Pneumonia (pulmonary Aspiration pneumonia. complications) Dehydration. Decreased rehabilitation potential Unintended weight loss

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1 Diet Soft Diet Purpose to alter foods so they can be successfully and safely swallowed. a. Nutrition Indicators a loss of body weight due to anorexia and abnormal labs are nutritional indicators for a patient to begin a soft diet. b. Criteria to Assign the Diet adequate dentition and mastication by the patient are required for this diet. Patients must also be able to tolerate mixed textures. c. Rationale for Diet this diet is a transition to a regular diet. Population The textures of this diet are appropriate for individuals with mild oral and/or pharyngeal phase dysphagia. Patients should be assessed for tolerance of mixed textures. It is expected that patients on this diet tolerate mixed textures. a. Overview Dysphagia or difficulty swallowing can be a medical or feeding issue at any age; however, it is particularly prevalent in older individuals. Identification of dysphagia is completed using medical history, clinical observation, and physical examination. Dysphagia is not a disease, but rather a disruption of a normal swallowing process. Without effective treatment, it can lead to: Malnutrition Pneumonia (pulmonary Aspiration pneumonia complications) Dehydration Decreased rehabilitation potential Unintended weight loss Decreased quality of life Depression Increased length of hospital stay Mortality Increased cost b. Disease Process Swallowing disorders are commonly seen in patients with the following conditions: Neurodegenerative disorders such as: o Parkinson s disease o Poliomyelitis o Multiple sclerosis o Post-polio syndrome o Guillain-Barre o Amytrophic lateral sclerosis o Huntington s disease o Multiple dystrophies

2 o Alzheimer s disease Neuromuscular disorders such as: o Spastic motor disorders o Achalasia o Scleroderma o Myasthenia gravis Esophageal cancer Type 1 diabetes, long-term Head and neck cancer Goiter Pharyngeal pouch Prebyphagia swallowing difficulty of old age Cardiovascular accident Gastroesophageal reflex (GERD) Esophageal varisces Inflammatory masses Head injury Aging also increases the risk for dysphagia. o Bulbar palsy o Amyloidosis o Chagas disease o Eaton-Lambert syndrome o Botulism c. Biochemical and Nutrient Needs Dietary guidelines for people with dysphagia, with the exception of those who have outstanding medical issues, are similar to those for the health population. The following recommendations should be used for daily food consumptions: Fats, oils, and sweets Use sparingly Milk, yogurt, and cheese 2-3 servings Meat, poultry, fish, etc 2-3 servings Vegetables 3-5 servings Fruits 2-4 servings Bread, cereal, rice, pasta 5-7 servings

3 General Guidelines a. Nutrition Rx Nutrition prescription should specify texture for both food and fluids. Foods should be soft and easy to chew and swallow. Food is almost of a regular texture but excludes very hard, sticky, or crunchy foods. Foods should be moist and of bite sizes (1/2 inch or smaller). b. Adequacy of Nutrition Rx Dietary guidelines for people with dysphagia, with the exception of those who have outstanding medical issues, are similar to those for the health population. c. Goals goals for the patient are: 1) Demonstrate the ability to swallow without evidence of airway penetration 2) Demonstrate the ability to swallow both solids & liquids without coughing or choking 3) Demonstrate adequate nutrient intake and hydration: - Maintenance of body weight - Nutrient-related laboratory values within normal limits d. Does it Meet DRI Yes. The only target nutrient levels that may be exceptions to the DRI are those that would be affected as a result of the disease state or prescribed drugs. Education Material a. Nutrition Therapy Educational material needed for: Cooking and preparation Foods recommended Foods to avoid in diet b. Ideas for Compliance Monitor food intake with 24-hour recall, food diary, or food frequency questions Need to observe acceptable and nutritional adequacy of the meal plan

4 If patients are unable to consume at least 50% of nutrient needs, the inserction of a percutaneous endoscoptic gastrostomy (PEG) may be needed to allow the patient to receive adequate nutrition while stabilizing intake from the mouth. Sample Menu a. Foods Recommended Food Group Dairy Desserts and sweets Fats Fruits Grains Meats and meat substitutes Soups Vegetables Other Foods Allowed Milk and milk beverages, yogurt drinks, cottage cheese, ricotta, soft cheeses, cheese sauce, sour cream All soft desserts, avoid nuts and hard candies Gravy, sauces, margarine, butter Most fresh, canned, or frozen fruits and fruit juices Soft breads, graham crackers, cooked and cold cereals in milk, waffles, pancakes, rice, pasta, toast without crust if tolerated Moist, shaven, tender meats with gravy or products made with ground meats, meat salads, macaroni and cheese, soft sandwiches, casseroles made with allowed foods, smooth peanut butter Well cooked with small pieces Well-cooked or canned vegetables, skinless soft potatoes, chopped/grated spinach and lettuce, slice cucumber Honey, sugar, syrup, fruit jellies b. Foods to Avoid Food Group Dairy Desserts and sweets Fruits Grains Meats and meat substitutes Vegetables Other Foods Not Allowed Hard cheeses Any with nuts or coconut, fried foods, jams, marmalades, hard or sticky candies Uncooked or dried fruits, any fruits with seeds or tough skins Coarse whole grains, any grain foods with nuts or seeds Any tough, fried, or stringy meat, hot dogs, cold cuts, sausage, chunky peanut butter, dry beans or peas, raw or fried eggs Any fried vegetables, raw vegetables if not tolerated Nuts, coconut, seeds, popcorn

5 c. Example of a meal plan Breakfast: ½ cup orange juice at the prescribed liquid consistency ½ cup well-moistened dry cereal with ¼ cup of milk 1 scrambled egg with cheese on a moist biscuit 8 oz milk and other drinks that have the prescribed liquid consistency Lunch: Dinner: 1 cup of moist beef stew in small chunks with variety of well-cooked vegetables 1 slice moistened bread with butter or margarine ½ cup canned fruit salad ½ cup pudding with a moist cookie 8 oz milk and other drinks that have the prescribed liquid consistency ½ cup potato soup made with milk at the prescribed liquid consistency 1 slice moistened bread with butter or margarine 3 oz moist chicken on ½ cup soft-cooked rice ½ cup green beans 1 slice apple pie with moist crust, cheese wedge, and ice cream 8 oz milk and other drinks that have the prescribed liquid consistency Nutrition Analysis: 2,433 calories, 103 g protein (17%), 285 g CHO (46%), 101 g fat (37%), 456 mg cholesterol, 4,612 mg sodium, 12 g fiber Websites a. Organizations with Websites emedicine Instance Access to the Minds of Medicine: International Scleroderma Network: b. Government Websites Nutrition and Your Health - Dietary Guidelines for Americans: References a. Journal articles references AHRQ. Diagnosis and Treatment of Swallowing Disorders (Dysphagia) in Acute-Care Stroke Patients. AHRQ Commissioned ECRI report Adeleye B, Rachal C. Comparison of the rheological properties of ready-to-serve and

6 powdered instant food - thickened beverages at different temperatures for dysphagic patients. J Am Diet Assoc. 2007;107(7): Akhtar AJ, Shaikh A, Funnye AS. Dysphagia in the elderly patient. Journal of the American Medical Directors Association. 2002;January/February: Bailey RL, Ledikwe JH, Smiciklas-Wright H, Mitchell DC, Jensen GL. Persistent oral health problems associated with comorbidity and impaired diet quality in older adults. J Am Diet Assoc. 2004;104(8):1273. Ballou Stahlman L, Mertz Garcia J, Hakel M, Chambers E, 4th. Comparison ratings of pureed versus molded fruits: preliminary results. Dysphagia. 2000;15:2-5. Brand N. Medications and dysphagia: how do they impact each other? Nutrition in Clinical Practice. 1999;14: Brody RA, Touger-Decker R, VonHagen S, Maillet JO. Role of registered dietitians in dysphagia screening. J Am Diet Assoc. 2000;100: Bulow M, Olsson R, Ekberg O. Videoradiographic analysis of how carbonated thin liquids and thickened liquids affect the physiology of swallowing in subjects with aspiration on thin liquids. Acta Radiol. 2003;44: Campbell-Taylor I. Drugs, dysphagia and nutrition. Dietetics in Developmental and Psychiatric Disorders. 1996;15:1-7. Cichero JA, Jackson O, Halley PJ, Murdoch BE. How thick is thick? Multicenter study of the rheological and material property characteristics of mealtime fluids and videofluoroscopy fluids. Dysphagia. 2000;15: Esfandyari T, Potter JW, Vaezi MF. Dysphagia: a cost analysis of the diagnostic approach. Am J Gastroenterol. 2002;97: Giel L, Ryker AM, Loyd A. Is there a need for standardization of a dysphagia diet? J Am Diet Assoc. 1996;96:suppl:A106. Goulding R, Bakheit AM. Evaluation of the benefits of monitoring fluid thickness in the dietary management of dysphagic stroke patients. Clin Rehab. 2000;14: Kuhlemeier KV, Palmer JB, Rosenberg D. Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients. Dysphagia. 2001;16: Leslie P, Carding PN, Wilson JA. Investigation and management of chronic dysphagia. BMJ. 2003;326: Lind CD. Dysphagia: evaluation and treatment. Gastroenterol Clin North Am. 2003;32:

7 Logemann JA. Multidisciplinary management of dysphagia. Acta Otorhinolaryngol Belg. 1994;48: Macqueen C, Taubert S, Cotter D, Stevens S, Frost G. Which commercial thickening agent do patients prefer? Dysphagia. 2003;18: Pardoe EM. Development of a multistage diet for dysphagia. J Am Diet Assoc. 1993;93: