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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
patient’s energy needs and number of
calories required will be low, necessitating the selection of nutrient-dense food.
“Nutrient dense” means that food with
low calorie content must also provide a
significant balance of protein, vitamins,
and minerals, with so-called empty
calories kept to a minimum. The goal is
to ensure nutritional adequacy of protein, vitamins, and minerals without
excess weight gain, likely to further
impact mobility.
NUTRITIONAL GOALS
Calories
Daily calorie requirements for adults
are based on a calculated reference
(ideal) weight for height in kilograms
(Table 13–3). A maintenance base is
25 to 35 kcal per kilogram reference
weight per day. Additional allowance
must be made for increased activity or
metabolic stress. The obese patient may
lose weight using their “ideal” weight
in the calculation and require adjustment of the energy goal if weight loss
is unacceptable.
Protein
Patients with dysphagia often present with significant weight loss that
includes loss of fat and loss of lean muscle mass. The loss of muscle mass negatively impacts swallowing function, as
effective swallowing relies on strong
muscular contraction. Rehabilitation
of swallowing function often focuses
on muscle-strengthening exercises but
must also include increased protein
intake to allow for recovery of adequate
muscle function for swallowing.
The National Academy of Medicine currently recommends 0.8
g of
protein per kilogram reference weight
daily dietary intake for an adult (Institute of Medicine, 2005). However,
with increasing recognition that loss
of muscle mass (sarcopenia) in older
adults leads to frailty, there is a call for
increased protein in both the younger
and older adult diet (>1.2 g protein per
kilogram per day) (Bauer et al., 2013;
Baum et al., 2016; Courtney-Martin
et al., 2016; Deutz et al., 2014; Traylor
et al., 2018). Individuals with higher
dietary protein intake demonstrate
greater muscle mass and fewer physi-
Table 13 – 3. Calculating Reference Weight (Ideal Body Weight)
Adult Male
(Hamwi Method)
Adult Female
(Hamwi Method)
Children Consult standardized growth curves. Some modified growth
Source: Reprinted with permission from Gottschlich, M., Matarese, L., & Shronts, E. (Eds.). (1993).
Nutrition support dietetics core curriculum (2nd ed.). Silver Spring, MD: Copyright 2017 American
Society for Parenteral and Enteral Nutrition.
106 lbs for first 5 feet; 6 lbs for each inch over 5 feet
Example:
100 lbs for first 5 feet; 5 lbs for each inch over 5 feet
Example: 5′4″ Reference weight = 120 lb = 54.5 kg
curves are available for specific conditions, i.e., Downs syndrome
5′9″ Reference weight = 160 lb = 72.7 kg
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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295
cal limitations (Khanal et al., 2021;
Nilsson et al., 2018). Increasing dietary
intake of protein above 1.2 g per kilogram per day in patients with sarcopenia and dysphagia has been associated
with an increase in tongue strength and
improved swallowing ability (Nagano
et al., 2020). It is important to note that
increasing dietary protein alone does
not always increase muscle mass in the
elderly and that both resistance training
and aerobic exercise are needed to optimize the benefits of increased dietary
protein (Rogeri et al., 2021). The type
and quality of the protein as well as the
timing of protein intake throughout
the day plays a role (Deer & Volpi,
2015). In particular, the amino acid leucine has been found to be important in
muscle metabolism and repair (Landi
et al., 2016; Szwiega et al., 2021). Food
sources of leucine include salmon,
chickpeas, brown rice, eggs, soybeans,
nuts, and beef.
The National Academy of Medicine sets a wide range for acceptable
protein intake as a percentage of total
calories
calories each day. Beyond that, there’s
relatively little information on the ideal
percentage of the dietary protein or the
healthiest target for calories contributed
by protein. In an analysis conducted at
Harvard among more than 130,000 men
and women who were followed for
up to 32 years, the percentage of calories from total protein intake was not
related to overall mortality or to specific causes of death (Song et al., 2016).
health conditions on protein metabolism must also be considered in individual patients (Phillips et al., 2020).
Protein requirements can be increased
— anywhere from 10% to 35% of
Lastly, the impact of secondary
or decreased depending on specific disease considerations, level of nutritional
debilitation, and metabolic stress
example, related to fever or sepsis. For
anabolism or during periods of stress,
the value is increased by 0.75 g protein
per kilogram reference weight. In burn
and trauma patients, protein requirements may be increased by an additional 1.2 g protein per kilogram (Phillips et al., 2020).
— for
Fluid
There are many accepted formulas to
determine appropriate fluid levels for
adults. A general guideline is 1 mL fluid
per kcal. Another method uses a range
of 25 to 40 mL per kilogram reference
weight per day. Fluid needs decrease
with age. Influences on fluid requirements include amount of total body
surface area, illness, activity level, and
temperature of the environment. Fluid
needs are, in part, proportional to body
surface area. The obese person would
have increased needs over the person
within their ideal weight range.
Vitamins and Minerals
In an adult eating orally, a multiple
vitamin/mineral supplement may be
indicated if nutritional energy needs
are less than 1,500 kcals per day (ADA
Reports, 2005; Fairfield & Fletcher,
2002). As individuals age, absorption
of vitamins and minerals may become
less efficient, necessitating a nutrient-dense diet. Check the National
Institutes of Health website for up-todate information on nutrient intake
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
recommendations (www.ods.od.nih
.gov). The site contains useful information on recommendations for healthy
intake of a variety of macro- and micronutrients.
TRANSLATING CALORIEPROTEIN-FLUID NEEDS INTO
A TREATMENT PLAN
Once the target values for calories,
protein, and fluid intake have been
established, the route of nutrient ingestion must be considered. Conventional
oral eating, facilitated by strategies
as needed, is the most desirable. Oral
intake combined with enteral tube feeding may also be recommended. This
combination may be used when fatigue
or some other limitation may impact
the patient’s ability to rely totally on
oral feeding. It cannot be emphasized
enough that patients receiving enteral
feeding are not necessarily precluded
from eating some orally. This may be
very important for the social and emotional well-being of the patient. Some
patients with progressive diseases causing dysphagia believe that once they
begin with enteral feeding, they will
no longer be able to eat orally. Actually,
if they supplement an oral diet with
tube feeds that allow them to receive
adequate hydration and nutrition, they
may be able to prolong the time they
can take foods by mouth because they
have maintained muscle strength and
coordination through good nutrition. It
may be possible to continue to eat orally
for pleasure and for social interaction
even if optimal nutrition cannot be supported completely by this route. Other
patients will require enteral feeding for
all their nutrition. Whatever method
is prescribed, constant reevaluation
is needed to determine if the current
option is working or remains appropriate. During these periods, the dietitian provides the team and the physician managing the patient’s care with a
quantitative analysis of food consumption by reviewing food diaries kept by
the patient or caregiver.
Oral Feeding
If oral feeding is recommended for the
patient, the dysphagia therapist will
determine what restrictions must be
applied to ensure safe oral feeding. The
dietitian will help identify foods that
both appeal to the patient and meet the
safety requirements imposed. In short,
the dietitian will translate the team’s
prescription into everyday foods that
the patient can consume in sufficient
quantities to meet nutrition or hydration needs.
Textures encompass a continuum
including pourable liquids of differing
viscosities, gel consistencies, slippery
puree foods that deform from shape
with gravity, stiffer purees that hold
their shape, combinations of puree and
ground texture, and a fine chop. The
normal adult swallower enjoys the full
range of the texture and viscosity, but
the dysphagic patient may find the tolerable viscosity range restricted, that
is, shifted to the low or high end, or
compressed from both extremes. The
texture continuum in relation to transit ability and airway protection is presented in Table 13–4.
Places stress on oral preparation and and pharyngeal
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transfer competence
Foods Requiring Mastication
in order of ascending difficulty
ground meat, regular
scrambled eggs, canned fruit,
soft cooked carrots, beets,
bread
Mashed potatoes,
puree scrambled eggs,
puree meat
chopped meat, sandwiches
(tuna, egg, bologna)
As the bolus becomes more
unrestricted diet
Less easily deformed,
viscous, it is less and less easily
deformed, less likely to move
in response to gravity, more
reliant on dental and lingual
competence for mastication
and transit, sensory
thus can obstruct
a narrow passage.
Transferred mostly by
compression.
continues
competence and judgment
of bolus characteristics,
adequate salivation, and
healthy mucosa.
TEXTURE OR VISCOSITY CONTINUUM
Relieves demands on agility of airway closure
and facilitates bolus transfer
Places stress on agility
of oral airway closure for
Table 13 – 4. Texture or Viscosity Continuum
swallow but facilitates bolus
transfer
Thin Liquids Thick Liquids Slippery Puree Puree
(assumed to be at
body temperature)
pudding, custard,
(assumed to be at
body temperature)
tomato juice, nectar,
(assumed to be at
body temperature)
apple juice, cranberry
puree fruit, puree
vegetables (not
starches)
apple juice with
thickener, Instant
Breakfast, ≥1.5 cal/
cc commercial
supplement
juice, non-, lowfat, and
whole milk, fruit ice,
sherbet, Jell-O, soft
drinks
EXAMPLE
297
Less easily deformed
so may obstruct a
narrow passage.
Slides in response
Less easily deformed
than thin liquids,
moves fairly readily in
response to gravity or
Easily deformed,
moves very readily in
response to gravity and
compression.
to gravity or
compression.
compression.
PROPERTIES
Foods Requiring Mastication
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in order of ascending difficulty
Adequate oral and
pharyngeal patency and
strength of constriction/
compression is requisite for
Purees are likely to stop
at obstacles and may
not slide easily along
dry mucosa. Purees will
Slippery purees are
more likely to stop at
obstacles such as
webs and strictures,
safe swallow of high viscosity
foods once mastication has
transformed the solid into
a puree. Adequate transfer
requires adequate salivary
and mucosal health.
Adequate airway protection
during swallow of solids
not move through the
pharynx without ade-
quate compression/
constriction. Complete
transit requires ade-
quate salivary and
mucosal health.
Because they do
not move readily in
but may be less likely
to “stick.”
Slippery purees
require less laryngeal
is reliant on adequately
complete oral and
response to gravity,
purees are less likely
agility but more
competent oral
pharyngeal transit. The
airway can be obstructed
if penetrated by solid bolus
residue, even if mastication is
to fall into the airway
quickly. However, if oral
and pharyngeal clear-
ing is incomplete due
and pharyngeal
constriction. If
the bolus is not
adequately
fairly adequate. The properties
of solids present a greater risk
of obstructing the airway than
liquids.
to poor constriction
or xerostomia, pharyn-
geal residue presents
a risk to the airway
after the swallow has
been completed. The
properties of purees
present a greater risk
transferred, residue
may fall into
the airway after
the swallow. The
properties of purees
present a greater risk
of obstructing the
airway than liquids.
of obstructing the air-
way than liquids.
Variably likely
(depending on the
continued
Thin Liquids Thick Liquids Slippery Puree Puree
Thin liquids are most
likely to move through
Table 13 – 4.
degree of thickness)
to move through the
digestive tract easily
the upper digestive
tract quickly and
completely.
without falling into the
airway and to pass
TRANSIT
fairly well through
narrow sites such as
strictures.
Swallow of thick
liquids requires less
laryngeal agility
because thick
liquids are less easily
deformed and move
more slowly (speed
varies with thickness)
in response to gravity
or compression.
Agility of laryngeal
airway closure for
swallow is a prerequisite
for ingestion of thin
liquids.
AIRWAY
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Foods Requiring Mastication
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in order of ascending difficulty
The goal of mastication
is to produce a “swallow
safe” bolus, probably one
approximating a puree. The
Patients who are able
to apply adequate
pressures to transfer
the bolus through the
Patients who are
slow to initiate
swallow gestures,
including airway
ability to tolerate degrees of
viscosity in the solid range is
dependent on lingual agility
and ROM, judgment re: bolus
readiness, salivary flow, and
dentition.
oral and pharyngeal
cavities completely
will tolerate puree
consistencies.
closure, but who
are able to apply
some compression
to accomplish oral
and pharyngeal
bolus transfer would
tolerate slippery
purees.
Patients with
Thin Liquids Thick Liquids Slippery Puree Puree
Patients with prolonged
prolonged or
incomplete oral,
pharyngeal, or
esophageal transit
or incomplete oral,
pharyngeal, or
esophageal transit
due to poor muscular
due to poor muscular
constriction or to
narrowing (e.g.,
constriction or to
narrowing, (e.g.,
stricture) but who are
299
stricture) are most
likely to achieve
adequate intake with
alert and enjoy good
laryngeal function are
most likely to achieve
liquid consistencies.
Patients with mild
cognitive deficits
or who show poor
oral bolus control or
adequate intake with
liquid consistencies.
PATIENTS
impaired initiation of
swallow gestures may
require thickened
liquids.
Source: From Susan McKenzie, M.S., and Beverly Lorens, R.D., M.S.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
The International Dysphagia Diet
Standardization Initiative (IDDSI) was
launched in 2013 with the goal of developing globally standardized terminology and definitions for the texture of
foods and liquids so that communication regarding dietary modification
recommendations would be understood across health care professionals,
systems, cultures and countries. The
IDDSI consists of eight levels of food
consistency thickness with detailed
instructions regarding testing methods
to determine the thickness category of
any given food or liquid (Figure 13–2)
(Cichero et al., 2017). Detailed instructions for determining food viscosity
are available on their website (www.
iddsi.org). The standardized methods
proposed in the IDDSI can be applied
to any foods and thus can be applied
across cultures with significantly different dietary customs. A further advantage of implementing the IDDIS testing
Figure 13–2. International Dysphagia Diet Standardization Initia-
tive Framework. © The International Dysphagia Diet Standardisation
Initiative 2019 @ https://iddsi.org/framework/Licensed under the
CreativeCommons Attribution Sharealike 4.0 License https://creativecommons.org/licenses/by-sa/4.0/legalcode. Derivative works
extending beyond language translation are NOT PERMITTED.
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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301
methods for various food stuffs is the
application of those testing methods to
the videofluoroscopic swallow study
with respect to the viscosities sampled
on the study. Those consistencies found
to be safe on the videofluoroscopic
swallowing study can be reproduced
with greater accuracy in the diet.
Many hospitals, rehabilitation centers, and long-term care facilities have
developed specialized diets for dysphagic patients. They are often called,
for example, a “soft diet,” “pureed
diet,” or “thickened liquids” (McCallum, 2003). However, there may be little
instruction and collaboration with the
kitchen staff, who may be left to determine the contents of such a diet on their
own. It is therefore important that members of the dysphagia team meet with
food service managers in the central
kitchen to sample and test food items
from the patient tray line and work
together to standardize the nomenclature and contents of modified diets
served at the facility (Appendix13–B).
Special Concerns:
Liquid Dysphagia
A patient with a thin liquid dysphagia may have difficulty maintaining
adequate hydration. All fluid intake
must be contained in some gradient
of thicker liquid to gel-form food. It is
helpful that pureed fruit, vegetables,
and meat contain a high percentage of
their weight as water. However, without some form of thick to thickened
liquids, a patient will likely consume
inadequate fluid. A variety of commercial thickeners is available either by
direct order or from local pharmacies.
Some common household foods also
work well for thickening. Examples of
commercial and household products
available for this purpose are listed in
Appendix 13–C.
If patients are able to consume sufficient fluid in the form of puree foods,
gels, and thick liquids, they may find
that the total calorie intake needed
for adequate hydration is higher than
needed for energy requirements, resulting in excess weight gain. Unwanted
weight gain may also occur in the
patient with dysphagia to dry foods
managed by preparing foods in more
sauce or gravy dishes, which increases
the moisture and slipperiness of the
foods but also increases the calories. These issues can be mitigated by
reducing the caloric value of the food
preparation.
NONORAL FEEDING
Total Parenteral Nutrition
When oral feeding is not an option for
a patient, other avenues of food intake
must be considered. One such alternative is total parenteral nutrition (TPN).
TPN is able to provide total nutrition
using a large flow capacity vein and a
central line, in contrast to peripheral
parenteral nutrition (PPN), using a
peripheral vein accessed with a simple
intravenous (IV) catheter. (PPN cannot usually meet full nutrition needs
related to the concentration of nutrients
in a low-flow, smaller, peripheral vein.)
Advances in enteral feeding formulas
and feeding tubes have made TPN less
popular than in the past. TPN is costly
and invasive, represents an infection
risk, and bypasses the gut, enhancing
potential for bacterial translocation (the
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
integrity of the gut is decreased with
lack of exposure to nutrients, and bacteria normally retained in the gut can
pass to the bloodstream) (Kudsk, 1994;
Kudsk et al., 1994; Minard & Kudsk,
1994; Moore & Moore, 1991). However,
TPN must be used when the gut is nonfunctional because of prolonged ileus,
or short bowel syndrome, or where
there are contraindications to placing
a feeding tube. For ICU patients, both
TPN and enteral feeding, used together,
may optimize nutrition better than the
use of either method alone (Alsharif
etal., 2020).
ENTERAL FEEDING
Severe dysphagia may require the
placement of a feeding tube to deliver
nutrition safely with sufficient volume.
Feeding tubes can be placed through
the nose or percutaneously from the
surface of the abdomen into the stomach and/or the jejunum (Figure 13–3).
An enteral feeding tube placed nasally
may have the tip of the tube located in
the stomach (nasogastric [NG]), duodenum (nasoduodenal [ND]), or jejunum
(nasojejunal [NJ]). Tubes placed percutaneously into the stomach (percuta-
Figure 13–3. Types and access sites of feeding tubes.
13. NUTRITIONAL CONSIDERATIONS IN DYSPHAGIA
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303
neous endoscopic gastrostomy [PEG])
may have single or dual lumens accessing the stomach (gastrostomy tube
[G-tube]), stomach and duodenum
(gastroduodenal tube [GD-tube]), or
jejunum (gastrojejunal tube [GJ-tube]).
Tubes may also be placed percutaneously directly into the jejunum (endoscopic jejunostomy [PEJ]). The use of
endoscopy during percutaneous feeding tube placement involves passing an
endoscope from the oral cavity through
the gastrointestinal (GI) tract to the point
of desired feeding tube insertion. The
use of endoscopy allows confirmation of
tube placement in the desired location.
Concurrent consideration of multiple factors is required to determine the
type of feeding tube that best serves the
needs of the patient. These include the
following:
n
Anticipated duration of enteral
feeding (and likelihood of return
to oral intake).
n
Ability to protect the airway,
degree of aspiration risk, and
pulmonary reserve to withstand
aspiration (delivery sites vary in
terms of possible airway risk from
reflux).
n
Presence of impaired gastric emp-
tying may preclude feeding into
the stomach (i.e., gastroparesis).
n
Types of enteral feeding formula
available (i.e., commercial ready
to feed, name brand or store
brand, or homemade).
n
Availability of feeding pump for
continuous feeding (gravity drip
bolus or syringe bolus recommended only into the stomach).
n
Cosmetic considerations (an NG
tube is visible, whereas a G-tube
or J-tube may be concealed behind
clothing).
n
Patient compliance with location
(i.e., an agitated patient can more
easily remove an NG tube than
a G-tube that can be concealed
behind a dressing or an abdominal binder when not in use).
n
Availability and condition of or-
gan to be an access site.
n
Selection of feeding schedule (con-
tinuous or intermittent feeds can
be delivered into stomach, duodenum, or jejunum, but bolus [gravity
or syringe] feeds should be administered only into the stomach).
Nasogastric feeding is generally
selected when the duration of time on
tube feeding will be relatively short
(perhaps weeks), with normal emptying of the stomach and no evidence of
uncontrolled esophageal reflux. Particular advantages of the NG tube are its
relatively noninvasive placement and
cost-effectiveness (Figures 13–4, 13–5,
and 13–6). In some cases, an NG tube
can be used to drain secretions or gas
before a postanesthesia patient’s stomach begins to regulate and then used
for feeding when more normal stomach
behavior is restored (see Figure 13–4).
Nasoduodenal tubes are appropriate
for short-term feeding when gastroesophageal reflux is expected or when
there is an increased aspiration risk or
decreased rate of stomach emptying.
Acontinuous feeding rate is employed
and commercial formulas are used primarily because these feeding tubes are
often smaller in diameter and more
prone to plugging (Figure 13–7).
The nasojejunal feeding route requires
a longer tube (43 in. compared with
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