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The Nutritional Challenges in Dysphagia: Not Only a Matter of Nutrients
DOI: http://dx.doi.org/10.5772/ TexLi.105167I
. Mouthfeel and texture perception
Ingestion of food is also guided by mouthfeel and texture perceptions as well as
appreciation of the masticated bolus. Oral processing is a complex progression of
neuromuscular interactions which prepares and assess food prior to swallowing.
As food is being broken down and imbibed with saliva, it is in contact with the oral
sensory receptors and an integrated sensory evaluation of tastes, volatile compounds and texture will occur [141 142, ].
Electromyography (EMG) has been used to assess electric activity of the main
masticatory muscles in healthy participants. Coupled to chewing cycle counts,
tongue mobility, tongue pressure, salivation or videofluoroscopy studies, the
mechanistic involved pre- and peri-swallowing can be assessed [143 148– ]. In a
study looking at gels and sols, muscle activity required until swallowing appeared to
be well correlated with the required force deployed for large compression deformation which occurs at the initiation of mastication [ ]. Tournier and colleagues 145
observed large inter-participant variation both for salivation and oral processing
after 5 healthy participants masticated 4 breads of different textures and compositions [ ]. Mori and colleagues studied the laterality of the posterior tongue move-146
ment in 20 young and health adults by [147]. Gummy jelly, sponge cake and mashed
potatoes were assessed as representative of gradient mastication intensity requirements at the initiation, middle and end of mastication stages. For the purpose of
the study, the participants were asked to masticate only on the right side or only on
the left side. They measured a more intense EMG activity on the side of mastication
for the gummy jelly and documented that tongue activity was affected by the food
texture. Finally, Matsuo and colleagues investigated the masticatory function of 22
young participants an 32 community-dwelling older individuals of either normal or
oral hypofunction. For their investigation, the test samples were a control meatloaf,
meatloaf containing lotus root, control chicken ball or chicken ball with almonds
slivers (10g per bite). The documented mean EMG amplitudes and integrated EMG
activity were lower for control samples which were softer test foods. Oral functions,
including dental condition, appeared to decline with age and would have influenced
the assessed mastication capacity [148].
The characterization of the biomechanics of bolus preparation and its impact
on swallowing capacity is still being investigated [ – ] and remains limited in 149 151
application for daily clinical investigations or association to diversified menu items
around the globe. Few foods have been assessed. However, the variability in bolus
process are highlighted and the impact could be important.
Individual physiognomy, quality of dentition and capacity to prepare foods
for deglutition are only one part of the complex equation. The foods and liquids
consumed bring their share of complexity. The lubrication of the bolus is also
dependent on salivation. Intra-oral assessment of bolus texture and correlation to
sensory perceptions are challenging.
. Development of adapted texture-modified foods
. Sensory evaluation
Acceptance by consumers of food products is a main priority for the food
industry. Development of new products is time consuming and costly. However,
the formal study of sensory evaluation of foods is a science with a relatively recent
history. As stated by M.A. Drake, sensory evaluation is a “collection of techniques
that seek to differentiate between a range of products based on all of their sensory
151
Dysphagia - New Advances
characteristics and to determine a quantitative description of all the sensory attributes that can be identified, not just the defects” [152]. Methods such as discrimination testing (Is there a difference between 2 formulations?), acceptability (Which
food would you prefer? Rating scales of relative dislike and like), descriptive
sensory evaluation (How can we discriminate between a range of products based on
all of their sensory characteristics?) have provided additional tools for application
in research, product development, and marketing [152, ]. Important develop-153
ments in the science of sensory evaluation were initially triggered in the U.S. by the
desire to optimize food intake in U.S. armed forces [152, –156]. With the cre-154
ation of the food acceptance program in 1945, the U.S. Army Quartermaster Food
and Container Institute (Chicago) had four main divisions which were food habit
studies, psycho-physiological studies, organoleptic studies and statistical theory.
In 1949 and 1950, psychologists David Peryam and Norman Girardot were hired to
lead the Food Acceptance Research Branch. As measurement is essential to building
comparative datasets, the staple nine-point hedonic scale (Table ) was developed
to assess food acceptance and preference [157, ]. This scale remains in use today 158
to asses customers appreciation of assorted food products such as chips [ ], beef 159
sausage using pigeon pea as binding agent [160] or yoghurt [161].
In the past, food development for the treatment of dysphagia customarily
stemmed from clinical settings [44, 72, ]. Researchers state that TMF and TF are 162
deemed to be at the core of the nutritional treatment for dysphagia diets [ , ], 65 163
therefore, it is essential to evaluate the sensory profile if optimal ingestion is to be
achieved. Limited publications have assessed sensory characteristics of TMF or TF.
Pureed peaches [ ], pureed carrots [164 165 167– ], meats [ , ], soups, pates and 166 167
timbales [ ] were assessed primarily by healthy young adult for sensory percep-167
tion. Thickened fluids have been studied more extensively: water with and without
barium, lemon flavored water, juices, milk and infant formula [63, , ]. But, 168 169
even fewer publications have included participants with impaired swallowing
[164 166, ]. Studies are mainly conducted with the participation of young healthy
adults. To be fair, several neurological diseases affect oral expression or comprehension of instructions which could render consumer assessments difficult. However,
when recommending approaches to improve nutritional intakes and adherence
to a proposed dysphagia diet, customer appreciation—likes and aversions of
patients—should be at the core of the plan. More sensory research should be done
with TMF and TF to help in developing complete, nutritious, appetizing and varied
menu plans.
. Rheological evaluation
Nutritional interventions for the treatment of dysphagia can take various
forms and should progress with the medical conditions. Foods are molecularly and
Like extremely
Like very much
Like moderately
Like slightly
Neither like nor dislike
Dislike slightly
Dislike moderately
Dislike very much
Dislike extremely
Table 3.
9-point hedonic scale [157].
152
The Nutritional Challenges in Dysphagia: Not Only a Matter of Nutrients
DOI: http://dx.doi.org/10.5772/ TexLi.105167I
structurally elaborate and diverse. Oral nutritional supplements, texture-modified
foods and thickened fluids often require the addition of the texture modifying
agents which only adds to the complexity of these matrices. Comparing foods items
is challenging in clinical trials. Over time, terminology and assessment methods
have been proposed [170]. Two major milestones in the evolution of dysphagia
diets development were the National Dysphagia Diet (NDD) [ ] in 1999 and the 171
International Dysphagia Diet Standardization Initiative (IDDSI) [39] in 2015.
Based on the work of food scientists Russell H. Mills [172] and Don Tymchuck
[173], the NDD was the first diet to propose a quantifiable measure to assess flow of TF.
Viscosity ranges were determine to discern different 3 different levels of consistency
for fluids. Concepts of food texture such as adhesiveness, cohesiveness, firmness and
springiness were also suggested to describe and classify TMF in 3 categories (Table ).
After an extensive literature review and consultation among researchers, clinicians and industry leaders, the IDDSI group propose a more extensive descriptive
framework and classification of the liquids with 5 levels to distinguish fluids and 5
levels for the MTF. A gravity flow test using a syringe is propose to measure liquid
flow and 4 levels are recommended ( ). The syringe was preferred to other Table
methods such as shear viscosity measurements or the use of empirical tests such as
the Bostwick consistometer [174] or the line spread test due to the accessibility and
ease of use of the syringe. But, velocity results obtained for various fluids using the
IDDSI syringe and the Bostwick consistometer are unexpected and the discriminating capacity of the IDDSI levels remain to be demonstrated (Figure ). The food
texture descriptive parameters are still suggested to explain the MTF. However,
other guidelines such as particle size, spoon-tilt test, drip test, fork pressure test and
visual cues were added.
Both frameworks had important repercussions in the research and industrial
arenas. By proposing a standardized terminology and food classification systems,
these approaches helped researchers, clinicians, patients as well as the food industry
to classify foods and allow better description of clinical protocols and comparison
NDD
—terminology IDDSI—terminology
Fluids units Drinks units
(ml after 10s)
Thin
Nectar-like
Honey-like
Spoon-thick
1–50 cP
3
50–350cP
351–
1750cP
≥1750cP
Thin—level—0
Slightly thick—level—1
Mildly thick—level—2 Moderately
thick—level—3
Extremely thick—level—4
≤1ml
1–4ml
4–8ml
8–10ml
≥10ml
Foods Foods
NDD level 1: dysphagia-pureed Liquidized—level—3 8–10ml
NDD level 2: dysphagia-
mechanical altered
Pureed—level—4 10ml≥
NDD level 3:
dysphagia-advanced
Minced & moist—level—5 Transitional foods
Regular Soft & bite-sized—level—6
Easy to chew-regular—level—7
National dysphagia diet.
International dysphagia diet standardization initiative.
centiPoise.
Table 4.
Terminology and rheological parameters associated to various levels of dysphagia diets.
153
Dysphagia - New Advances
of interventions. Still, clinical trials will be required to assess their impact on
nutritional status of patients suffering from dysphagia. The main novelty of these
proposed frameworks was the use of rheology.
Rheology is the science of deformation and flow of matter [ ]. In the context 175
of oropharyngeal dysphagia, fluids and semi-solid foods are the object of interest.
Two (2) extensive reviews helped the understanding of the science of rheology
specifically in the perspective of oropharyngeal dysphagia treatment [176, ].177
First, the review published by Gallegos et al. [176] focused on the rheology of
fluids. Providing a short review of basic rheological concepts, they present fundamental parameters impacting the flow of fluids such as stress, strain and strain rate
(Table ), type of fluids Newtonian, non-Newtonian, viscoplastic fluids as well as
time-dependent viscous flow behavior, shear viscosity and extensional viscosity. In
light of their work, it becomes evident that a bolus will undergo major pressure and
deformation before and during the course of deglutition. The various forces applied
(i.e. shear rates) throughout swallowing are challenging to measure and have not
been clearly established. For the moment, a shear rate of 50s−1 is generally used in the
Figure 4.
Bostwick flow test and syringe flow test of common products (AAFC—Saint-Hyacinthe Research and
Development Center (Canada)—unpublished data).
Variable Description Units
Stress (τ or σ) Force per unit area Pascals (Pa)
Strain ( Relative variation of position in the flow direction Non dimensionalϒ)
Strain rate (‘ Strain variation over timeϒ) s
−1
These variables are temperature, pH, pressure and time dependent in Non-Newtonian fluids.
Swallowing imposes a stress on the bolus and deformation of the fluid occurs. The composition of the bolus will
influenced its rheological behavior.
Table 5.
Fundamental dynamic and kinematic variables of flow [ ].176
154
The Nutritional Challenges in Dysphagia: Not Only a Matter of Nutrients
DOI: http://dx.doi.org/10.5772/ TexLi.105167I
literature. Salivary alpha-amylase and the presence of contrast fluids (barium) are
also addressed since their presence impacts the bolus texture parameters and rheological behavior as the bolus is being processed orally prior or during swallowing.
Raheem and colleagues proposed a comprehensive review of the publications
addressing the TMF. They present the various tests, both sensory and instrumental,
available to the food industry to measure textural characteristics of foods. Similarly
to the work done with TF, the rheological assessment of TMF is scare in the literature. According to this review, a better understanding of the complex food matrices
used in the nutritional treatment of dysphagia, by all stakeholders, must take place
to improve TMF.
. Bridging the gaps
As early as 1963, Dr. Alina Szczesniak [ , ] led the food industry in bridg-178 179
ing the gap between the emerging technologies of the times and the sensory evaluations of foods. By developing standard rating scale to describe the mechanical
characteristics of foods that were now assessed by texturemeters, Dr. Szczesniak
demonstrated that although more repeatable and quantifiable, the data obtained for
instruments remained insignificant in product development if they were not linked
to human assessment and ratings. This vision of correlating instrumental and
sensory assessments should inspire more future research in nutritional treatment
for dysphagia. The recent ‘mouthfeel wheel’ terminology should be a step in the
right direction [ ].180
. Conclusion
Dysphagia is a condition affecting dietary intake. Although often underestimated, chronic undernutrition can exacerbate frailty and can lead to poor physical
condition, declined immune system, sarcopenia and pneumonia. In view of the current literature, nutritional content, texture and consistency as well as appearance
of texture-modified foods should be improved. An assortment of foods and fluids
should be investigated to reflect more realistic food intake patterns. Above all, a
personalized nutritional intervention is essential to prevent health decline.
Eating is indispensable to subsistence in addition to being a critical part of the
social aspect of life. New texture-modified foods should be developed with the
involvement of individuals affected by dysphagia to improve taste, textural profiles
and overall acceptability. Clinical trials should improve documentation of the
dysphagia severity level, nutritional intervention (foods/fluids offered) and food
intake prescribed, nutrient density, satisfaction of meals and adaptation to patients
nutritional needs. Research done to date, although essential to understanding this
complex health issue, is still theoretical and lacks integration of expertise. We
must improve clients/patients consultation. A large number of foods and fluids are
required to build an nutritious and appealing menu which is an essential element
to improve intakes. An open-sourced international clinical database for nutritional
interventions in dysphagia, similar to existing food composition databases
[181 184– ], would be a valuable tool to build a strong resource base. While archiving
details of various food or fluids formulations, nutritional values and rheological
parameters (when available), this compendium would support knowledge transfer
and benefit food/pharmaceutical industries, researchers, clinicians as well as clients.
Finally, clinicians and research teams must continue to progress in bridging the
knowledge gap between the foods used to evaluate dysphagia severity (with and
without barium), the foods and the fluids available for nutritional interventions
155
Dysphagia - New Advances
Notes/thanks/other declarations
The author is co-inventor of the CA2467625C patent. The current assignee of
this patent is Her Majesty the Queen in Right of Canada.
156
and recommendations for the development of commercial foods available for
oropharyngeal dysphagia treatment.
Acknowledgements
First, I wish to thank Sophie Turcot for her support in organizing and maintaining our laboratory facilities as well as her reliability and diligence in her scientific
work. I wish to acknowledge Francis Villeneuve for his methodical approach in
the multiple rheological tests conducted. Finally, I wish to extend my most sincere gratitude to Amélie Giroux, Patricia Décarie and Vivianne Chagnon of the
Association professionnelle des nutritionnistes experts en dysphagie for their patientcentered approach to clinical nutrition.
The Nutritional Challenges in Dysphagia: Not Only a Matter of Nutrients
DOI: http://dx.doi.org/10.5772/ TexLi.105167I
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