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f you have ever swallowed a food or liquid only to have it "go down the wrong way," then you have an idea of what it might be like to have dysphagia. Now multiply that experience by the more than 600 times a day that we normally swallow, and you can imagine how difficult it would be to deal with that on a daily basis.
       Approximately 6 to 15 million Americans are affected by dysphagia (chewing and swallowing problems). About 53 to 74 percent of nursing home residents, 14 percent of hospital patients, and 33 percent of rehabilitation center patients have some form of dysphagia, which can have a dramatic impact on nutritional status.
       People who are likely to develop dysphagia include those who have had a cerebral vascular accident, those who have neuromuscular diseases (such as Parkinson's disease, Huntington's chorea, or multiple sclerosis), cancer of the head, neck, or esophagus, radiation treatment to the head or neck area, those with dementia, and people who are on medications that cause sedation, impair cognition, or decrease production of saliva.
Warning signs of dysphagia include:
* Taking a long time to begin a swallow or needing to swallow three or four times for each bite of food
* Coughing, frequent throat clearing, lack of a gag reflex, or weak cough (before, during, or after a swallow)
* Difficulty controlling liquids in mouth, difficulty controlling mouth secretions, or a wet/gurgly voice
* Pocketing food in mouth, spitting food out, or refusing to eat
* Repeated upper respiratory infections, persistent low-grade fever
* Unintentional weight loss
* Fullness or tightness in the throat or chest or a sensation of food sticking in sternal area.
       Residents displaying any of these signs should be referred to a speech language pathologist (SLP) for a bedside evaluation. If the SLP determines it is necessary, a barium swallow (a moving x-ray of the swallowing process) may be completed to determine the type of problem and how best to treat it. Treatment usually consists of a combination of swallowing exercises, swallowing techniques, and food/fluid consistency alterations. The primary objectives of treatment are to make swallowing safe, avoid aspiration pneumonia, and assure adequate nutrition and hydration. If swallowing is determined to be unsafe, an enteral feeding may be recommended. However, many residents can be treated by altering food/fluid consistencies and working with the SLP on safe swallowing strategies.

Diet Textures for Residents with Dysphagia
       The SLP and dietetics professional will determine the appropriate consistencies of food and fluid for each resident. Foods and fluids should be easy to swallow, nutrient dense, and served in an appetizing way to encourage eating.
       The National Dysphagia Diet Task Force (NDDTF), a group of registered dietitians (RD), SLPs, researchers, and industry leaders, have developed a nationally standardized definition for food and fluid consistencies for dysphagia treatment. The NDDTF has defined four diet levels:
* Level 1--Dysphagia pureed: The dysphagia pureed diet includes pureed, homogenous, cohesive, pudding-like foods.
* Level 2--Dysphagia mechanically altered: Foods in the dysphagia mechanically altered level are cohesive, moist, and semisolid. This diet requires some chewing ability. Included in this diet are ground or minced meats with fork-mashable fruits and vegetables. Excluded are most bread products, crackers, and other dry foods.
* Level 3--Dysphagia advanced: The dysphagia advanced diet is soft-solid. This diet requires more chewing ability. Examples of foods included in the dysphagia advanced diet are easy-to-cut meats, fruits, and vegetables. Excluded are hard, crunchy fruits and vegetables, sticky foods, and very dry foods.
* Level 4--Regular: This diet includes any solid textured foods.
       Facility staff must become more conscious of how to present and prepare food for dysphagia residents. The food must look and taste good, or residents won't want to eat it--and these residents are already at risk for malnutrition and dehydration. We must assure that they receive adequate nutrients to maintain health.
       Mechanical soft diets (such as level 1 and 2) consist of ground or chopped meats, soft fruits and vegetables that can be mashed with a fork, and extra gravies and sauces to moisten foods and make them easier to swallow. The goal is to keep the resident at the highest level of consistency tolerated. Plate presentation is extremely important. Mechanically altered diets should be served on china dishes just like all other diets. Avoid divided dishes unless the resident needs it to enhance independence in eating.
       The pureed diet (level 1) is used as an alternative for those who cannot tolerate regular or mechanical soft foods. It is generally a cohesive, moist mashed potato or pudding-like consistency. Making pureed food appear and taste as close to the regular diet as possible while easing the chewing and swallowing process poses a real challenge to kitchen staff's creativity.
       Standardized pureed recipes help to assure a product that is consistent in taste, appearance, consistency, and nutrient content. Pureed souffles, gelled bread/dessert products, and layered products all enhance the appearance of the diet. It doesn't have to be difficult--there are simple things that can be done to make food look more appealing:
* Utilizing smaller scoops to make meat look like meatballs
* Using sauces and gravies over meats and vegetables to garnish
* Sprinkling fruits or desserts with colored gelatin powder to add color, or using whipped topping to add an appealing garnish
* Using a slurry mixture to prepare bread products that look the same as the regular product but are of the proper consistency for the dysphagia diet
* Layering gelled bread with pureed meat to create the appearance of a sandwich
* Layering pureed pasta with pureed meat and sauce to create the appearance of lasagna or spaghetti
* Using pastry bags to create special effects, such as mixing two different colored vegetables (peas and carrots for example) and piping them onto the plate to create vegetables with flair
* Varying shapes using molds, souffles, mousse, and gelled bread products.
       Food thickeners and pre-prepared pureed products can allow variety in the pureed diet. Pre-prepared molded or gelled foods, such as meats, vegetables, and bread products, can make residents feel that they are receiving a more normal diet.

Liquids for Residents with Dysphagia
       It is very important to work with the SLP to determine the type of liquid that is safe for each individual to swallow. Thin liquids are usually the most difficult to swallow. Thickening liquids slows the time it takes for the fluid to move through the mouth and esophagus, allows better control of the swallow, and decreases risk of aspiration pneumonia. The NDDTF has defined liquid consistencies as follows:
* Thin: ice cream, sherbet, gelatin, water, coffee, tea, soda, ices, tomato juice, or anything that will liquefy in the mouth within a few seconds
* Nectar-like: apricot or peach nectar, or those liquids thickened to nectar consistency
* Honey-like: thickened to honey consistency
* Spoon thick: thickened to a pudding consistency.
       Thickening liquids can be achieved using modified food starch thickeners (a powder that is added to the liquid) or prethickened liquids that take the guesswork and potential human error out of the thickening process.

Avoiding Malnutrition and Weight Loss
       Dysphagia residents are at risk for malnutrition and dehydration, so it is important to assure adequate nutritional intake of calories, protein, and nutrients. This can be achieved by using enhanced foods, supplements, and calorie and protein boosters to increase nutrient density without dramatically increasing volume. Monitor food intake and weight status, and interview residents to honor food preferences and assess whether food and fluids are accepted.
       It is extremely important to position residents properly for best swallowing ability. Work closely with the SLP for tips on how to make swallowing easier for individual residents. Be sure staff members are well trained on feeding techniques for dysphagia. Don't forget to have residents reevaluated to assure that they are receiving the least restrictive diet.

Making it Easier
       There are many products available to enhance the ease of preparation and allow more creativity in the presentation of pureed foods. Various modified food starches and enhancers are available that allow foods to be formed to look more like their regular counterparts. Food molds that are shaped like various meats or vegetables can be used to enhance appearance. Some manufacturers have developed ready-to-serve foods for the pureed diet.
       Refer to Suggested Reading for a partial listing of resources to assist you in achieving the goal of appetizing and appealing pureed foods for your residents.

Acknowledgement
       This article is adapted from the presentation, "It's Tough to Swallow: Dysphagia Causes and Treatments," and the book, It's Tough to Swallow: Nutrition and Dining for Dysphagia (copyright 2002 Becky Dorner & Associates).

Suggested Reading
1. Dorner B. It's Tough to Swallow: Nutrition and Dining for Dysphagia. Akron, OH: Becky Dorner & Associates, 2002.
2. Brown A, et al. Establishing labels and standards for thickened liquids in the dysphagia diet. The Consultant Dietitians 1998;12(2).
3. Deering C, Russell C, Womack P. Perspectives on Dysphagia: A Continuing Education Self-Study for Dietetics Professionals. Waterloo, IA: The Consultant Dietitians in Health Care Facilities, 2001.
4. Felt P, et al. National Dysphagia Task Force. The National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association, 2002.
5. Lorman J. Swallowing Problems: A Guide for the Patient and Family. Stow, OH: Interactive Therapeutics, 1998.
6. Sonies B, et al. Disease state management: Dysphagia. Proceedings of the Fourth Annual Ross Medical Nutrition and Device Roundtable in Charleston, SC, April 1999. Nutrition in Clinical Practice Oct. 1999 Supplement.