Understanding Mechanical Soft Diets
Long term disability is the most frequent post stroke complication. A little more than 50% of persons with stroke will experience permanent one-sided weakness or paralysis. This one-sided weakness or paralysis may not only affect your loved one’s arms and legs, but also could alter their ability to swallow. In people with stroke a common complication is poor nutrition due to limited intake of food, which can affect as many as 63% of stroke survivors. Some of this poor nutrition is caused by limited ability to swallow food, and many stroke survivors require special diets to prevent or reverse this deficit.
WHAT IS DYSPHAGIA (Dis-FAY-juh)?
Dysphagia is difficulty with swallowing. In the case of a loved one with a stroke, it was caused by the nerve and brain damage of the stroke. The damage may have also affected the ability to chew or move food around with the tongue.
Signs of Dysphagia:
- Food or drink leaking from the mouth
- Gurgling voice after eating or drinking
- Coughing during or right after eating
- Extra effort or time needed to chew and swallow
- Frequent pneumonia, or chest congestion after eating
- Weight loss and dehydration.
Consequences of Dysphagia and Malnutrition:
- Social Isolation
- Decreased enjoyment from eating
- Lung infections (e.g. Pneumonia)
- Urinary tract infections
- Slower wound healing
- Increased pressure ulcers
- Decline in functioning
- Higher death rates.
If my loved one can chew, why the special diet?
There are actually different stages of swallowing (see the diagram above). While your loved one can chew and control the food in their mouth (Stage 1) and initiate swallowing (Stage 2) the body may not be able to do the rest. If your loved one can chew and swallow, but is still on a special diet, their body might not be closing off their airway (Stage 3) or carrying the food to their stomach (Stage 4) as it once did. This might cause coughing, difficulty breathing, and/or vomiting. Sometimes your loved one may have NO symptoms at all, but may still be suffering from dysphagia.
IMPORTANT: ALWAYS CONTACT YOUR CARE PROVIDER, doctor, nurse practitioner, or speech-language pathologist, IF SYMPTOMS WORSEN or BEFORE you make any changes to his or her diet.
Is this problem forever?
This answer depends on how much damage the stroke caused to the brain. Many individuals, after therapy with a speech-language pathologist will be able to return to a normal diet. As time goes on inflammation in parts of the brain that control swallowing may disappear and allow normal swallowing again.
What is a Mechanical Soft Diet?
Mechanically altered diets consist of foods that can be safely and successfully swallowed. Foods are mechanically altered by whipping, blending, grinding, chopping, or mashing so that they are easy to chew and swallow. Foods that are in large chunks or pieces or that are very hard and cannot be chewed easily are to be avoided. Mechanically altered diets are described by the National Dysphagia Diet Guidelines and are on a level system. The National Dysphagia Diet guidelines apply to foods as well as liquids which may need altered as well depending on the person’s ability to swallow. The following describes the different levels of diet that your loved one might need.
Level 1- This diet consists of pureed, consistent, and unified foods. There should be no chunks, or mixed textures. The food should be “pudding-like” and should not need to be chewed or be difficult to move with the tongue. Examples of foods include smooth puddings, custards, yogurt, oatmeal, pureed fruits, and pureed meats. It may also be beneficial to sweeten, salt, pepper, and spice food according to taste preference. A pureed diet does not mean a bland diet.
Level 2- This level diet consists of foods that are moist, soft-texture, and easily swallowed. Meats are ground or finely cut to equal size no bigger than ¼ inch. All pureed foods from level 1 are also okay to eat. Level 2 foods are able to be easily chewed but must be in small bites; also some textures can be mixed such as found in a casserole dish. Examples of foods are soft-pancakes well moistened with syrup, soft canned fruits, soft cookies dipped in milk, soft meats like fish, moist macaroni, and scrambled eggs. Some additives to help flavor food at this level are ketchup, salsa, and jams.
Visit the following link for further information on this diet level with an in-depth food group review. http://www.dysphagia-diet.com/Images/Level%202%20Dysphagia%20Mechanically%20Altered%20Diet.pdf .
Level 3- This diet level includes food that is nearly normal excluding very hard, sticky, or crunchy foods. Foods should not be overly dry and should still be moist and bite sized. Foods to avoid include dry bread, toast, crackers, coarse cereal like shredded wheat, foods with nuts, seeds, fruits that are difficult to chew such as apples, tough dry meats, and chunky peanut butter.
Dysphagia may not only affect your loved one’s ability to eat but also his/her ability to drink. Some restrictions may be put on the use of straws, or drinking of carbonated drinks. However, changes can also include the need to thicken the liquids. There are many different types of thickeners; these could be starches (e.g. cornstarch), vegetable gums (e.g. Xanthan gum), or proteins (e.g. Gelatin) to name a few. Each different type of thickener has its benefits and drawbacks based on the type of liquids being thickened. Finding a thickener that works best for your loved one may take some time and sampling. It is important to follow the directions on the can/package carefully and mix the thickener until completely dissolved. In some cases you may need to let the drink sit a set number of minutes before drinking. This guarantees appropriate thickness. Some liquids may separate over time or continue to get thicker depending on which thickener is used so check the consistency before your loved one consumes the beverage/liquid food.
- SOME PRODUCTS ARE AVALIABLE PRE-THICKENED
- Hormel Thick & Easy® and Resource® make pre-thickened juices, water, tea, and milk at all levels of thickness.
- Thick-It® has thickened soup and pureed meals.
- Resource® also has pre-thickened instant coffee powder available in caffeinated and decaffeinated selections.
Levels of liquid thick-ness are below:
- Thin- Thin liquids means there are no restrictions. Water, milk, juice, coffee, tea, ice cream, sherbet, broth based soups, are all allowed with no thickener needed.
- Nectar Thick- Liquids must be thickened to a nectar consistency such as maple syrup, Ensure, pear/apricot nectar or eggnog consistency.
- Honey Thick- Liquids that are honey thick must be thickened to the consistency of honey, these cannot be taken by a straw.
- Pudding Thick/ Spoon Thick- liquids that are pudding thick need to be taken with a spoon.
- Remember anything that is liquid at room temperature is considered a liquid. This includes ice cream, sherbet, and popsicles, as well as soups/broths that will all need to be thickened or not served for the safety of your loved one.
In some cases the thickener, although not flavored, may change the taste, mouth feel or texture of the liquid. To make sure your loved one is getting enough fluids to prevent dehydration you can add flavoring or make drinks stronger tasting to your loved ones liking.
- Hormel Thick & Easy Instant Food Thickener
- Nestle Nutritional Thicken Up
- Thick-It Instant Food Thickener Powder
- Simply Thick Thickening Gel (Nectar & Honey)
- Resource ThickenUp
- Others may be recommended by your pharmacist, dietitian, or speech therapist.
FINAL TIPS FOR FEEDING:
- Have the person sitting upright for meals and for 30 minutes after to avoid aspiration.
- Make eating easier by putting a towel behind your loved ones back and remembering chin to chest when swallowing.
- Coaching may be needed by family members, small reminders like chew your food, and swallow multiple times.
- Making sure your family member is taking small bites and drinking small sips.
- Checking the cheeks for food left behind (or pocketed), after eating.
- Performing good oral hygiene after meals to decrease the risk of lung infections.
The following are some web sites to provide you with more information related to dysphagia and mechanical soft diets. (Please click to view the web sites.)
Want More Information on Dysphagia?
Want More Information on Thickened Liquids?
Akhtar, A.J., Shaikh, A., & Funnye, A.S. (2002). Dysphagia in the elderly patient. Journal of the American Medical Directors Association, 3(1), 16-20.
American Dietetic Association©. (2012). National dysphagia level 1: Pureed nutrition therapy. Retrieved from http://nutritioncaremanual.org/
American Dietetic Association©. (2002). Level 1 dysphagia pureed. National dysphagia diet: Standardization for optimal care. Retrieved from http://www.dysphagia-diet.com/App_Themes/Skin_3/images/Level1DysphagiaPureedDiet.pdf
American Dietetic Association©. (2012). Level 2 nutrition therapy for dysphagia: Mechanically altered foods. Retrieved from http://nutritioncaremanual.org/
American Dietetic Association©. (2002). Level 2 dysphagia mechanically altered. National dysphagia diet: Standardization for optimal care. Retrieved from http://www.dysphagia-diet.com/App_Themes/Skin_3/images/Level2DysphagiaMechanicallyAlteredDiet.pdf
American Dietetic Association©. National dysphagia level 3 advanced nutrition therapy Retrieved from http://www.nutritioncaremanual.org/
Black, J., & Hawks, J. (2009). Medical surgical nursing clinical management for positive outcomes (8th ed., p. 480). St. Louis, Missouri: Saunders, Elsevier.
Bouziana, S., & Konstantinos, T. (2011) Malnutrition in patients with acute stroke. Journal of Nutrition and Metabolism. doi:10.1155/2011/167898
Dalton, C., Caples, M., & Marsh, L. (2011) Management of dysphagia. Learning Disability Practice, 14(9), 32-38.
Germain I, Dufresne T, & Gray-Donald K. (2006). A novel dysphagia diet improves the nutrient intake of institutionalized elders. J Am Diet Assoc., 106(10), 1614-1623
Goulding, R., & Bathetic, A. M. (2000). Evaluation of the benefits of monitoring fluid thickness in the dietary management of dysphagia stroke patients. Clinical Rehab, 14, 119-124.
Logemann, J. A., Veis, S., & Colangelo, L. (1999). A screening procedure for oropharyngeal dysphagia. Dysphagia, 14(1), 44-51.
McCollough, G., Pelletier, C., & Steele, C. (2003). National dysphagia diet: what to swallow? ASHA Leader, 8(20),16.
McCallum SL. (2003). The national dysphagia diet: Implementation at a regional rehabilitation center and hospital system. Journal of American Dietitian Association, 103, 381-384.
National Dysphagia Diet Task Force. (2002). National dysphagia diet: standardization for optimal care. Chicago, IL: American Dietetic Association.
Perry, L, & McLaren, S. (2003). Eating difficulties after stroke. Journal of Advanced Nursing, 43(4), 360-369.
Queensland Health Dieticians. (2007). Thickened fluids. Retrieved from http://www.health.qld.gov.au/nutrition/resources/txt_mod_tf.pdf
Ramsey, D. J., Smithard, D. G., & Kalra, L. (2003). Early assessments of dysphagia and aspiration risk in acute stroke patients. Stroke, 34, 1252-1257.
Sayadi, R., & Herskowitz, J. (2010). Swallow safely: How swallowing problems threaten the elderly and others. a caregiver's guide to recognition, treatment, and prevention. (1st ed., pp. 13-27). Natick, MA: Inside/Outside Press.
University of Pittsburgh Medical Center. (2012). Patient education, thickened liquids: Honey thick. Retrieved from http://www.upmc.com/HealthAtoZ/patienteducation/N/Pages/thickenedliquidshoney-thick.aspx
Developed in 2012 by Matt Dixon, BSPS, at the University of Toledo for Caring~Web.