“What’s the safest diet for this patient?”
As dysphagia clinicians, we’re asked this a lot. Physicians, nurses, and family members all want to do what’s best, and preventing aspiration with diet changes seems like a straightforward solution. Unfortunately, it’s not that simple.
Diet modifications, such as reducing the texture of the foods we provide or thickening liquids, seem like benign interventions, but the fact is that these interventions can sometimes have unintended consequences.
Here’s what we know:
1. Thick liquids increase risk of dehydration.
Several studies have documented that consuming thickened liquids increases our patients’ risk of dehydration.1, 2, 3 There is nothing inherently dehydrating about thickened liquids—in fact, most commercial thickeners return almost all of the water back to the bloodstream for bioavailability.4
So what’s the problem? People drink less! Why?
- They don’t like the taste and texture of the thick liquids.
- They’re full for longer periods of time after consuming thick liquids.
- The thickened liquids are more difficult to prepare.
- In residential facilities, they are often offered liquids less frequently than those who are on regular liquids.
2. Texture modifications are difficult to achieve at home.
Speech-language pathologists often recommend bringing diet texture down to decrease choking risk and compensate for difficulties with oral bolus management. Makes sense, right? The problem is that we don’t always think about the burden of texture modification for patients and their families.
When we bring texture down, particularly to a puree level, we need to add fluid. The additional fluids have the potential to dilute the food’s caloric and protein density—particularly for families who are trying to do this on their own without the benefit of commercial kitchens. In fact, texture-modified diets are often lacking in calories, protein, and micronutrients.5, 6
3. Texture modifications often result in reduced intake.
Remember that diluting effect we were just talking about? In addition to reducing protein and caloric density, pureeing food also reduces flavor intensity.
What’s your first thought when you take the cover off that tray of pureed food? Texture-modified diets don’t look appetizing and they don’t taste good, so it’s not surprising that people eat less.
4. Dietary modifications have social consequences.
A while back, I ran into the wife of a former patient in the grocery store. We chatted a bit about how things were going at home, and she reported that her husband was doing well overall. He was following his diet modifications, using his strategies, and eating safely and comfortably.
Then she said something that has stayed with me to this day. “Our meals are awfully quiet, though.” Her husband had to eat slowly and carefully and concentrate on using his strategies. That meant little to no conversation. “Dinner used to be our time to share our day, talk about the kids, make our plans,” she said. “Now there’s no talking so he can concentrate on eating.”
Food is an important social tool. It’s how we celebrate holidays, get together with friends, maintain social relationships, and form new ones. When we recommend texture modifications or thickened liquids, we must remember that we’re also imposing a degree of social isolation.
So, what is the safest diet? Is it the one that reduces aspiration risk but increases the likelihood of dehydration? Is it the one that decreases choking risk but results in nutritional compromise?
Is dysphagia management more important than quality of life?
There are no easy answers to these questions. We owe it to our clients and their families to have frank discussions about the benefits and risks of the diets we’re recommending so that they can make informed choices because dietary modifications have consequences.
- Howard, M. M., Nissenson, P. M., Meeks, L. & Rosario, E. R. (2018). Use of textured thin liquids in patients with dysphagia. American Journal of Speech-Language Pathology, 27(2): 827–835.
- Crary, M. A., Carnaby, G. D., Shabbir, Y., Miller, L., & Silliman, S. (2016). Clinical variables associated with hydration status in acute ischemic stroke patients with dysphagia. Dysphagia, 31(1): 60–5.
- Robbins, J., Gensler, G., Hind, J., Logemann, J. A., Lindblad, A. S., Brandt, D., et al. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Annals of Internal Medicine, 148(7): 509–18.
- Cichero, J. A. (2013). Thickening agents used for dysphagia management: effect on bioavailability of water, medication and feelings of satiety. Nutrition Journal, 12: 54.
- Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005). Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition and Dietetics: The Official Journal of the British Dietetic Association, 18(3): 213–9.
- Keller, H., Chambers, L., Niezgoda, H., & Duizer, L. (2012). Issues associated with the use of modified texture foods. Journal of Nutrition, Health & Aging, 16(3): 195–200.