Dietary treatment in Dysphagia

Marjory Macleod

ESPEN Congress Gothenburg 2011

Assessment and treatment of dysphagia – What is the evidence?

Dietary treatment

in

Dysphagia

Marjory Macleod

Advanced Dietetic Practitioner

33rd Congress of Clinical Nutrition & Metabolism

ESPEN, Gothenburg 3-6th

September 2011

Outline of Presentation

Current dietary interventions

Current challenges

Strategies for improving Nutrition

Hydration

Ethical Issues

3 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Dietary Interventions: Management and Aims

Maximise health and well being

(Burton et al, 2011)

Minimise the risk of under-nutrition and dehydration (Flintsone et al, 2001)

Minimise risk of aspiration pneumonia (Perry & Love 2001)

Maintain oral nutrition (Burton et al, 2011)

Texture Modified Diets (TMD) are the foundation of dysphagia management

4 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Dietary management of dysphagia aims to:-

Current Dietary Interventions: Dietary Management

Texture modification (Rothenberg et al, 2007,Germain et al ,2006, Garcia & Chambers

2010)

Fluid modification (Butt and Lamb, 2005, Garcia et al, 2005)

Education and Training (Ginocchio et al, 2009, Dune, 2008, Garcia, 2008)

Interdisciplinary management (Dyer, 2003, Nazaro, 2009)

5 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Dietary Interventions: Texture Definitions

Rheological properties Objective measures (National Dysphagia Task Force ,2002)

Subjective evidence for

foods and fluids (UK food textures ,2011, UK fluid, 2002,

Irish Nutrition & Dietetic Institute, 2009,

Atherton et al, 2007)

Rheological properties Objective and sensory

methods (Wendin et al, 2010)

6 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Dietary Interventions: Modified Diets -Soft/Minced/Mashed

Examples:

flaked fish in sauce

stewed apples

custard

Foods easily mashed with a fork require

very little chewing.

7 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Dietary Interventions: Modified Diets - Thick and Thin Puree

Food that has been pureed or has puree texture. Can be poured.

Tinned tomato soup

Food that has been pureed or has puree texture.

Can hold its own shape on a plate, can be piped layered or molded. Can be eaten with a fork no chewing required.

Mousse

Smooth fromage frais

Sieved mashed potatoes 8

Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Challenges: Texture Descriptions

Soft

9 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Challenges: Variety

sweet potato,

potato powder

breadcrumbs

Bread and potato

can be adapted for

most TMD.

10 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Challenges: Snacks

Fruit

Nuts

Crisps

Sweets

Biscuits

Sausage rolls/pastries

Sandwiches

Cake

Cake and custard

Smooth yoghurt

Normal Snacks TMD

11 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Challenges: Preparation

Achieving smooth

puree

Moulded foods

Commercially

prepared TMD

foods 12 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Challenges: Separation

Some pureed foods are not stable!

Beef stew Carrot

13 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Challenges: Stabilisation

Food Products

Nutritional Products

14 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Current Challenges: Nutritional Inadequacies

Energy (Wright et al, 2005, Nowsen et al, 2003)

Protein (Wright et al, 2005, Nowsen et al, 2003)

Micronutrients (Lengyel et al, 2008)

Fluid (Finestone et al, 2001)

15 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Strategies: Nutrition - Food Fortification & Enriching Normal Diet

Small/frequent meals (Taylor & Barr, 2006)

Nutrient-dense meals (Lorefalt et al, 2005)

Mealtime assistance (Wright et al, 2008)

Food fortification (Adolphe et al, 2009)

Oral Nutritional supplement (Baldwin & Parson, 2004)

Enteral Nutrition (Nice 2011, Foley et al, 2008)

16 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Strategies: Nutrition - Food Fortification & Enriching Normal Diet

Protein

adding extra skimmed milk

powder to milk

Adding extra egg to mashed potatoes/puddings

Adding cheese to potatoes, soups and savoury dishes

Oral nutritional supplements especially for dysphagia

Energy

Adding double cream to soups,

mashed potatoes, sauces or desserts

Adding butter or margarine to vegetables, pasta, scrambled egg or in cooking

Adding jam/honey/syrup to breakfast cereals or puddings

Adding glucose or glucose polymers to drinks and foods

17 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Strategies: Fluid Texture Modification – Consistency Definitions

Consistency

UK / US

Description

Examples of naturally thick

fluids

Syrup

/ Nectar

Can be drunk through a

straw/cup if preferred. Leaves

thin coat on back of spoon

Strained thick

smoothie,

e.g. Innocent UK

Custard

/ Honey

Cannot be drunk easily through

a normal straw.

Can be drunk from a cup

Leaves thick coat on back of

spoon

McDonald’s

milkshake

Pudding

/Spoon

thick

Thickened to stage that needs

to be taken from a spoon

Thick custard

18 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Strategies: Fluid Texture Modification – Understanding Thickeners

STARCH

Particles expand like a balloon

capturing the fluid

Can be added to hot or cold

drinks

Less effective water binding

than gum

Starchy/grainy flavour and

texture

Metabolism and water

absorption in the small intestine

More prone to chemical

reactions with base fluids

Starch/grainy flavour and

texture**

GUMS

Interact with liquid by forming “nets”

that trap liquid

Hot liquids may need to be cooled

then re-heated

Excellent water binding properties.

More stable

Metabolism and water absorption in

the large intestine

Sensory perceptions slick/oily

flavour and texture**

**(Lotong et al, 2003, Pellier C, 1997, Matt et al,2006)

19 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Strategies: Fluid Texture Modification – Consistency Challenges

Achieving fluid viscosity (Goulding & Bakheit, 2000, Garcia et al, 2010)

Effect of time on viscosity (Garcia et al, 2008,2005, O’Leary et al 2011)

Saliva (Hanson et al,2011)

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Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Strategies: Fluid Texture Modification – Achieving Hydration

Patients requiring thickened fluids are less

likely to meet fluid requirements (Finestone et al,2001,Vivanti et al, 2009)

Fluid content from foods (Vivanti et al, 2009)

Standard protocols for mixing (Queensland Health Dietitians, 2007, Anderson, 2008)

Pre-thickened drinks (Wheelan, 2001)

Free fluid (Panther, 2005, Garon et al,1997)

Enteral Hydration (Vivanti et al, 2009)

21 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Beneficence Benefit and risks

Justice

Respect for autonomy Advanced decisions/

end of life wishes

Non-maleficence Avoidance of harm-

physical/psychosocial

Disease trajectory/

expected outcome

22 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

Strategies: Ethical Issues

Summary

Evidence exists to support TMD

Nutrition and hydration is very often compromised

Consistency may not always be achieved.

MDT/Interdisciplinary management.

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Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011

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