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		Dysphagia Diet 5 Levels for Difficulty In Swallowing Diet Learn how the new prebiotic soluble fibers benefit bowel health and many GI disorders Purpose Dysphagia means difficulty with chewing or swallowing food or liquid. To understand how this might happen, it is important to know something about how swallowing occurs. First, food must be chewed thoroughly. Then it is moved to the back of the mouth by tightening the cheek muscles and pressing the tongue against the roof of the mouth. From this point on the process becomes automatic -- it is a reflex that people do not actively control. In "rapid- fire" succession, the soft palate closes the nasal airway to prevent food from backing into it, the airway into the lungs is closed, and the esophagus (food pipe) relaxes allowing food and liquid to enter it. The muscular esophagus then contracts in a wave-like action, sweeping the food along into the stomach. A blockage or a malfunction anywhere in this part of the body or in the nervous system controlling swallowing can result in dysphagia. There are two types: Esophageal dysphagia occurs when food/liquid stops in the esophagus. This happens most often because of consistent stomach acid refluxing (backing up) into the esophagus. Over time, the reflux causes inflammation and a narrowing (stricture) of the esophagus. Food and eventually liquids feel like they are sticking in the middle and lower chest. There may be chest discomfort or even real pain. Fortunately, physicians can usually dilate (widen) this narrowing, and there is now treatment available to keep it from returning. Cancer, hiatus hernia, and certain muscle disorders of the esophagus are less frequent causes of esophageal dysphagia. Solid food is usually more of a problem than liquids Oropharyngeal dysphagia involves difficulty moving food to the back of the mouth and starting the swallowing process. This type of dysphagia can result from various nerve or brain disorders such as stroke, cerebral palsy, multiple sclerosis, Parkinson's and Alzheimer's diseases, cancer of the neck or throat, a blow to the brain or neck, or even dental disorders. Depending on the cause, symptoms may include drooling, choking, coughing during or after meals, pocketing of food between the teeth and cheeks, gurgly voice quality, inability to suck from a straw, nasal regurgitation (food backing into the nasal passage), chronic respiratory infection, or weight loss. Liquids are usually more of a problem in oropharyngeal dysphagia. The first step in treatment is to make the proper diagnosis. This involves a medical history and various tests to find the cause of the dysphagia. Often a team approach to treatment is needed. Several types of health care providers -- physicians, registered dietitian, psychologist, speech pathologist, occupational therapist -- work together to develop the best program. An important part of the treatment is helping the patient get adequate nutrition, while protecting against complications such as pneumonia from food or liquid getting into the lungs. Obviously, this requires a specialized diet. There are five different diet levels from puréed (level 1) up through modified regular food (level 5). The diets vary in texture and consistency, and are chosen depending on which would be most effective for a specific patient. Nutrition facts These diets are all nutritionally adequate. However, some patients may have difficulty taking enough fluid and food to get all the energy and nutrients they need. In this case, an adjustment to diet or treatment will be required. Liquids Fluids are essential to maintain body functions. Usually 6 to 8 cups of liquid (48-64 oz) are needed daily. For some dysphagia patients, this may present problems because thin liquid can be more difficult to swallow. In this case, fluid can be thickened to make it easier to swallow. However, close monitoring by the dysphagia team is required for anyone drinking less than 4 cups of thickened fluid a day or anyone not progressing to thin liquids within 4 weeks. Calories The greater problem for some patients is eating enough calories. The whole process of eating simply becomes too difficult and too tiring. However, calorie and protein intake can be increased by fortifying the foods the patient does eat. Fortify milk by adding 1 cup of dry powdered milk to one quart of liquid milk. Use this protein fortified milk when making hot cooked creamed soups, sauces, milkshakes, and puddings. Also add margarine, sugar, honey, jelly, or puréed baby food to increase calories. Add strained baby fruit to juices, milkshakes, and cooked cereals. Add 1 jar of strained baby meat to soup, such as strained chicken noodle soup. Also add strained baby meats to sauces and gravies, and mix with strained vegetables. Add juice to prepared fruit, cereal, or milkshakes. Special Considerations The following are some general guidelines for safe swallowing. Remember that dysphagia patients have individual requirements, so all of these guidelines may not apply to every patient. Maintain an upright position (as near 90 degrees as possible) whenever eating or drinking. Take small bites -- only 1/2 to 1 teaspoon at a time. Eat slowly. It may also help to eat only one food at a time. Avoid talking while eating. When one side of the mouth is weak, place food into the stronger side of the mouth. At the end of the meal, check the inside of the cheek for any food that may have been pocketed. Try turning the head down, tucking the chin to the chest, and bending the body forward when swallowing. This often provides greater swallowing ease and helps prevent food from entering the airway. Do not mix solid foods and liquids in the same mouthful and do not "wash foods down" with liquids, unless you have been instructed to do so by the therapist. Eat in a relaxed atmosphere, with no distractions. Following each meal, sit in an upright position (90 degree angle) for 30 to 45 minutes. Learn how the new prebiotic soluble fibers benefit bowel health and many GI disorders Level 1 Puréed Foods Foods in this group are puréed to a smooth, mashed potato-like consistency. If necessary, the puréed foods can keep their shape with the addition of a thickening agent. Meat is puréed to a smooth pasty consistency. Hot broth or hot gravy may be added to the puréed meat, approximately 1 oz of liquid per 3 oz serving of meat. CAUTION: If any food does not purée into a smooth consistency, it may make eating or swallowing more difficult. For example, zucchini seeds sometimes do not blend well. Hot Foods Cold Foods Puréed meats, poultry, & fish Puréed cottage cheese Puréed tuna, ham, & chicken salad Puréed fruit Pureed scrambled eggs & cheese Thickened juices & nectars Baby cereals Thickened milk or eggnog Thinned cooked cereals (no lumps) Malts Puréed French toast or pancakes Thick milkshakes Mashed potatoes Ice cream Puréed parsley, au gratin, scalloped potatoes, candied sweet potatoes Fruit or Italian ice, sherbet Puréed buttered or Alfredo noodles Plain yogurt Puréed vegetables (no corn or peas) Smooth & drinkable yogurt Puréed soups & creamed soups Smooth pudding, mousse, custard Puréed scalloped apples Whipped gelatin Gravies Sugar, syrup, honey, jelly Sauces: cheese, tomato, barbecue, white, creamed Cream Decaffeinated coffee or tea Non-dairy creamer Margarine Mayonnaise Ketchup, mustard Sample Menu, Level 1 Breakfast Lunch Dinner orange juice 1/2 cup cream of wheat 1/2 cup scrambled eggs with cheese 1/2 cup decaffeinated tea 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp ketchup 1 Tbsp margarine 1 tsp salt 1/4 tsp sugar 2 tsp pineapple juice 1/2 cup puréed beef 3 oz gravy 2 Tbsp mashed potatoes 1/2 cup puréed fresh broccoli 1/2 cup apple sauce 1/2 cup decaffeinated coffee 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp puréed turkey barley soup 3/4 cup puréed Hawaiian chicken 3 oz mashed potatoes 1/2 cup puréed spinach 1/2 cup frozen yogurt 1/2 cup decaffeinated tea 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp This Sample Diet Provides the Following Calories 1657 Fat 61 gm Protein 92 gm Sodium 2590 mg Carbohydrates 198 gm Fiber 3163 mg Level 2 Minced Foods Foods in this group should be minced/chopped into very small pieces (1/8 inch). The flecks of food are similar in size to sesame seeds. Hot Foods Cold Foods Minced meat, fish, poultry Cottage cheese Minced stuffed fish Junior baby fruit Flaked fish Semi-thickened juices Junior baby meats Nectars Minced soft cooked, scrambled, poached eggs Ripe mashed bananas Minced soufflé & omelets Minced canned fruit Minced soft French toast Pineapple sauce Minced soft pancakes Milk Cooked cereals Milkshakes Minced potatoes Custard Minced buttered or Alfredo noodles Puddings, including rice & tapioca Minced vegetables Yogurt Creamed soups Fruit ice, Italian ice, sherbet Puréed vegetables soup or alphabet soup Whipped gelatin Minced scalloped apples Junior baby desserts Gravies Sugar, syrup, honey, jelly Sauces: cheese, creamed, barbecue, tomato, white Cream Decaffeinated coffee or tea Margarine Sample Menu, Level 2 Breakfast Lunch Dinner orange juice 1/2 cup oatmeal 1/2 cup scrambled eggs with cheese 1/2 cup decaffeinated tea 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp ketchup 1 Tbsp margarine 1 tsp salt 1/4 tsp sugar 2 tsp pineapple juice 1/2 cup minced beef 3 oz gravy 2 Tbsp mashed potatoes 1/2 cup minced fresh broccoli 1/2 cup applesauce 1/2 cup decaffeinated coffee 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp puréed turkey barley soup 3/4 cup minced Hawaiian chicken 3 oz mashed potatoes 1/2 cup puréed spinach 1/2 cup frozen yogurt 1/2 cup decaffeinated tea 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp This Sample Diet Provides the Following Calories 2022 Fat 80 gm Protein 111 gm Sodium 2992 mg Carbohydrates 231 gm Potassium 4182 mg Level 3 Ground Foods Foods in this group should be ground/diced into 1/4-inch pieces. These pieces of food are similar in size to rice. Hot Foods Cold Foods Ground meat, fish, poultry Cottage cheese Ground meat salads (no raw eggs) Smooth fruited yogurt Ground Swedish meatballs Fruit juices or nectars Scrambled eggs or soufflés Ground canned fruit Ground poached eggs Crushed pineapple Cooked cereals Ripe bananas Ground soft French toast Lemonade/Limeade (no pulp) Ground potatoes Milk Ground noodles Ice cream Ground baked potato (no skin) Custard Ground well-cooked frozen vegetables (no corn, peas, or mixed vegetables) Puddings or mousse Ground canned vegetables Fruit ice, Italian ice, sherbet Creamed soups Cream Puréed vegetables soup or alphabet soup Non-dairy creamer Ground scalloped apples Margarine Gravies Mayonnaise Sauces: cheese, creamed, barbecue, tomato, white Ketchup Decaffeinated tea or coffee Mustard Sample Menu, Level 3 Breakfast Lunch Dinner orange juice 1/2 cup oatmeal 1/2 cup scrambled eggs with cheese 1/2 cup decaffeinated tea 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp ketchup 1 Tbsp margarine 1 tsp salt 1/4 tsp sugar 2 tsp pineapple juice 1/2 cup ground beef 3 oz gravy 2 Tbsp mashed potatoes 1/2 cup cooked spinach 1/2 cup applesauce 1/2 cup decaffeinated coffee 1 cup whole milk non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp puréed turkey barley soup 3/4 cup ground Hawaiian chicken 3 oz mashed potatoes 1/2 cup ground fresh broccoli 1/2 cup frozen yogurt 1/2 cup decaffeinated tea 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp This Sample Diet Provides the Following Calories 2022 Fat 80 gm Protein 111 gm Sodium 2992 mg Carbohydrates 231 gm Potassium 4182 mg Level 4 Chopped Foods Foods in this group should be chopped into 1/2-inch pieces. These pieces of food are similar in size to uncooked elbow macaroni or croutons (small bread cubes). Hot Foods Cold Foods Chopped meat or poultry Cottage cheese Chopped Swedish meatballs Yogurt Meat salads (ground or flaked meat) Milk Flaked fish Milkshakes Poached or scrambled eggs Soft, cold, dry cereal Soufflés and omelets Soft bread (if approved by speech or occupational therapy) Cooked cereals Fruit juice or nectars Chopped French toast or pancakes Chopped canned fruit Chopped noodles or pasta (no rice) Canned fruit cocktail Chopped cooked vegetables (no frozen peas, corn, or mixed vegetables) Pudding, mousse, custard Chopped canned small sweet peas Ice cream Creamed soup or vegetable soup Fruit ice, Italian ice, sherbet Canned chicken noodle soup Cream cheese Chopped potatoes (all kind) Whipped topping Gravies Whipped gelatin Bacon dressing Sugar, syrup, honey, jam, jelly Sauces: cheese, creamed, barbecue, tomato, white Decaffeinated tea or coffee Sample Menu, Level 4 Breakfast Lunch Dinner orange juice 1/2 cup oatmeal 1/2 cup scrambled eggs with cheese 1/2 cup decaffeinated tea 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp ketchup 1 Tbsp margarine 1 tsp salt 1/4 tsp sugar 2 tsp pineapple juice 1/2 cup chopped beef 3 oz gravy 2 Tbsp mashed potatoes 1/2 cup chopped fresh broccoli 1/2 cup applesauce 1/2 cup decaffeinated coffee 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp turkey barley soup 3/4 cup chopped Hawaiian chicken 3 oz mashed potatoes 1/2 cup cooked spinach 1/2 cup frozen yogurt 1/2 cup decaffeinated tea 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp This Sample Diet Provides the Following Calories 2097 Fat 82 gm Protein 113 gm Sodium 3213 mg Carbohydrates 243 gm Potassium 4201 mg Level 5 Modified Regular Foods Foods in this group are soft, moist, regularly textured foods Hot Foods Cold Foods Soft, moist meat, fish, poultry Soft cheeses Baked fish Cottage cheese Meat Salads Cream cheese Soufflés and omelets Yogurt Eggs Milk Stuffed shells Milkshakes Spaghetti with meat sauce Cold dry cereals (no nuts, dried fruit, coconut) Cooked cereal Crackers French toast or pancakes Soft breads (no hard rolls) Toast Fruit juices or nectars Noodles or pasta (no rice) Canned fruit Potatoes (all types) Ripe bananas Soft, cooked vegetables (no corn, lima, or baked beans) Peeled, ripe, fresh fruit Creamed soups or vegetable soup Cakes (no nuts, dried fruit, coconut) Canned chicken noodle soup Plain doughnuts Gravies Ice cream Bacon dressing Pudding, mousse, custard Sauces: cheese, creamed, barbecue, tomato, white Fruit ice, Italian ice, sherbet Decaffeinated tea or coffee Whipped gelatin Regular gelatin Canned fruited gelatin molds Sugar, syrup, honey, jam, jelly Cream Non-dairy creamer Margarine Oil Mayonnaise Ketchup Mustard Sample Menu, Level 5 Breakfast Lunch Dinner orange juice 1/2 cup oatmeal 1/2 cup cheese omelet toast 1 slice decaffeinated tea 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp ketchup 1 Tbsp margarine 1 tsp salt 1/4 tsp sugar 2 tsp jelly 2 tsp pineapple juice 1/2 cup hamburger on bun 3 oz steak fries 1/2 cup green beans 1/2 cup applesauce 1/2 cup decaffeinated coffee 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp salt 1/4 tsp sugar 1 tsp ketchup 2 Tbsp turkey barley soup 3/4 cup Hawaiian chicken 3 oz mashed potatoes 1/2 cup fresh broccoli 1/2 cup frozen yogurt 1/2 cup decaffeinated tea 1 cup non-dairy creamer 2 Tbsp saltine crackers 6 margarine 1 tsp salt 1/4 tsp sugar 1 tsp This Sample Diet Provides the Following Calories 2851 Fat 120 gm Protein 129 gm Sodium 4062 mg Carbohydrates 327 gm Potassium 4609 mg Commercial Thickening Agents Product Manufacturer Phone Thick n Easy American Institutional Products, Inc. (717) 569-1866 Thick-it Milani Foods, Inc. (800) 333-0033 Thick Set Bernard Fine Foods, Inc. (800) 538-3663 Thixx Bernard Fine Foods, Inc. (800) 323-3663 Textures/Consistencies of Foods The following are examples of medium and thick liquids and foods. Medium (nectar consistency): eggnog fruit nectars (apricot, peach, pear) honey thick creamed soups soft set pudding with added milk tomato juice buttermilk ice cream (no nuts or fruit chunks) milkshakes Thick (yogurt or pudding consistency): cooked hot cereal pudding custard gravy yogurt (no nuts or fruit chunks) cottage cheese mixed in blender with milk or fruit thick malt and milkshakes Thickening and Thinning Agents Foods can be thickened or thinned to individual requirements. Many foods can be used to change a liquid to a different consistency. The amount of thickening agent needed to reach a certain food consistency varies depending on the food being thickened and on the thickening agent used. How to Thin Liquids Add hot milk-based liquids (hot milk or cream) to puréed soups, puréed vegetables, or cooked cereal. Add other hot liquids (broth, gravy, sauces) to mashed potatoes, puréed or ground meats, and puréed or chopped vegetables. Butter or melted margarine may also be used. Add cold milk-based liquids to cream, yogurt, cold soups, puréed fruits, or puddings and custards. How to Thicken Liquids and Foods Add baby rice or commercial thickener to hot milk-based liquids. Add potato flakes, mashed potatoes, or flaked baby cereal to other hot liquids (soups, sauces, gravies). Add plain unflavored gelatin, puréed fruits, banana flakes, or a commercial thickener to cold liquids. Add potato flakes, mashed potatoes, thick sauces or gravies, canned puréed or strained meat (baby food), or a commercial thickener to puréed soups. Add flaked baby cereal, flavored gelatin, cooked cream of rice or wheat cereal, or a commercial thickener to puréed fruits. Add mashed white or sweet potatoes, potato flakes, sauces, or commercial thickener to puréed vegetables. If a Food is Too Thin, Add One of the Following: baby cereal banana flakes bread crumbs cornstarch cooked cereals (cream of wheat or rice) custard mix graham cracker crumbs gravy instant potato flakes mashed potatoes plain unflavored gelatin powder plain sauces (white, cheese, tomato) puréed fruits (baby food) puréed meats (baby food) puréed vegetables (baby food) saltine cracker crumbs If a Food is Too Thick, Add One of the Following: broth bouillon gravy juice liquid flavored gelatin melted hot butter/margarine milk (hot or cold) plain yogurt strained puréed soups Recipes Fruit Shake In a blender, place 1-1/2 cups of fresh, frozen, or canned fruit with 1 cup fortified milk. Mix until smooth. Fruit Blend In a blender, mix 1/4 cup apple juice, 1/4 cup orange juice, and 1 cup canned peaches or pears. Mix until smooth. High-Protein Smoothies In a blender, mix 1 cup fruit-flavored yogurt and 1 cup fortified milk with soft, fresh, peeled fruit or soft, canned fruit, and 1 cup of cottage cheese. Mix until smooth. Cottage Cheese Pudding Mix together 1/4 cup cottage cheese and 3 T baby fruit. Chill. Creamed Vegetable Soup In a blender, add 1/2 cup strained or very soft cooked vegetable; 1/2 cup fortified milk, cream, or plain yogurt, 1 tsp margarine; salt, onion powder, and crushed dried parsley flakes to taste. Mix to desired consistency. Other Tips to Make Foods Easier to Chew and Swallow To avoid forming a hard crust on the top of a food or around the edges, cook the food in a covered casserole dish. To make soft scrambled eggs, cook the eggs in the top of a double boiler. To keep meat or fish moist, cook in tomato juice or tomato soup. To make puréed meat, first drain soft, cooked meat. Place meat in a food processor or blender to make a paste. Add hot liquid (broth) to the paste and thin to desired consistency. Related Diseases Esophagitis and Stricture Related Procedures Upper GI Endoscopy (EGD) | Esophageal Dilatation | Esophageal Manometry This material does not cover all information and is not intended as a subsitute for professional care. Please consult with your physician on any matters regarding your health. © Copyright Chek Med Systems®, Inc., All Rights Reserved.
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