Managing Dysphagia Through

Diet Modifications
Evidence-based help for patients with impaired swallowing.

O scar Smith, age 68, suffered a stroke two days

ago. Although he was quickly stabilized, his apparent difficulty

swallowing (as evidenced by frequent coughing, drooling, and pocketing of meat chunks) caused concern among the
nursing staff. (This case is a composite based on the authors’ experiences.) As a result, his physician ordered his regular
diet changed to one of pureed foods and nectar-thick fluids pending further testing by the speech-language pathol- ogist.
But his wife continues to offer him sips of her coffee and bites of his favorite get-well candies and cookies, not realizing
dangerous for him. It’s up to the nursing staff to explain
that these are now extremely the importance of dietary
modification to the Smiths until the other members of the health care team, such as the dietitian, provide further
counseling.
Mealtime may normally be the least taxing part of a pa tient’s day, but for someone with dysphagia— impaired
swallowing—that seemingly innocuous tray of food becomes a stressful proposition. Difficulty swallowing isn’t only
inconvenient and embarrassing; over time, it can also lead to malnutrition,1, 2 de hy ­dration,2 aspiration pneumonia,3­6 and
even death.7
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26 AJN ▼

2.4
HOURS Continuing Education

By Jane Mertz Garcia, PhD, CCC-SLP, and Edgar Chambers

IV, PhD

OVERVIEW: Dysphagia can lead to malnutrition, dehydration, aspiration pneumonia, and even
death. The condition has diverse causes and symptoms vary widely. Nurses are likely to
encounter patients with dysphagia in various settings, including acute care medical units,
rehabilitation centers, and skilled nursing facilities. Dietary modification—altering the consistency
of foods and liquids—is a fundamental aspect of dysphagia management. This article describes
normal and impaired swal­lowing, discusses several types and levels of dietary modification, and
offers readers a concise list of nursing considerations.

Keywords: dysphagia, impaired swallowing, dietary modification, malnutrition, aspiration

pneumonia
 Oropharyngeal dysphagia—characterized by diffi­culty
sfer of a liquid or food bolus from the mouth to the
Because dysphagia has diverse causes, nurses are likely—often occurs in patients who’ve had acute neurologic
to encounter it in numerous settings, including acute care medical a result of stroke or traumatic brain injury, or in those
units, rehabilitation centers, and skilled nursing facilities. And essive neurologic disease such as amyotrophic lateral
while the management of dysphagia is multidisciplinary, it’s the Parkinson’s disease. A recent study found that
nurse who is most likely to be in frequent contact with the patient n patients with acute stroke ranges from 51% to 55%
and can best observe and identify any swallowing difficulties. clinical testing) and

WHO HAS DYSPHAGIA? In a survey of primary care patients

in a clinic waiting room, nearly 23% reported symptoms of
dysphagia; the prevalence increased with age.8 Figure 1. Normal
Dysphagia may be oropharyngeal or

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from 64% to 78% (when using instrument testing).5 Oth Because the likelihood of stroke, as well as of other diseases associated
patients with acute stroke echo these findings, with with dysphagia, increases with age, dysphagia is most common
present in 53% to 57%.9, 10 And approximately 300,000 among the elderly.12, 13 In a survey of older adults living
people with neurologic disorders develop dysphagia independently, 33% re ported having problems swallowing.14 A
the United States, according to a 1999 report by the Japanese study of community­dwelling older adults found that
Health Care Policy and Research (now the Agency fo nearly 14% had dysphagia.15 The management of dys­ phagia is
Research and Quality).11 becoming increasingly important as the elderly population
Esophageal dysphagia—characterized by difficulty in p continues to grow. According to the U.S. Census Bureau, 20% of
down the esophagus—is common in patients with the population will be age 65 or older by 2050.16
disorder, sphincter abnormal­ity, or mechanical obstruc
by a stricture. NORMAL SWALLOWING Swallowing requires well­coordinated
 timing of sen­sory and motor mechanisms to safely tran which applies additional pressure to move the bolus O opening
lus through the oral cavity, pharynx, and esophagus (Fig of the upper esophageal segment to
Major components include: allow the bolus to enter the esophagus
• Continued propulsion and clearance. In this final phase, the
bolus passes through the esophagus un ­ til it’s cleared into the
stomach.

IMPAIRED SWALLOWING Detecting dysphagia. Symptoms

of impaired swal­lowing vary greatly.18 For example, patients who
have difficulty with bolus preparation and propulsion may show
signs such as drooling, leakage of liquid or food while eating, or
having food stuck in the mouth (often described as “pocketing”).
• Bolus preparation. Although liquids need l Coughing while drinking or
preparation, initial containment within the oral cavity
to prevent leakage and tongue control to prevent spil
pharynx) is essential. Chewing consists of a series o
cular actions that contribute to the preparation of a sol
include adequate rotary, lateral jaw motion
mastication, along with tongue control to manipulat
Bolus prep­aration is influenced by several factors inc
consistency, bite size, and the ability to mix the bolus w
• Propulsion of a bolus. Motor control of the tongue
to effectively control and transport the prepared bolu eating (before, during, or after the pharyngeal swallow) is always a
back of the oral cavity. concern; this may be a result of nu merous problems, including a
• The pharyngeal swallow, which reflects a com­ple slow swallow response, poor laryngeal closure to protect the
of events. The patient’s age and airway, or ineffective bolus clearance by the pharyngeal
the bolus type and volume all affect the temporal relationship constrictors. It’s im portant to note that nearly 55% of patients who
the following17: aspirate don’t cough or show any overt symptoms of aspiration
O soft palate retraction and elevation to prevent (described as “silent aspirators”).19
material from entering the nasal cavity O hyoid and laryngea Some patients may feel that food or pills are getting “stuck”
elevation and anterior movement to enhance relaxation of th in their throat. Others may exhibit a notice­ able change in their
upper esophageal segment O laryngeal closure (thanks to the voice (which may sound “wet” or hoarse) when eating or drinking.
epiglottis, false vocal folds, and true vocal folds) to protect Complications of untreated dysphagia. Aspira­ tion
the airway from possible penetration or aspi­ration of the occurs in about half (43% to 54%) of patients who’ve had a stroke,
bolus O contraction of the three pharyngeal constric tors 37% of whom develop pneumo­nia, which results in death for about
to help propel the bolus through the pharynx O movement o 4%.3 In a recent study, 72% of patients with aspiration pneumonia
the base of the tongue toward the posterior pharyngeal wal acquired in continuing care facilities had a neurologic

Patients with dysphagia have a longer hospital stay than

nondysphagic patients; in addition, they’re more likely to be
discharged to other care facilities (as opposed to home).
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28 AJN ▼
Table 1. Food Textures that Affect the Management of Dysphagia 26

Food Texture Description Example

when
Adhesiveness Effort required to overcome the adhes
compressed
of the food to the palate
Removing peanut butter from the palate ding is more cohesive than a gelatin
requires more effort than removing ert
marshmallow fluff

Cohesiveness Whether food is deformed or sheared

Firmness Force needed to compress a semisolid food Cream cheese requires greater effort to
compress
than whipped cream

“Fracturability” Force required to break a solid food In response to a bite, peanut brittle
fractures into
pieces while a corn muffin crumbles
inal shape after being compressed
Hardness Force required to compress a food to attain
certain deformation ng of marshmallow released in the
Chewing a hot dog just prior to th
shearing

Springiness Rate or degree that a food returns to its o

 Viscosity Rate of flow per unit of force Thickness of water vs. a milk shake
sessment conducted by the speech­language pathologist; this may
Yield Stress Minimum shear stress applied before flowfollowed by instru­mental meas ures such as a modified barium
begins wallow,
Effort of ketchup to flow from a bottle vs. with the participation of a radiologist. If dysphagia is
management plan needs to be instituted.
water
Multidisciplinary management of dysphagia is
ded for both children and adults and may in ­clude a
interventions. Some measures seek to improve the
of the patient’s swallow while others strive to redirect
disease that resulted in dysphagia, and 24% of all pa tients with
For exam­ ple, the speech­language pathologist may
aspiration pneumonia (acquired in com­ munity or in continuing
a change in the patient’s head position, such as a head
care facilities) died.6

chin­down position, in order to direct bo ­lus flow away

Patients with dysphagia have a longer hospital stay than
rway entrance.21 The pathol­ ogist may also suggest
nondysphagic patients; in addition, they’re more likely to be
repeat swallow,” which requires the patient to use
discharged to other care facilities (as op ­posed to home).7, 10, 20
wallows to help clear any remaining bolus from an
Dysphagia can also affect a patient’s quality of life and airway.22 The nursing staff should ensure the consis­tent
emotional well­being. A multinational European survey of 360 ion of these interventions.
patients found that dysphagia made life less enjoyable for 55% of
Dietary modification—altering the consistency
respondents. In addition, 41% reported experiencing anxiety or
nd liquids—is a fundamental aspect of dys ­ phagia
panic during meals, and 36% said they tended to avoid having
t. Dietary modification is most ef ­ fective when
meals with others because of their symptoms. Half of the
d by a team, including a nurse, physician,
respondents reported eating less, and one­third said they stopped
age pathologist, dietitian, and occupational therapist.
eating even though they still felt hun gry. The authors concluded
ach professional’s role may vary according to the
that “patients attrib­uted their increased sense of isolation and loss
f various health care facilities and the licensure re
of self­ esteem to swallowing difficulties.”1 Other researchers con
of each state.
cur on the importance of eating and drinking to quality of life.
The nurse is essential to the team, as she or he
Humbert and Robbins suggest that “dysphagia is becoming a
contact with the patient and can best moni­tor the diet’s
national health care bur­den and concern.”13
ion as well as any ensuing problems; the
MANAGEMENT If dysphagia is suspected, the physician, age pathologist typically makes treatment
ations to the patient’s
typically in col laboration with the speech­language patholo­gist,
will run a series of tests. Evaluation often con­sists of a clinical

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ad phy sician that may include texture modifications to

hesiveness, cohesiveness, firmness, “fracturability,” food and/or drink; the dietitian ensures that those clin­
hard ness, springiness, viscosity, and yield stress (see ical recommendations are balanced with the nutri tional
Table 126). needs of the patient and monitors the patient’s caloric
Levels of texture modification. Food texture is of ­and nutritional intake, selects the specific foods and
ten modified according to a patient’s oral motor con­liquids best suited to the patient’s dietary needs, and
trol. The NDD prescribes four levels of modification, manages the staff that prepares the food; and the occu­
with level 1 for patients with significant impairment pational therapist helps to improve eating and drink­
in control, levels 2 and 3 for patients with some ability ing by con sidering the patient’s motor and sensory
to chew, and level 4 for patients able to eat an unre­skills and adapt ing the environment to the pa tient’s
stricted, regular diet (for details, see Table 226). needs.
Some researchers have speculated that certain diets The degree of dietary modification should be based
(particularly those consisting of pureed foods) may be on each patient’s swallowing capacity and must be reg­
 visually unappealing and lacking in taste. These foods ularly evaluated and adjusted. Recommended meth­
may also feel unpleasant in the mouth.24 Efforts to ods of fluid and food modification are numerous and
overcome these unappealing qualities have had incon­often vary from one care setting to another. Concerns
sistent results: for example, some studies have shown over the lack of standardization led to the formation
that “molding” food into familiar shapes may help of the National Dysphagia Diet Task Force, and to
improve eating,27, 28 while others have found that such the publication in 2002 of the National Dysphagia
measures have little effect.29, 30 Diet (NDD) by the American Dietetic As sociation.
The NDD encourages the use of standardized rec­While this publication has gone a long way to standard­
ipes to ensure that foods are modified in a consis ­ize dietary modification for dysphagia, ad ditional peer­
tent manner. For example, without a standard recipe, reviewed studies are needed to support its recommen­
mashed potatoes may end up being too dry or too dations.
sticky from one meal to the next, causing difficulties In this article we use the terms and labels defined
for the patient with dysphagia. by the NDD, while acknowledging that they may
Additional factors that may contribute to the need be different from those defined by other dysphagia
for dietary modification include problems with teeth diets.or dentures, mental or behavioral disorders, and post­

Altering solids. Texture represents the composi tion

surgical care. of a food item. Bourne defined textural properties to
Altering liquids. The fast transit of thin liquids such include a “group of physical characteristics that arise
as water, coffee, or juice creates risks for some pa ­from the structural elements of the food, are sensed
tients, particularly those with poor motor skills who primarily by the feeling of touch, are related to the
are unable to contain fluids in their mouths, those deformation, disintegration, and flow of the food un ­
with slow or irregular pharyngeal response, those with der a force, and are measured objectively by functions
compromised airway protection, and those with re ­of mass, time, and distance.”23 It’s estimated that in
duced cognitive awareness. When modifying liquids, nursing homes, food textures are modified for 31% to
the objective is to create a consistency that matches, 48% of patients.24, 25
as much as possible, the patient’s capacity for swal­The NDD identifies food textures that should be
lowing. taken into consideration when deciding how to mod­
The NDD includes standard labels and suggested ify diet for a patient with dysphagia.26 These include
ranges for various liquid consistencies. Measured in
Table 2. The Levels of Dietary Modification as Defined by the National Dysphagia Diet26
Dietary Modification Description Level 1: Pureed Pureed, homogenous, and cohesive
(pudding­like) foods, not those that
require bolus formation, controlled manipulation, or mastication
Level 2: Mechanically Altered Moist, soft­textured foods that are easily formed into a bolus; meats
that
are ground or minced (pieces no larger than one­fourth of an inch) but are moist with some
cohesion; level 1 food items are also allowed
Level 3: Advanced Nearly all textures except for hard, sticky, or crunchy foods; foods still
need to be moist and bite­size
Level 4: Regular All foods
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30 AJN ▼
units of viscosity called centipoises (cP), these consis­tencies are ange juice), only one­third of facili­ ties use these exclusively;
classified as follows: thin (1 to 50 cP), nectar­like (51 to 350 cP), hers rely to some extent on thickeners that are mixed with a fluid
honey­like (351 to 1,750 cP), and spoon thick (greater than 1,750 achieve a target level of consistency.31 Commercially available
cP).26 ckening agents (ready­to­serve, powdered, or gel thickeners) don’t
Although some modified fluids are available for ecify viscosity ranges, meaning that target levels of consistency
purchase in a ready­to­serve form (such as prethick­ ened water or ay or may not fit the suggested ranges of the NDD even when
 prepared to specification.32­34 n them, and they are less likely to interact with the base
wever, some drinks, such as adult nutritional beverages,
n gredients that may interact with the gum thickener and
s. Achieving the target level of thickness is further com
preparation. Labels with unclear guidelines may lead to
results.36 Furthermore, many health care providers aren’t
formally instructed

Starch-based thickeners. When preparing modified

liquids, it’s important to note whether the thickening agent is starch­
or gum­based. Starch particles expand like a balloon by capturing
the fluid, meaning that flu­ids prepared with starch­based thickeners
often keep absorbing more liquid and get thicker after their initial
preparation.33­35 Consequently, a modified drink pre­ pared with a
starch­based thickener 20 to 30 minutes prior to mealtime may be on.31, 37 A recent study showed that most health care
much more viscous by the time it’s consumed. Additionally, when ere unable to consistently pre­pare modified liquids that
refrigerated, fluids modified with starch thickeners may become the NDD range for nectar­or honey­like thickness.37 In
too thick because starch interacts with temperature.34 idn’t prepare any samples that fit the NDD range for
Prethickened fluids have been shown to be con­sistently ness, and about one­third (31%) didn’t do so for nectar
thicker than those modified with an instant thickener.32 his means that many pa ­tients are receiving liquids that
Gum-based thickeners interact with the liquid in a or too thin (usually too thick), putting them at higher
k
different manner. Thickening by forming “nets” that trap liquids, edical complications such as aspiration pneumonia.
gum thickeners typically require care ­ful prep aration; they must of an overly thickened fluid can increase the risk of
be vigorously shaken or blended with the base fluid to for some, as it may be more dif ficult to clear from the
appropriately thicken it. Otherwise, the patient is served a mixed addition, thick­ eners may negatively affect the flavor
consis­ tency (thin fluid with thicker, moistened gum strands of drinks, potentially making them less appetizing to
39, 40

intermixed). However, if mixed properly, gum­based thickeners will s therefore essential that fluids be modi­ fied to the
maintain relatively stable viscosity over time.33 consistency and according to each patient’s swallowing
The base liquid and the way it interacts with the is will ensure that patients aren’t needlessly receiving
thickening agent are other factors to consider when modifying fied fluids that are unacceptable to them.
41

liquids. Starches are more prone to chemi­ cal interactions when Some facilities have implemented the Frazier
mixed with certain fluids. This helps to explain why drinks such as
33 Protocol, which permits patients who normally aren’t
orange juice may consume thin liquids to drink plain water between
thicken in a different manner when mixed with starch than water een suggested that con­suming plain water by itself is
and apple juice do. Because orange juice has pulp, it naturally ous than consuming it with food or other liquids,
results in a slightly thicker drink. It also contains acid that can bond as ­ pirated it’s less likely to cause problems.
with the starch particles, rapidly thickening the juice, but causing y, aggressive oral care and hygiene is an important as
the bonds to break down over time (hours or days). Gums, in protocol’s use. This protocol evolved from con­ cerns
contrast, are more stable. Their masses of strands capture fluid
26 t compliance with thickened fluids

Thickeners may negatively affect the flavor and texture of

drinks, making them less appetizing to patients. It’s therefore
essential that fluids be modified to the appropriate consistency
 and according to each patient’s swallowing capacity.

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and patients’ desire to consume thin fluids regardless of their aspiration risk.42 However, some research ers have cautioned
that the evidence in support of the protocol has been primarily based on a single institu­tion’s data.43
The use of thickened liquids has become a com­mon intervention in dysphagia management. In some settings, thickened
fluids are recommended for one­fourth to three­fourths of adult patients.31 In a study of 252 skilled nursing facilities, 92%
served thick ­ened liquids to residents with dysphagia.44
For a short list of nursing considerations when taking care of patients with dysphagia, see What You Can Do.26, 45
REVISITING MR. SMITH It’s evident that the get­well treats Mr. Smith is eating are unsafe. His favorite caramels are
very adhesive (or sticky) and firm (requiring more effort to com­press). Consequently, as he tries to chew the caramel, he
needs to apply more force to create a cohesive bo lus, which may be difficult for him because of his compromised oral

motor skills. Because the caramel also tends to adhere to his palate, Mr. Smith, who has What You Can Do
limited strength and range of tongue movement, may have trouble transporting it safely to the back of his
When caring for a patient with dysphagia, consider the following:
mouth. His favorite cookie—a gingersnap—also taxes his mastication skills and oral control because of its
•
Educate and inform patients, their loved ones, and caregivers about the hardness and fracturability (its
tendency to break into parts with each bite). A part of the cookie could eas­ importance of dietary modifications.
 Bear in mind that the attitudes of nurses and other caregivers about patients’ diet can influence
patients’ consumption.
ily slip into his pharynx, putting him at risk for aspi­ration. In addition, sips of his wife’s coffee may lead to aspiration
because Mr. Smith can’t control the oral flow as he did before his stroke.
•
Become well­informed about modification practices at your facility. Although this article focused
on the National Dysphagia Diet (NDD), know that labels and descriptions tend to vary from one
care setting to another.
Although Mrs. Smith is well­intentioned, these get­well treats are dangerous to her husband. It’s up to the nursing staff to
counsel her about his dysphagia and to help her implement the recommended dietary changes.
•
Recognize that some consistencies are simply less safe than others. For example, thin fluids
such as coffee or juice may be the most dangerous consistency for a patient with dysphagia.
Similarly, some food textures, including those that are noncohesive or that easily separate (such
as rice
REEVALUATION, OFTEN OVERLOOKED One concern for patients who receive modified diets is that as their
swallowing improves, their diet isn’t always readjusted to a less restrictive level. It’s been and chunky soup), as
well as “sticky” foods (such as peanut butter or dry
shown that many nursing home residents remain at mashed potatoes), may be harmful.26
•
Remember that not all thickening agents are the same. Ask the speech­ the same level for extended
periods of time without systematic reevaluation of their status.24 Reevaluation of these residents revealed that 91% received
a more language pathologist and the dietitian about the thickening products
restrictive diet than they could tolerate. ▼ served to patients. Make sure that fluids are thickened
appropriately and prepared in a manner consistent with product guidelines. Bear in mind that
thicker is not necessarily better for patients with impaired swallowing.
•
Training is essential. It’s been shown that when implementing the NDD, ongoing training in
dysphagia management, including how liquids should be thickened, results in higher caloric
intake by patients, greater
Jane Mertz Garcia is professor of communication sciences and acceptance of some foods, and fewer calls questioning

the diet modifi­cations.45

disorders, School of Family Studies and Human Services, Kansas State University, where Edgar Chambers IV is distinguished professor of sensory analysis
and consumer behavior and director
•
Monitor a patient’s status and advocate for systematic reevaluation. of the Sensory Analysis Center, Department of
Human Nutrition. Contact author, Jane Mertz Garcia: jgarcia@ksu.edu. The au thors Maintain communication with other

members of the dysphagia team to determine if, and when, additional assessment or
modifications are
of this article have no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.
indicated. The nursing staff can help to ensure that patients receive liq­uids and foods
appropriate to their needs.
REFERENCES
•
 Be an active part of the dysphagia team. The ability to eat and drink greatly contributes to a
patient’s physical and emotional well­being.
For 20 additional continuing nursing education ar­ticles on nutrition topics, go to www.nursingcenter. com/ce.
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Inadequate fluid intakes in dysphagic acute stroke. Clin Nutr 2001;20(5):423­8.

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