1. 1 Purees That Please, Part 1 Provided Courtesy of Nutrition411.com Review Date 4/14 G-1559 Contributed by Judy Schlager, RD, LD Updated by Nutrition411.com staff

2. 2 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 The Dysphagia Diet

3. 3 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 Dysphagia Diet Progression

4. 4 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 Dysphagia Diet Progression (cont’d)

5. 5 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

6. 6 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

7. 7 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 Dysphagia Diet Progression (cont’d)

8. 8 NDD 2—mechanically altered: Assess patients for tolerance to mixed textures Expect that some mixed textures are tolerated in this diet Dysphagia Diet Progression (cont’d)

9. 9 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

10. 10 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 Dysphagia Diet Progression (cont’d)

11. 11 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

12. 12 NDD 4—regular: Any solid-texture food All beverages are included Dysphagia Diet Progression (cont’d)

13. 13 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 Characteristics of Pureed Foods

14. 14 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

15. 15 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

16. 16 Commercial Thickeners in Liquids (cont’d) Properties of starch thickeners (cont’d): Indigestible in upper gastrointestinal tract Low susceptibility to enzymatic hydrolysis High water-binding capability Good fiber source Good bulk for colon

17. 17 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

18. 18 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

19. 19 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

20. Academy of Nutrition and Dietetics. Nutrition Care Manual ®. Nutrition Care Manual Web site. www.nutritioncaremanual.org. Accessed April 26, 2014. www.nutritioncaremanual.org National Dysphagia Diet Task Force. National Dysphagia Diet: Standardization for Optimal Care. Chicago, IL: American Dietetic Association; 2002. 20 References