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Dysphagia Diet: A Difference of Textures

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What is a Dysphagia Diet?

First, let’s discuss what Dysphagia means. It is a clinical term that describes chewing and swallowing problems. These problems affect young and old, rich and poor, and everyone in between. It can be short term or long term and affects around 1 in 25 adults every year. These problems can be painful and frustrating and may require a change in your diet.

However, the topic of the dysphagia diet is even more confusing . There has been a of lack of consistency when discussing the differences in diet textures. Learning what is appropriate to eat for a person struggling to chew or swallow can be a real struggle and often requires intervention by a healthcare professional.

The aim of this blog is to bring clarity and introduce you to options and resources you didn’t know are available. Follow along while I explain dysphagia and the different textures you need to know about to manage chewing and swallowing problems, including dysphagia diets and the differences between them.

Different Types of Dysphagia

View of mouth and throat showing trachea (breathing tube) in yellow at the front of the throat and the esophagus in pink at the back.
Mouth, pharynx, esophagus, trachea

Difficulty chewing of course occurs in the mouth. Swallowing difficulty occurs anywhere between the mouth and stomach.

Esophageal type occurs in the esophagus. This is the tube that connects the mouth and stomach. It may feel like food gets stuck on the way to the stomach, causing pain or discomfort.

Oropharyngeal type occurs when the muscles in the throat are weak. This can lead to choking or gagging when trying to swallow and can mean your food or drink ends up in your lungs instead of your stomach.

Chewing and swallowing difficulty has different causes. These could be genetic (passed from your parents to you), a result of your environment, or related to a serious health problem. Regardless of the cause, they are hard to deal with, especially without the right resources. Listed below are reasons a person would have chewing or swallowing problems.

Causes of Swallowing Difficulty

  • MS (Multiple Sclerosis) – a disease of the nervous system 
  • ALS (Amyotrophic Lateral Sclerosis) or Lou Gehrig’s Disease – a quickly progressing disease that causes weakened muscles and is fatal
  • Stroke (Blood flow in the brain stops, blocked by a clot. The brain does not receive enough oxygen. This can cause damage to nerves and muscles in the body)
  • Cancer or effects of cancer treatment, like radiation or surgery
  • Parkinson’s Disease – a progressive movement disorder causing tremors and stiffening of muscles
  • Eosinophilic esophagitis – inflammation in the esophagus caused by white blood cells (immune cells)
  • Xerostomia, better known as dry mouth
  • Advanced age
  • After intubation (for example, some people with severe covid had a tube inserted through the mouth, into the lungs to help them breath and caused trauma to the mouth and throat)
  • Esophageal stricture (narrowing of the esophagus)

 Causes of Chewing Difficulty

  • Broken or missing teeth
  • TMJ – Temporomandibular joint disorder (the jaw joints are weak, or have unnecessary pressure on them)
  • Poorly fitting dentures
  • General mouth pain

Dysphagia Symptoms

So how do you know if you are struggling with dysphagia? Observing a person while they eat, or being self aware of how it feels to chew and move food around in the mouth, can give you hints as to what may be going on.

Speech therapists and Doctors can use a swallow study, or X-ray while swallowing, to diagnose dysphagia. Otherwise known as a fluoroscopy or barium swallow, it helps to see if food or liquid is “going down the right tube”. As a result, this gives you a good idea as to whether or not there is a problem. In addition, the following problems are clues that can mean dysphagia is the problem you or a loved one is experiencing:

  • Drooling while eating
  • Gagging or choking while eating or drinking
  • Coughing, especially while trying to swallow
  • Heartburn or GERD (gastroesophageal reflux disorder)
  • Regurgitation, meaning food comes back up after swallowing
  • Excessive saliva production
  • Runny nose while eating
  • Feeling like food sticks in the esophagus after swallowing
  • Unexplained weight loss
  • Problems swallowing pills or medications

Complications of Dysphagia

Dysphagia can lead to serious problems, including weight loss, pneumonia, anxiety, and depression. Likewise, there are many people with dysphagia that are unable to feed themselves and this can further complicate an already troubling situation. Having a good support system, including family and friends, will improve your health outcomes.

When food texture is not at the right consistency, food or liquid end up in the lungs instead of the stomach. This term is called aspirating. This means bacteria and liquid enter the lungs, and can cause an infection called pneumonia and also causes difficulty breathing. This ultimately can result in hospitalization, increased cost, and difficulty healing.

Treatment

The treatment depends on the underlying cause. These options include strengthening exercises, a change in food texture or thickness of liquids (i.e dysphagia diet), therapy, surgery, medication, or a combination of these.

A Speech Language Pathologist (SLP), otherwise known as a Speech Therapist, is a professional that should be part of your care team and treatment plan. Here is a list of ideas that can help you manage your chewing or swallowing difficulty while you work with your care team:

  • Cut food into very small pieces
  • Chew your food very well
  • Eat slowly
  • Tuck your chin while swallowing
  • Avoid foods that have mixed consistencies, (solid and liquid food in the same time, cereal for example)
  • Include extra sauce or gravy, and sip a drink between bites to increase moisture and improve ability to move food around in the mouth
  • Therapeutic intervention by a speech therapist (SLP), doctor, dietitian (RD), dentist, and other healthcare practitioners
  • Exercises to strengthen mouth and throat muscles (given to you by your doctor or speech therapist)
  • Altered (modified) food and liquid consistency – use a blender or food processor to obtain these consistencies
  • Put pills or other medications in applesauce or pudding to make swallowing easier

Altered Food and Liquid Textures

There are two frameworks for dysphagia diets, the National Dysphagia Diet and IDDSI (International Dysphagia Diet Standardisation Initiative). The diets used for chewing or swallowing problems aim to simplify which texture is safest for a person struggling with chewing and swallowing.

Changing food and drink texture will make chewing and swallowing easier and prevent additional health problems. However, this can depend on the severity of your underlying problem. So what is the difference between these two diets?

National Dysphagia Diet

The National Dysphagia Diet has been used for two decades, published by the Academy of Nutrition and Dietetics in 2002. A team of dietitians (RD’s), speech therapists (SLP’s), and a food scientist were in the group that developed the parameters. It has four levels of different texture foods and four levels of thickened liquids. Therefore, eight different textural properties describe the altered texture needs of people that don’t tolerate solid food and regular, thin liquids.

Dysphagia Diet Level 1 – Pureed or Puree Diet

The food is blended to a smooth, thick consistency. It is homogenous, which means it has a consistent, uniform texture with no lumps or chunks.

Getting to this texture requires a good blender or food processor and lots of moisture. Adding sauce is always a good idea.

Creme Brulé – a smooth, pureed consistency dessert

Dysphagia Diet Level 2 – Mechanically Altered or Mechanical Soft Diet

The food is semi-solid, moist, and cohesive. The consistency is easy to chew and manipulate (move around with the tongue). It should improve your ability to chew and allow swallowing with less trouble. You get food to this consistency with a food processor, chef knife, or other chopping tool. Cook fruit and vegetable well, until very soft, requiring very little work to chew. Always add extra sauce or gravy.

Dysphagia Diet Level 3 – Advanced Texture Diet

This texture has moisture and needs more ability to chew, it is less homogenous. Advanced food types should be less uniform and are cut up with a knife instead of chopping into tiny pieces. Cook vegetables until very soft. Always add extra sauce or gravy.

Dysphagia Diet Level 4 – Regular

For level 4, there is no change in texture. This is what we call a general diet without being modified, well cooked, or having changes to make is easier to chew and swallow.

Two glasses carrot juice with fresh carrots of table next to juice glasses, thin liquid, IDDSI level 0
Carrots & carrot juice

Thickened Liquids

  • Thin – water, juice, and other liquids that do not have thickeners added
  • Nectar thick – a small amount of thickener mixes with the liquid of choice. The liquid flows easily but not as fast as water
  • Honey thick – a very thick liquid that flows at the same rate as cold honey
  • Pudding or spoon thick – this texture is more solid than liquid and does not flow, it plops

IDDSI (International Dysphagia Diet Standardization Initiative)

IDDSI was implemented in 2019. It corrects confusion with the National Dysphagia Diet. This framework replaces the National Dysphagia Diet, and is used globally to bring consistency to the wording of the dysphagia diet. Additionally, it has eight levels and takes into account both food and liquid. Drinks are categorized from 0 to 4, and food is categorized from 3-7 (notice the overlap of 3 and 4).

Thin liquids equal a zero (0) in the IDDSI framework. One (1) correlates with nectar thick liquids, two (2) with honey thick liquids, three (3) consists of liquidized foods or moderately thick liquids, four (4) is extremely thick liquids like pudding and also includes pureed foods, these are almost solid but very soft. The transitional foods are five through seven, they refer to the stages between completely pureed, homogenous food and no texture changes at all.

The IDDSI framework accounts for the fact that some foods are liquids and creates overlap with level three and four. Both can be considered a correct consistency for food and liquid. These two include a lot of moisture. We as people, in every culture, mix our foods and liquids together (soup for example). It is inevitable. Food can still be fun and flavorful while at the correct consistency.

The dysphagia diet can be incredibly confusing but healthcare professionals are working diligently to bring clarity and support to those who need it. Don’t confuse the dysphagia diet with a soft diet. A soft diet is used to treat stomach upset and GI problems. The IDDSI is in place to help distinguish what food consistencies are safe for people with chewing and swallowing problems. 

Conclusion

In conclusion, dysphagia diet textures can be confusing and complicated. IDDSI is the go-to, up to date information that healthcare professionals are using. It brings consistency to our terminology and provides additional guidance for changing textures of food and drinks. Following this guide can be helpful. A Doctor and Speech Therapist’s involvement in your care following a diagnosis of dysphagia will benefit you. Also, an RD might be your next step in managing your nutrition concerns, like weight loss and increasing flavor in your food.

Problems like shame and anxiety around food should be addressed when they happen, and they will happen. You may eat less because you are not happy with the texture or other limitations. These texture changes are necessary when swallowing becomes a problem, utilize your dietitian and speech therapist as much as you can. Learning to prepare foods properly can lead to greater satisfaction with eating and drinking different textures.

Furthermore, in a place like a hospital or nursing home, an RD can downgrade (but not upgrade) a diet, this means they can change the texture from regular to altered if a person is unsafe eating regular food. A Speech Therapist should always be consulted for upgrading a diet.

For any questions you have regarding your diet or the diet of a loved one, please reach out to your doctor, speech therapist or dietitian, or email me at RDN@catludwig.com. My goal is to bring fun and flavor back to your altered texture diet.

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