A common question that I hear is that a person with swallowing difficulties (dysphagia) says “I have to have modified texture food or fluids but I don’t like it and I’m not sure if I still need it.” While this question seems quite simple, it raises many complicated issues.
Causes of swallowing difficulties
Swallowing difficulties (dysphagia) are a common consequence of numerous medical conditions, including stroke, chronic neurological diseases and head and neck surgery. These difficulties can cause changes in sensation, muscle strength and coordination for people which in turn can impact on their health, intake of nutrition and hydration as well as their quality of life. Swallowing difficulties can also be associated with aging, in some cases, due to missing teeth, or reduced muscle strength in the tongue and throat. Other changes occur in the ability to smell and taste, and also how we breathe during a swallow. Aging is also often associated with increasing use of prescription medications that produce a dry mouth, another factor that can lead to swallowing difficulties.
Why we modify texture
Commonly one of the treatment options prescribed by Speech and Language Therapists for swallowing difficulties can involve some degree of texture modification of foods, fluids and medicine. Modification of the texture of foods to soft & bite-sized, minced & moist or pureed is usually to minimize the risk of choking caused by difficulties in moving the food around the mouth and chewing. When drinking, some people with swallowing difficulties have problems coordinating the timing of their swallowing which can cause fast-moving liquids to go down the wrong way into the airway. Modified the consistency of fluids is designed to make them slightly thicker so that in some people with dysphagia the fluid moves slower in the throat and can less likely to go straight down the wrong way. However, it is not always the case that pureed foods and thickened fluids are easier and safer to swallow. These textures are thicker and can leave more residue in the mouth and throat after the swallow. For some people, particularly those who have a fatiguing swallow, residue that stays in the mouth or throat after their first swallow can also go down the wrong way also1.
A very large project has been completed looking at standardizing the terminology for different consistencies of food and fluids over the whole world. The International Dysphagic Diet Standardisation initiative (IDDSI) was a project that ran for some 3 years to create and agree a standard set of descriptors for dysphagic diets and now is in the implementation stage.
Source found here
This important work provides a means of ensuring, for example, that a thickened fluid sold as mildly thick in one country is the same viscosity (thickness) as the same type of drink in another country. There are detailed descriptions and pictures available on the website which provides guidance on the food and fluid consistencies so that individuals and organisations can make these foods at the correct consistency. This makes it easier to make recommendations for people with dysphagia who move both nationally and internationally, and can also enable them to travel more easily too. In addition, it provides a common terminology to support future research.
The optimal therapeutic diet
As a part of the International Dysphagic Diet Standardisation initiative (IDDSI) researchers looked at all the research evidence for what is the optimal therapeutic diet across different countries, in different languages and with different populations (people with no swallowing difficulties, people with stroke, babies with feeding and swallowing difficulties). They discovered that there were no universal recommendations across all of these groups of people with dysphagia. Their conclusion was:
“On the basis of the current review, we are obliged to point out that the best available evidence regarding the selection of an optimal food consistency for a person with dysphagia comes from the careful exploration of tolerance for different foods in a comprehensive clinical swallowing assessment”.1
Not only does the medical condition, age of the person and what other health problems all influence what are the best consistencies people can manage. What we also know about the nature of dysphagia, is that it changes over time. For some people, with a condition that can recover and improve (such as a hemispheric stroke) it can mean that what they couldn’t swallow safely when they first had their stroke, they may now be able to manage safely giving them more options of different things to eat and drink. For other people, such as those with a progressive disease, it may be that they can no longer eat some things safely that they used to be able to eat or drink.
Swallowing ability changes over time
Generally speaking, there are many reasons why swallowing changes over time. We may consider that some changes are typical of the aging process or we adapt to them so gradually that we aren’t aware that we’re making compensations. For some people with dysphagia due to deteriorating conditions, they may also not want to face that changes in their swallowing ability are signalling further deterioration of their condition. For other people with dysphagia, neurological recovery over time and continued practice of swallowing their saliva and oral intake can bring about improvements in their swallowing function.
Therefore, my response to the person with dysphagia who asked the question “I have to have modified texture food or fluids but I don’t like it and I’m not sure if I still need it” is that it is important to seek a review comprehensive swallowing assessment by a Speech and Language Therapist who specializes in dysphagia. Then you will know if there are other options available to you to eat and drink safely that can potentially improve your quality of life.
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Written by Kimerley Clarke, Speech and Language Therapist, MRCSLT, MSPA, MASLTIP, Director, Web Speech and Language Therapy
International Dysphagia Diet Standardisation Initiative (IDDSI) Framework Evidence Statement (2016) Retrieved on 21.2.17 from http://iddsi.org/wp-content/uploads/2016/10/Opt_Evidence_IDDSI-Framework_10October2016_ZSEdit_final.pdf