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Why and When Should a Speech-Language Pathologist Modify a Patient’s Diet?

Published On 8.14.20

By Rene Jablonski, MA, CCC-SLP

Speech-Language Pathologist

I want you to imagine something. You sit down 3 times a day to eat a meal, you snack between meals, and drink various liquids. Every time you do this, you cough, you choke, your nose runs, your eyes water, you take over an hour to eat your food, and to be honest, you probably stress out about eating/drinking. As a result of the stress, you start to lose weight, you stop eating foods you love, and you become an introvert as eating is a large part of your socialization. You can no longer appreciate the joy of eating and your appetite has significantly declined due to the trouble you are experiencing.

So I ask you this-Why do we allow someone to continue living their life this way? What quality of life is there when you stress out about eating and cough/choke with every meal you consume? Would you rather stay on a diet that you cannot handle or modify your diet slightly so that you can handle it and enjoy eating and drinking?

The end result of keeping someone on a diet they cannot handle is a quality of life that is horrendous, hence why modified diets were created and are used today by speech-language pathologists. It is a controversial topic as many people’s current views of modified diets are “why would you put someone on puree? Why would you thicken their liquids? Who would eat ground up food?” Let’s review the dysphagia diet protocol and determine why these diets were made and how they would help make swallowing easier, more comfortable, and less stressful.

What are the different stages of dysphagia?

Let’s discuss and clear the air about what exactly is dysphagia. Dysphagia can be broken down into four different phases: the oral preparatory stage, the oral stage, the pharyngeal stage, and the esophageal stage.

The oral preparatory stage includes chewing, mixing the food with saliva. It also includes the orientation of feeding utensils, how the person takes the food off the utensil or accepts the liquids from a cup.

The oral stage includes the act of taking the masticated food and mixing it with saliva to create a bolus. The tongue then moves the bolus back toward the back of the oral cavity.

The pharyngeal stage occurs when the vocal folds close to keep food and liquids from entering the airway. The larynx rises inside the neck and the epiglottis moves down to cover the airway, providing even more airway protection. The pharyngeal stage starts the swallow and squeezes the food down the throat. You need to close off your airway in order to keep food or liquid out and prevent penetration/aspiration.

The esophageal stage includes the bolus moving into the esophagus, the muscular tube that contracts to push the bolus into the stomach. In this phase, the bolus is propelled downward by a peristaltic movement. The lower esophageal sphincter relaxes at the initiation of the swallow, and this relaxation persists until the food bolus has been propelled downward by a peristaltic movement. The lower esophageal sphincter relaxes at the initiation of the swallow, and this relaxation persists until the food bolus has been propelled into the stomach. If the esophageal stage is affected, the patient might experience heartburn, vomiting, burping, or abdominal pain.

As a result of any of these dysphagia’s, there is an increased risk of aspiration. This is when food and fluid enter the airways below the true vocal folds which can result in aspiration pneumonia. Therefore the use of modified diets is utilized to try to prevent aspiration and its consequences in those with dysphagia.

What is IDDSI—International Dysphagia Diet Standardization Initiative?

Second, let’s talk about what exactly are the modified diets that exist out there. Different settings (rehabilitation centers, nursing homes, hospitals, group homes, etc) use different terminology, including but not limited to, puree, ground, chopped, mechanical soft, soft solids, minced, regular, ½ inch, ¼ inch, dysphagia 1, dysphagia 2, dysphagia 3, thin liquids, blenderized, nectar thickened liquids, honey thickened liquids, spoon thick liquids and pudding thick liquids. Speech Pathologists are constantly asked to clarify what each of these terms means by dietary, other therapists, Certified nursing assistants, RN’s, and medical doctors.

Due to the variety of diets used, there was a need for a standardized dysphagia diet. Therefore, The International Dysphagia Diet Standardization Initiative Inc. (IDDSI) was founded in 2012 by a multi-professional international group of volunteers. The IDDSI framework provides a common terminology to describe food textures and drink thickness. The IDDSI is a new diet structure that was created to maintain uniformity of diets on a global scale. As the plethora of dysphagia diet terminology, labels, numbers, and levels of food texture and thickened drinks has only led to greater opportunities for confusion. The framework is designed to avoid the confusion created by variable terminology and definitions to describe modified diets around the world. The effort is expected to improve the safety and care for all individuals with dysphagia, across all cultures.) The IDDSI, consists of a continuum of 8 levels (0-7) where drinks are measured from levels 0-4 and foods are measured from 3-7.

When does a Speech-Langauge Pathologist decide to Thicken Liquids?

Logemann (1998) argued that diet modifications including thickened liquids should be used only when other methods have failed. Although that scenario may represent the ideal, McCullough et al. (2004) reported that the use of thickened liquids has become one of the most common recommendations made by clinicians. The researchers concluded that this method is used because it is easy to implement. So let’s talk about what methods an SLP may trial before recommending thickened liquids or modified diets.

Maneuvers—Are there other techniques an SLP can use before recommending an altered diet consistency and thickened liquid?

There are many different maneuvers that an SLP may attempt or try in order to eliminate penetration/aspiration of thin liquids or solids before they move ahead and recommend an altered diet or thickened liquid.

Maneuvers are specific strategies that clinicians use to change the timing or strength of particular movements of swallowing. Some maneuvers require following multistep directions and may not be appropriate for patients with cognitive impairments. Examples of maneuvers include the following:

  • Effortful swallow —increases posterior tongue base movement to facilitate bolus clearance. The patient is instructed to swallow and push hard with the tongue against the hard palate (Huckabee & Steele, 2006).
  • Mendelsohn maneuver —designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway. The patient holds the larynx in an elevated position at the peak of hyolaryngeal elevation.
  • Supraglottic swallow —designed to close the vocal folds by voluntarily holding one’s breath before and during swallow in order to protect the airway. The patient is instructed to hold his or her breath just before swallowing to close the vocal folds. The swallow is followed immediately by a volitional cough.
  • Super-supraglottic swallow —designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow. The super-supraglottic swallow is similar to the supraglottic swallow; however, it involves increased effort during the breath-hold before the swallow, which facilitates glottal closure (Donzelli & Brady, 2004).

Pacing and Feeding Strategies

Specific volumes of food per swallow may result in faster pharyngeal swallow responses. As a result, a Speech-Language Pathologist may recommend modifying the bolus size (i.e., bigger/smaller bolus amounts) particularly for patients who require a greater volume to adequately stimulate a swallow response or for patients that require multiple swallows per bolus. In addition, a patient may also require verbal or visual cueing and assistance to maintain an appropriate rate during meals. Specifically, if a person is impulsive, or has decreased initiation, which are two types of cognitive deficits, that may affect a patient’s pace during meals and affect any of the stages of a swallow.

Postural/Position Techniques

You can use postural techniques to redirect the movement of the bolus in the oral cavity and pharynx and modify pharyngeal dimensions in a systematic way. Postural techniques may be appropriate to use with patients with neurological impairments, head and neck cancer resections, and other structural damage. These postural/position techniques may allow a patient to remain on thin liquids safely. Examples of postural techniques include the following:

  • Chin-down posture—the chin is tucked down toward the neck during the swallow. Which may bring the tongue base closer to the posterior pharyngeal wall, narrow the opening to the airway, and widen the vallecular space.
  • Chin-up posture—the chin is tilted up, which may facilitate the movement of the bolus from the oral cavity.
  • Head rotation (turn to the side) —the head is turned to either the left or the right side, typically toward the damaged or weak side (although the opposite side may be attempted if there is limited success with the first side) to direct the bolus to the stronger of the lateral channels of the pharynx.
  • Head tilt—the head is tilted toward the strong side to keep the food on the chewing surface.

Why modify solids?

Modified texture food is easier and safer to swallow for those with chewing problems. A modified texture/consistency can also allow a person to easily clear food from the pharynx and reduce the amount of pharyngeal stasis a person might have and reduce the risk of penetration/aspiration after the swallow.

According to ASHA: Diet Modifications, you can alter the texture of food to allow for safe oral intake. This may include changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods. Modifications of the taste or temperature may also be employed to change the sensory input of the bolus. Clinicians consult with the patients and caregivers to identify patient preferences and values for food when discussing modifications to oral intake. Consulting with the team, including a dietitian, is also a relevant consideration when altering a diet to ensure that the patient’s nutritional needs continue to be met.

Why thicken liquids?

It is important to keep in mind that if any of the four aforementioned stages are affected, there may be a need to thicken someone’s liquids in order to eliminate and/or reduce the risk of penetration/aspiration. What we don’t realize is how quickly thin liquids move once in the oral cavity. This rapid movement can result in discoordination and reduced control resulting in premature spillage of liquids over the base of the tongue, and thin liquids entering the airway (penetration/aspiration) before the swallow and/or during the swallow. Now, thickened liquids can be used to slow down the speed of liquids and improve the oral control of liquids. The thickened liquid may be used to manage the dysphagia, slow down the flow rate of liquids, and improve bolus control to prevent aspiration and improve swallow safety.

Conclusion

In conclusion, Speech-Language pathologists are not quick to recommend someone is placed on an altered diet or thickened liquids. In reality, we look at many options such as pacing, postural/position techniques, and maneuvers. But we must consider the patient’s cognitive ability to use these different options. If a person is unable to cognitively utilize these options, a speech pathologist will then move forward in their evaluation and trial thickened liquids or an altered diet. It is important to keep in mind that if an altered diet consistency or thickened liquid is recommended, it is to make eating/drinking more comfortable and safer for the patient and eliminate the deficits seen during the swallowing evaluation.

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