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Purees That Please, Part 1

Contributed by Judy Schlager, RD, LD Updated by Nutrition411.com staff Review Date 4/14 G-1559

The Dysphagia Diet

• Choosing the correct diet: – Must individualize – Goal: Rehabilitate to the highest practical level of the dysphagia diet progression – Must use collaborative effort to reach decision – Must have careful swallow evaluation by a qualified therapist 2

Dysphagia Diet Progression National Dysphagia Diet (NDD) 1—pureed:

• Pureed, homogenous, and cohesive foods • Pudding-like foods • No coarse textures, raw fruits or vegetables, nuts, etc • All foods requiring bolus formation, controlled manipulation, or mastication are excluded 3

Dysphagia Diet Progression (cont’d) NDD 1—pureed:

• Rationale: This diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities, and reduced ability to protect their airway • Close or complete supervision and alternate feeding methods sometimes are required 4

The Pureed Diet The pureed diet has only one purpose:

• To enable the patient/resident to ingest adequate nutrition in comfort and safety • Modification is in texture only • Further modifications merely impose further complications 5

Dysphagia Diet Progression NDD 1—mechanically altered:

• Foods are moist, soft textured, and easily formed into a bolus • Meats are ground or minced, not larger than ¼̋ pieces—still moist with some cohesion • All foods from Level 1 are acceptable at this level 6

Dysphagia Diet Progression (cont’d) NDD 2—mechanically altered:

• Rationale: This diet is a transition from the pureed textures to more solid textures • Chewing ability is required • Textures are appropriate for individuals with mild to moderate oral and/or pharyngeal dysphagia 7

Dysphagia Diet Progression (cont’d) NDD 2—mechanically altered:

• Assess patients for tolerance to mixed textures • Expect that some mixed textures are tolerated in this diet 8

Dysphagia Diet Progression (cont’d) NDD 3—dysphagia advanced:

• Foods are of nearly regular textures, with the exception of very hard, sticky, or crunchy foods • Foods still are moist and in bite-size pieces at the oral phase of the swallow 9

Dysphagia Diet Progression (cont’d) NDD 3—dysphagia advanced:

• Rationale: This diet is a transition to a regular diet • Adequate dentition and mastication are required • Textures of this diet are appropriate for individuals with mild oral and/or pharyngeal phase dysphagia 10

Dysphagia Diet Progression (cont’d) NDD 3—dysphagia advanced:

• Assess patients for tolerance of mixed textures • Expect that mixed textures are tolerated on this diet 11

Dysphagia Diet Progression (cont’d) NDD 4—regular:

• Any solid-texture food • All beverages are included 12

Characteristics of Pureed Foods For dysphagic diets:

• Puree consistency should support straw when placed in center of food • Foods are dense in relation to volume • Temperatures are cold or hot, not tepid • Thicken liquids PRN (as needed) • Textures uniform—no combined textures • Smooth, not sticky • Foods to avoid—seeds, nuts, and crunchy foods 13

Foods for Dysphagic Patients Foods must form a cohesive bolus:

• Use sauces and gravies • Avoid rice, cottage cheese, and ground meats without sauces and gravies • Liquids usually are thickened 14

Commercial Thickeners in Liquids Properties of starch thickeners:

• Pregelatinized and agglomerated to instantize • Only the water portion of the item is thickened • Normal metabolism reverses the thickening process, thus releasing the water to make it available for hydration 15

Commercial Thickeners in Liquids (cont’d) Properties of starch thickeners

• High water-binding capability • Good fiber source • Good bulk for colon

(cont’d):

• Indigestible in upper gastrointestinal tract • Low susceptibility to enzymatic hydrolysis 16

Facility-Thickened vs Prethickened Liquids Facility thickened:

• Advantages: – For use with all liquids – Less costly • Disadvantages: – Unsafe=lumps – Inaccurate measuring=inconsistent results – Constant training of staff members – Risk of fines because of improper viscosity levels 17

Facility-Thickened vs Prethickened Liquids (cont’d) Prethickened:

• Advantages: – Safer=no lumps – No staff training • Disadvantages: – More costly – Not all necessary liquids available – Flavors sometimes not as good as with facility thickened liquids 18

Viscosity Borders and Ranges For thickened liquids:

• Thin=1 to 50 centipoise (cP) • Nectar-like=51 to 350 cP • Honey-like=351 to 1750 cP • Spoon thick=more than 1750 cP 19

References

Academy of Nutrition and Dietetics. Manual ® . Nutrition Care Manual Web site. www.nutritioncaremanual.org

2014.

Nutrition Care . Accessed April 26, National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care . Chicago, IL: American Dietetic Association; 2002. 20