Dysphagia Diet 5 Levels Difficulty In Swallowing Diet
Dysphagia means difficulty with chewing or swallowing food or liquid. To understand how this might happen, it is important to know something about how swallowing occurs. First, food must be chewed thoroughly. Then it is moved to the back of the mouth by tightening the cheek muscles and pressing the tongue against the roof of the mouth. From this point on the process becomes automatic -- it is a reflex that people do not actively control. In "rapid- fire" succession, the soft palate closes the nasal airway to prevent food from backing into it, the airway into the lungs is closed, and the esophagus (food pipe) relaxes allowing food and liquid to enter it. The muscular esophagus then contracts in a wave-like action, sweeping the food along into the stomach. A blockage or a malfunction anywhere in this part of the body or in the nervous system controlling swallowing can result in dysphagia. There are two types:
Esophageal dysphagia occurs when food/liquid stops in the esophagus. This happens most often because of consistent stomach acid refluxing (backing up) into the esophagus. Over time, the reflux causes inflammation and a narrowing (stricture) of the esophagus. Food and eventually liquids feel like they are sticking in the middle and lower chest. There may be chest discomfort or even real pain. Fortunately, physicians can usually dilate (widen) this narrowing, and there is now treatment available to keep it from returning. Cancer, hiatus hernia, and certain muscle disorders of the esophagus are less frequent causes of esophageal dysphagia.
Oropharyngeal dysphagia involves difficulty moving food to the back of the mouth and starting the swallowing process. This type of dysphagia can result from various nerve or brain disorders such as stroke, cerebral palsy, multiple sclerosis, Parkinson's and Alzheimer's diseases, cancer of the neck or throat, a blow to the brain or neck, or even dental disorders. Depending on the cause, symptoms may include drooling, choking, coughing during or after meals, pocketing of food between the teeth and cheeks, gurgly voice quality, inability to suck from a straw, nasal regurgitation (food backing into the nasal passage), chronic respiratory infection, or weight loss.
The first step in treating oropharyngeal dysphagia is to make the proper diagnosis. This involves a medical history and various tests to find the cause of the dysphagia. Often a team approach to treatment is needed. Several types of health care providers -- physicians, registered dietitian, psychologist, speech pathologist, occupational therapist -- work together to develop the best program.
An important part of the treatment is helping the patient get adequate nutrition, while protecting against complications such as pneumonia from food or liquid getting into the lungs. Obviously, this requires a specialized diet. There are five different diet levels from puréed (level 1) up through modified regular food (level 5). The diets vary in texture and consistency, and are chosen depending on which would be most effective for a specific patient.
Nutrition facts
These diets are all nutritionally adequate. However, some patients may have difficulty taking enough fluid and
food to get all the energy and nutrients they need. In this case, an adjustment to diet or treatment will be required.
Liquids
Fluids are essential to maintain body functions. Usually 6 to 8 cups of liquid (48-64 oz) are needed daily. For
some dysphagia patients, this may present problems because thin liquid can be more difficult to swallow. In this
case, fluid can be thickened to make it easier to swallow. However, close monitoring by the dysphagia team is required
for anyone drinking less than 4 cups of thickened fluid a day or anyone not progressing to thin liquids within
4 weeks.
Calories
The greater problem for some patients is eating enough calories. The whole process of eating simply becomes too
difficult and too tiring. However, calorie and protein intake can be increased by fortifying the foods the patient
does eat.
- Fortify milk by adding 1 cup of dry powdered milk to one quart of liquid milk. Use this protein fortified milk when making hot cooked creamed soups, sauces, milkshakes, and puddings. Also add margarine, sugar, honey, jelly, or puréed baby food to increase calories.
- Add strained baby fruit to juices, milkshakes, and cooked cereals.
- Add 1 jar of strained baby meat to soup, such as strained chicken noodle soup. Also add strained baby meats to sauces and gravies, and mix with strained vegetables.
- Add juice to prepared fruit, cereal, or milkshakes.
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Special Considerations |
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The following are some general guidelines for safe swallowing. Remember that dysphagia patients have individual requirements, so all of these guidelines may not apply to every patient.
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Level 1 |
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| Foods in this group are puréed to a smooth, mashed potato-like consistency. If necessary, the puréed
foods can keep their shape with the addition of a thickening agent. Meat is puréed to a smooth pasty consistency.
Hot broth or hot gravy may be added to the puréed meat, approximately 1 oz of liquid per 3 oz serving of
meat. CAUTION: If any food does not purée into a smooth consistency, it may make eating or swallowing more difficult. For example, zucchini seeds sometimes do not blend well. |
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| Hot Foods | Cold Foods |
| Puréed meats, poultry, & fish | Puréed cottage cheese |
| Puréed tuna, ham, & chicken salad | Puréed fruit |
| Pureed scrambled eggs & cheese | Thickened juices & nectars |
| Baby cereals | Thickened milk or eggnog |
| Thinned cooked cereals (no lumps) | Malts |
| Puréed French toast or pancakes | Thick milkshakes |
| Mashed potatoes | Ice cream |
| Puréed parsley, au gratin, scalloped potatoes, candied sweet potatoes | Fruit or Italian ice, sherbet |
| Puréed buttered or Alfredo noodles | Plain yogurt |
| Puréed vegetables (no corn or peas) | Smooth & drinkable yogurt |
| Puréed soups & creamed soups | Smooth pudding, mousse, custard |
| Puréed scalloped apples | Whipped gelatin |
| Gravies | Sugar, syrup, honey, jelly |
| Sauces: cheese, tomato, barbecue, white, creamed | Cream |
| Decaffeinated coffee or tea | Non-dairy creamer |
| Margarine | |
| Mayonnaise | |
| Ketchup, mustard | |
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Sample Menu, Level 1 |
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Breakfast |
Lunch |
Dinner |
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This Sample Diet Provides the Following |
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| Calories |
1657 |
Fat |
61 gm |
| Protein |
92 gm |
Sodium |
2590 mg |
| Carbohydrates |
198 gm |
Fiber |
3163 mg |
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Level 2 |
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| Foods in this group should be minced/chopped into very small pieces (1/8 inch). The flecks of food are similar in size to sesame seeds. | |
| Hot Foods | Cold Foods |
| Minced meat, fish, poultry | Cottage cheese |
| Minced stuffed fish | Junior baby fruit |
| Flaked fish | Semi-thickened juices |
| Junior baby meats | Nectars |
| Minced soft cooked, scrambled, poached eggs | Ripe mashed bananas |
| Minced soufflé & omelets | Minced canned fruit |
| Minced soft French toast | Pineapple sauce |
| Minced soft pancakes | Milk |
| Cooked cereals | Milkshakes |
| Minced potatoes | Custard |
| Minced buttered or Alfredo noodles | Puddings, including rice & tapioca |
| Minced vegetables | Yogurt |
| Creamed soups | Fruit ice, Italian ice, sherbet |
| Puréed vegetables soup or alphabet soup | Whipped gelatin |
| Minced scalloped apples | Junior baby desserts |
| Gravies | Sugar, syrup, honey, jelly |
| Sauces: cheese, creamed, barbecue, tomato, white | Cream |
| Decaffeinated coffee or tea | Margarine |
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Sample Menu, Level 2 |
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| Breakfast | Lunch | Dinner |
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This Sample Diet Provides the Following |
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| Calories |
2022 |
Fat |
80 gm |
| Protein |
111 gm |
Sodium |
2992 mg |
| Carbohydrates |
231 gm |
Potassium |
4182 mg |
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Level 3 |
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| Foods in this group should be ground/diced into 1/4-inch pieces. These pieces of food are similar in size to rice. | |
| Hot Foods | Cold Foods |
| Ground meat, fish, poultry | Cottage cheese |
| Ground meat salads (no raw eggs) | Smooth fruited yogurt |
| Ground Swedish meatballs | Fruit juices or nectars |
| Scrambled eggs or soufflés | Ground canned fruit |
| Ground poached eggs | Crushed pineapple |
| Cooked cereals | Ripe bananas |
| Ground soft French toast | Lemonade/Limeade (no pulp) |
| Ground potatoes | Milk |
| Ground noodles | Ice cream |
| Ground baked potato (no skin) | Custard |
| Ground well-cooked frozen vegetables (no corn, peas, or mixed vegetables) | Puddings or mousse |
| Ground canned vegetables | Fruit ice, Italian ice, sherbet |
| Creamed soups | Cream |
| Puréed vegetables soup or alphabet soup | Non-dairy creamer |
| Ground scalloped apples | Margarine |
| Gravies | Mayonnaise |
| Sauces: cheese, creamed, barbecue, tomato, white | Ketchup |
| Decaffeinated tea or coffee | Mustard |
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Sample Menu, Level 3 |
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| Breakfast | Lunch | Dinner |
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This Sample Diet Provides the Following |
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| Calories |
2022 |
Fat |
80 gm |
| Protein |
111 gm |
Sodium |
2992 mg |
| Carbohydrates |
231 gm |
Potassium |
4182 mg |
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Level 4 |
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| Foods in this group should be chopped into 1/2-inch pieces. These pieces of food are similar in size to uncooked elbow macaroni or croutons (small bread cubes). | |
| Hot Foods | Cold Foods |
| Chopped meat or poultry | Cottage cheese |
| Chopped Swedish meatballs | Yogurt |
| Meat salads (ground or flaked meat) | Milk |
| Flaked fish | Milkshakes |
| Poached or scrambled eggs | Soft, cold, dry cereal |
| Soufflés and omelets | Soft bread (if approved by speech or occupational therapy) |
| Cooked cereals | Fruit juice or nectars |
| Chopped French toast or pancakes | Chopped canned fruit |
| Chopped noodles or pasta (no rice) | Canned fruit cocktail |
| Chopped cooked vegetables (no frozen peas, corn, or mixed vegetables) | Pudding, mousse, custard |
| Chopped canned small sweet peas | Ice cream |
| Creamed soup or vegetable soup | Fruit ice, Italian ice, sherbet |
| Canned chicken noodle soup | Cream cheese |
| Chopped potatoes (all kind) | Whipped topping |
| Gravies | Whipped gelatin |
| Bacon dressing | Sugar, syrup, honey, jam, jelly |
| Sauces: cheese, creamed, barbecue, tomato, white | |
| Decaffeinated tea or coffee | |
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Sample Menu, Level 4 |
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| Breakfast | Lunch | Dinner |
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This Sample Diet Provides the Following |
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| Calories |
2097 |
Fat |
82 gm |
| Protein |
113 gm |
Sodium |
3213 mg |
| Carbohydrates |
243 gm |
Potassium |
4201 mg |
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Level 5 |
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| Foods in this group are soft, moist, regularly textured foods | |
| Hot Foods | Cold Foods |
| Soft, moist meat, fish, poultry | Soft cheeses |
| Baked fish | Cottage cheese |
| Meat Salads | Cream cheese |
| Soufflés and omelets | Yogurt |
| Eggs | Milk |
| Stuffed shells | Milkshakes |
| Spaghetti with meat sauce | Cold dry cereals (no nuts, dried fruit, coconut) |
| Cooked cereal | Crackers |
| French toast or pancakes | Soft breads (no hard rolls) |
| Toast | Fruit juices or nectars |
| Noodles or pasta (no rice) | Canned fruit |
| Potatoes (all types) | Ripe bananas |
| Soft, cooked vegetables (no corn, lima, or baked beans) | Peeled, ripe, fresh fruit |
| Creamed soups or vegetable soup | Cakes (no nuts, dried fruit, coconut) |
| Canned chicken noodle soup | Plain doughnuts |
| Gravies | Ice cream |
| Bacon dressing | Pudding, mousse, custard |
| Sauces: cheese, creamed, barbecue, tomato, white | Fruit ice, Italian ice, sherbet |
| Decaffeinated tea or coffee | Whipped gelatin |
| Regular gelatin | |
| Canned fruited gelatin molds | |
| Sugar, syrup, honey, jam, jelly | |
| Cream | |
| Non-dairy creamer | |
| Margarine | |
| Oil | |
| Mayonnaise | |
| Ketchup | |
| Mustard | |
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Sample Menu, Level 5 |
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| Breakfast | Lunch | Dinner |
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This Sample Diet Provides the Following |
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| Calories |
2851 |
Fat |
120 gm |
| Protein |
129 gm |
Sodium |
4062 mg |
| Carbohydrates |
327 gm |
Potassium |
4609 mg |