Dressing up Dysphagia Diets

With the older adult population, there is an increase in the number of people who have suffered from a stroke, have dementia or Alzheimer’s and may develop side effects that can impact the way food and liquids are consumed. When muscles in the face, mouth or throat becomes weak, a person may not be able to safely swallow regular textured food or liquids, resulting in dysphagia. Patients with dysphagia in long term care require Texture Modified (TM) foods to ensure they can safely consume meals without risk of aspiration. The downside of TM foods is that the appearance of the food is altered and there may be additional changes made to taste and nutrition profile. People who require dysphagia diets may have foods that have been texturized to a minced, soft mechanical or pureed consistency depending on their swallowing function and risk of aspiration. Regular foods can be modified by chopping, mincing, grinding or blending to ensure the proper texture is achieved and as a result of modifying the food texture, other changes can result such as fluid loss or nutrient changes [1]. With dysphagia diets, sometimes the focus is solely on achieving the right texture that the visual appeal of meal itself takes a back seat. More focus should be placed on ensuring residents and patients on dysphagia diets view their food as appetizing so that they can enjoy their meal.

Patients and residents on dysphagia diets may experience weight loss and under nutrition due to poor appetite or intake which can lead to poor wound healing and decline in overall health. According to Keller et all, undernutrition is a significant problem in 40-80 % of older adults that live in long-term or continuing care, are admitted to acute care, or are living in the community receiving meal assistance[2]. In addition to the increased risk of undernutrition, use of TM foods, especially pureed food, can affect quality of life because a large part of the pleasurable experience of chewing and manipulating food in the mouth is removed with TM foods[1]. Patients with dysphagia need their food modified so they can swallow safely but there are ways to improve the meal experience and overall appeal of the meal to make food more acceptable by patients and residents on a dysphagia diet.

There are several concerns with patients on dysphagia diets, especially for those on a pureed diet. Family, caregivers and the interprofessional team want to make sure the food is the right texture and that the meal is actually consumed. In addition, it is important that the nutrition profile is adequate to meeting the needs of the person. For the patient or resident, their concerns are a bit different. What determines the way we consume our next meal? Visual appearance, smell, taste, and texture all influence the way we consume our food. For patients and residents on a dysphagia diet, their feelings are the same, but there are misconceptions that poor intake is due to lack of appetite or the food doesn’t taste good, which may be the case sometimes but not always. As Keller et al discusses, although taste is paramount, appearance is also believed to influence consumption and thus nutrient intake, if the food is visually appealing it will be perceived more positively by staff, family and persons with dysphagia [1]. TM foods that are typically prepared in house may be unappealing due to its appearance and consistency and fear of consuming a messy meal in front of other residents [1, 2]. If the food looks unappealing, the person is less likely to consume it, creating a cycle of poor appetite and intake. Many of us may not realize how recognizable features of a meal can impact the way we eat it or if it is eaten at all. Would you eat that grey blob that you are not sure if it is a meat, starch or a vegetable? Persons with dysphagia comment that food can be unrecognizable due to bland colours and forms on the plate, and will therefore affect consumption [3]. Taking the extra step to create a visually appealing plate will help promote appetite and intake of people on dysphagia diets, and ultimately help to maintain their nutrition status.

There are many challenges with TM foods in long term care including lack of consistency, education of dietary staff, and changes in nutrition profile. The Ministry of Health and Long Term Care (MOHLTC) requires that standardized recipes for all food textures should be used and can be obtained from a food service supplier database [4]. Consistency can play a large role in meal consumption because sometimes TM foods prepared in house appear different and inconsistent each time it is served, resulting in various appearances when the same meal is prepared. The lack of consistency from foods prepared in house is due to recipe changes and alterations from in house chefs that may not use the standardized recipe and “eye ball” many steps and overall texture [4]. Dietary staff interact most often with patients and residents in long term care so it is crucial that they understand dysphagia diets to ensure the food is presented and fed in a respected manner. Patients will respond to a staff member who comments on the unappealing look of a meal and therefore not want to consume it. In addition, nutrient profiles, specifically, protein content differ between in-house pureed and regular texture food which increases the importance of intake for individuals [5]. So the challenge lies in trying to achieve a TM meal that can be visually appealing and help to increase appetite and intake.

So how can we dress up dysphagia? Is that even possible or safe? It sure is! Those that require dysphagia diets need to be able to swallow their foods safely but there are many ways to improve the appeal, pleasure and meal experience of TM foods. TM foods, especially pureed can still appear more visually appealing, and can be accommodating to meet individual preferences. Dietary staff agree, the area requiring the most improvement in production of in-house foods are improvement to the visual appeal of pureed foods [4]. Food can be presented in a way that makes the food recognizable with molding and piping the food into shapes that resemble its original form which can make a huge difference in pureed foods that have a variety of colour added to the plate. Piping and molding meals may be more time consuming for in house preparation, in which case there are options to procure commercial products from companies that have worked hard to perfect their texture and viscosity of pureed foods. Ready-to-Use individually portioned products may potentially have greater appeal if they preserve flavour, enhance colour, improve texture, are easier to use, and reform the food to provide a more appetizing appearance [2]. Simple additions to the plates with garnishes and nutritionally approved spices can also add to the visual appeal. It is important to modify the dysphagia menu and be able to provide alternatives for residents because perceptions of consumers are different from the healthy older adult population and efforts should be made to capture their liking [4, 5].

Food preferences should be taken for patients on TM diets because often times, they are receiving different items than their tablemates, which can promote poor intake and encourage social isolation. For example, if there is beef and potatoes on the menu, there should be a couple of meat and starch options for the residents to choose from. Giving the patient the choice to pick their meal can make a difference in the way the meal is consumed and how much of the meal is consumed.

TM foods can impact food intake and ultimately nutrition status of a patient or resident. It is important to find ways to make TM foods, especially pureed foods, visually appealing which can help promote intake. In addition, greater attention should be given to educate dietary staff on dysphagia diets to allow better understanding of some of the challenges associated with them so they can serve and feed meals with greater understanding and empathy. Listening to patient preferences can help tailor a meal to be more enjoyable and help increase intake. While there are challenges with TM diets, there a few improvements that can be made to help maintain nutrition status for patients and make their meal an enjoyable one.

References:

1. Keller, H., et al., Issues associated with the use of modified texture foods. J Nutr Health Aging, 2012. 16(3): p. 195-200.
2. Keller, H.H., et al., A Mix of Bulk and Ready-to-Use Modified-Texture Food: Impact on Older Adults Requiring Dysphagic Food. Canadian Journal on Aging / La Revue canadienne du vieillissement, 2012. 31(3): p. 335-348.
3. Keller, H.H. and L.M. Duizer, What do consumers think of pureed food? Making the most of the indistinguishable food. J Nutr Gerontol Geriatr, 2014. 33(3): p. 139-59.
4. Ilhamto, N., et al., In-house pureed food production in long-term care: perspectives of dietary staff and implications for improvement. J Nutr Gerontol Geriatr, 2014. 33(3): p. 210-28.
5. Ettinger, L., H.H. Keller, and L.M. Duizer, Characterizing commercial pureed foods: sensory, nutritional, and textural analysis. J Nutr Gerontol Geriatr, 2014. 33(3): p. 179-97.