.” Chicago, IL: American Dietetic Association; 2002.

Womack, P., “The Dysphagia Challenge, Techniques for the Individual.” Bellevue WA: Challenge Books Publishing; 3rd edition 1999. 425-641-4540

Womack, P., “Dysphagia – Is It Mystery or Challenge?” The Consultant Dietitian Vol. 25, 3, 2001.

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