Dealing with
Dysphagia
Sysco Corporation
Inservice Program
Outline
• Learning Objectives
• Key Concepts
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Common signs and symptoms of dysphagia include:
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Difficulty or pain when swallowing
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Excessive swallows for each bite
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Coughing or choking while eating or drinking
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Food or fluids leaking from the mouth or nose
The NDD defines 4 levels of liquid viscosities and 4 levels
of semi-solid/solid food textures.
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Liquids: thin, nectar-like, honey-like, spoon-thick
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Semi-solid/solid foods: pureed, mechanically
altered, advanced, regular
When thickening liquids, it is important to measure, mix,
and wait to ensure the liquid achieves the proper
consistency.
• Questions
Learning Objectives
After completing this program, participants will
be able to:
• Recognize common signs and symptoms of dysphagia
• Explain the risk of aspiration with dysphagic residents
• Classify liquids according to NDD guidelines for liquid
viscosity
• Demonstrate the 3 rules when using food thickener
• Classify semi-solid and solid foods according to NDD
guidelines for food texture
What is Dysphagia?
A condition affecting and impairing one of the
phases of swallowing.
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Swallowing involves 7 pairs of
nerves and 26 muscle groups.
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It is not generally considered
a diagnosis, but a symptom
caused by a variety of disorders.
Trachea
Esophagus
Stomach
Lungs
Common Causes of Dysphagia
Dysphagia has multiple possible causes and
occurs most frequently in older adults. Any
condition that weakens or damages the
muscles and nerves used in swallowing may
cause dysphagia, such as:
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Stroke
Cancer of the head, neck, or esophagus
Multiple sclerosis
Parkinson’s disease
Head injury or trauma
Alzheimer’s disease, dementia
Loss of muscle tissue during the aging process can also
contribute to a weaker swallow
Signs and Symptoms of
Dysphagia
• Difficulty swallowing
• Drooling
• Complaints of painful
swallowing
• Excessive swallows for
each bite
• Coughing or choking
before, during, or after
swallowing
• Wet-sounding/gargled
cough or voice after
swallowing
• Oral or nasal regurgitation
• Slow eating
• Requiring more than 45
minutes to finish meals
• Pocketing food in cheeks
• Frequent throat clearing
• Excessive hiccupping,
burping, or indigestion
• Recurrent chest infections
• Unexplained weight loss
• Dehydration
What is aspiration?
Aspiration is the entry of food, fluid, or foreign
materials into the trachea and lungs.
• Normally, food enters the mouth and travels down the
esophagus into the stomach.
• Aspiration occurs when food or fluids inadvertently travel
down the trachea into the lungs, which are only meant to be
exposed to air.
• Most people cough to prevent foreign substances from being
inhaled into the lungs; however, those
with difficulty swallowing may be more likely to
inadvertently inhale foreign substances.
Why is a dysphagic resident at
risk for pneumonia?
Aspiration is a primary complication of dysphagia
and may lead to life threatening conditions.
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Any foreign substances that enter the lungs may cause an
infection. Bacteria can thrive and multiply when the lungs
harbor these substances, and this can lead to the development
of aspiration pneumonia.
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Aspiration pneumonia is a major cause of morbidity and
mortality among the elderly who are hospitalized or in nursing
homes.
How does dysphagia affect a
resident’s nutritional status?
It is important that all residents eat a
nutritionally adequate diet.
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However, dysphagia can make it difficult for those
residents to consume enough food and fluids to remain
adequately nourished. They are at risk for dehydration,
weight loss, nutritional deficiencies, and malnutrition.
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In severe cases of dysphagia, you may notice that some
residents can no longer consume food and fluids by
mouth. They must use alternative nutrition support,
such as the use of a feeding tube, to meet their
nutritional needs.
National Dysphagia Diet (NDD)
The NDD was published in 2002 to establish
uniform, standardized terminology and
practices for dysphagia management. It
classifies food and fluids along a spectrum
and defines levels of nutrition intervention.
• A dysphagia diet is one that incorporates modified
textures of foods and/or consistencies of liquids. It is
important to follow all guidelines accordingly.
• The NDD outlines 4 levels of liquid viscosity and 4 levels
of food texture, to ensure consistency when prescribing
diets. It includes or excludes items at each level relative
to standard comparison foods.
National Dysphagia Diet (NDD)
Reviewing the results of swallowing
evaluations and diagnostic tests allows the
healthcare team to determine how a
resident handles various textures and
consistencies of food and liquids.
• This assessment is necessary in order to assign the
appropriate NDD levels.
• However, a resident’s diet may still need to be
individualized based on their needs and preferences.
• Prescribed NDD levels may be modified as their degree of
impairment changes or improves. Diets may be upgraded
if and when it is safe for the resident.
NDD Semi-Solid or Solid Foods
Foods are classified into one of the following 4
levels, depending on their method of
preparation and texture:
1) NDD Level 1 Dysphagia Pureed: Includes food of a
“pudding-like” consistency; smooth, pureed, or well
mashed; homogenous (with no lumps); cohesive;
requires no chewing
2) NDD Level 2 Dysphagia Mechanically Altered:
Foods should be moist, cohesive, and soft textured;
includes tender ground or finely diced meats, soft
cooked vegetables, soft, ripe or canned fruit, and some
moistened cereals
3) NDD Level 3 Dysphagia Advanced: Includes most
regular foods, except very hard, sticky, or crunchy items
4) NDD Level 4 Regular: All foods are allowed
NDD Liquids
Liquids are classified into one of the
following 4 levels, based on their viscosity
or thickness:
1) Thin: examples include water, milk, juice, coffee, tea,
carbonated drinks, gelatin, ice cream, sherbet, sorbet,
and broth-based soups
2) Nectar-like: coats a spoon and falls in small droplets;
examples include fruit nectars, maple syrup, Ensure
Plus (Chilled), eggnog, tomato juice, and cream-based
soups
3) Honey-like: drips from a spoon in small clumps;
examples include commercially prepared pre-thickened
liquids; thin liquids are to be thickened by trained staff
members using instant food thickener
4) Spoon-thick: falls from a spoon in large clumps; thin
liquids are to be thickened to pudding consistency by
trained staff members using instant food thickener
Why are liquids thickened for
some dysphagic residents?
Modification of liquid consistencies for
dysphagia management is a common practice.
• Beverages may need to be specially prepared for
residents with this condition, since swallowing of liquids
requires a great deal of coordination and control.
• Because the muscles involved in swallowing are
weakened or impaired with dysphagia, thickened liquids
may facilitate the swallowing reflex and decrease the risk
for aspiration.
• Liquids must be thickened to the appropriate consistency,
so as to reflect the physician’s order for the resident.
Pre-Thickened Liquids and
Food Thickeners
Pre-Thickened Liquids
Food Thickeners
• Commercially prepared
pre- thickened liquids are
available and provide an
option to ensure product
consistency.
• To increase liquid viscosity,
commercial starch thickeners
are stirred into hot or cold
beverages and other liquid
foods, such as soup broth.
• Most pre-thickened liquids
are color-coded to easily
distinguish between nectarlike or honey-like.
• Food thickeners allow for the
flexibility to prepare only the
amount necessary to thicken
the liquid.
Rules to remember when using
powdered food thickeners
1) Measure the thickener.
2) Mix well.
3) Wait to allow the liquid to thicken to the
proper consistency before using or serving.
NOTE: The steps and measurements to thicken liquids
will differ based on the brand and type of thickener used.
Always follow the manufacturer’s instructions.
Types of Food and Liquids to be
Avoided with Dysphagia
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Fibrous, gristly meats
Dry, crumbly, crispy food, with hard edges
Sticky foods
Small pieces
 Examples: nuts, seeds, popcorn, or coconut
• Raw, crunchy fruits and vegetables
 Especially with skins or seeds, or which produce a lot of
pulp
• Tough, chewy, crusty breads
• Spicy, acidic, or tart foods
• Extremely hot liquids and beverages
General Menu vs.
Texture Modified Menus
LUNCH
Regular
Diet
NDD Level 3
Dysphagia Advanced
(Mechanical Soft diet
in IMPAC)
NDD Level 2
Dysphagia
Mechanically Altered
(Dysphagia diet
in IMPAC)
NDD Level 1
Dysphagia Pureed
(Pureed diet
in IMPAC)
BBQ Chicken
3 oz
BBQ Chicken GR
BBQ Chicken GR
#8 Scoop
BBQ Chicken PU
BBQ Sauce
No
2 oz
4 oz
2 oz
Ranch Beans
½ cup
X
#10 Scoop
Ranch Beans PU
#10 Scoop
Ranch Beans PU
Cole Slaw
½ cup
Steamed Cabbage
#8 Scoop
Steamed Cabbage PU
#8 Scoop
Steamed Cabbage PU
Bread
1 slice
Bread/Margarine
#16 Scoop
Bread PU
#16 Scoop
Bread PU
Lemon Bar
2”x3”
square
X
#10 Scoop
Lemon Bar PU
#10 Scoop
Lemon Bar PU
Garnish
Parsley Sprig
1 each
No
No
No
Eye Appeal of Pureed or
Mechanically Altered Foods
Ideas to improve the visual presentation:
• Use attractive plates and silverware to improve the visual
appeal of a meal.
• Plate food with appropriate and colorful garnishes.
• Shape pureed and ground foods to resemble traditional
dishes.
 Use small scoops so that pureed meat resembles
meatballs
 Use food molds to restore pureed meats to their
traditional shape
 Use a pastry bag to pipe pureed pasta into a swirly
design
Eye Appeal of Pureed or
Mechanically Altered Foods
Condiments and Garnishes
• Gelatin: cubed, sliced, or
stamped out with a cutter
• Condiments: ketchup,
mustard, pureed pickle,
mayonnaise, jelly, gravy,
and salad dressing
• Sauces: chocolate,
butterscotch, cheese, or
fruit
• Cheeses: grated or
shredded cheeses sprinkled
on hot food
• Herbs or spices
• Graham cracker, or fine
bread, crumbs
• Whipped cream
Pureed Pork Dinner
Taste Appeal of Pureed Foods
Appealing plate presentations and quality
tasting foods will help support the resident in
maintaining adequate intake and, ultimately,
proper nutritional status. All foods served
should be well seasoned and have a
distinctive flavor.
The following ingredients can enhance food flavors:
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Garlic
Ground herbs or spices
Flavored extracts
Lemon zest
Butter
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Meat base
Fruit puree
Cheese
Gravy
Sauces
Meal Time Tips
Serving and feeding residents with dysphagia requires extra
care and consideration. Some tips to properly feed residents,
and items to check on at the end of the meal, include:
• Minimize distractions: Turn off televisions and seat the
resident in a quiet area.
• Properly seat the resident at a 90° angle.
• If feeding assistance is provided, make sure reasonably
sized bites are given and feeding is not forced or rushed.
• Make sure the resident maintains an upright position for
at least 30 minutes after a meal.
• Check to see that no leftover food remains in the
resident’s mouth.
• Support independence in eating whenever possible to
enhance quality of life.
• Make sure residents follow meals by brushing their teeth
to reduce dental caries. Encourage optimal mouth care.
For More Information
Take advantage of the following videos provided by our partner:
Videos are available in English and Spanish at the address below:
http://www.800-45-sysco.com
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About Thickened Liquids
The Puréed Diet Made Easy
The Mechanically Altered Diet Made Easy
Pleasing Plate Presentations for the Dysphagia Diet
Med-Diet is also your source for dysphagia products:
thickeners, purees, pre-thickened liquids, supplements,
adaptive equipment, puree molds, and much more!
Med-Diet Videos
Access at http://www.800-45-sysco.com
Questions?
Thank you for your participation!
References
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Russell, Carlene. “Dining with Dysphagia.” Dietary Manager. June
2002:11-16.
National Institute of Deafness and other Communication
Disorders. NIDCD Fact Sheet Dysphagia. Available from:
http://www.nidcd.nih.gov/health/voice/dysph
Escott-Stump, S. (2008). Dysphagia. In D. B. Troy (Ed.), Nutrition
and Diagnosis-Related Care (6ted., pp. 363-365). Baltimore, MD:
Lippincott Williams and Wilkins.
Nelms, M., Sucher, K., & Long, S. (2007). Diseases of the Upper
Gastrointestinal Tract. In P. Marshall (Ed.), Nutrition Therapy and
Pathophysiology (pp. 421-455). Belmont, CA: Thomson
Brooks/Cole.
Garcia, JM., Chambers IV, E., Molander, M., “Thickened Liquids:
Practice Patterns of Speech-Language Pathologists.” AJ SpeechLang Path. February 2005:4-13.
New National Dysphagia Diet Videos. (2011). Retrieved April 18,
2011, from Med-Diet Laboratories website:
http://www.dysphagia-diet.com/video.htm
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