Dysphagia…the role of a dietitian

This blog post was written as a guest blog post for Speech Therapy Works (www.speechtherapyworks.co.uk) run by Sandra Robinson.

As the result of swallowing difficulties, it is highly likely that a person’s eating and drinking is affected. The degree to which their eating and drinking is affected will vary on an individual basis. One of the major consequences of dysphagia not being identified and/or not being managed appropriately is malnutrition.  

Malnutrition is the result of an imbalance of the energy, protein and other important nutrients in the body resulting in the following:

  • loss of muscle mass
  • weight loss
  • reduced ability to fight infection
  • increased risk of falls
  • impaired wound healing

Malnutrition is a severe complication of dysphagia and studies suggest up to 50% individual with dysphagia are at risk of malnutrition and 16% are malnourished1.

Why does malnutrition occur in people with dysphagia?

There are numerous reasons why a person with dysphagia becomes malnourished or is at increased risk of malnutrition. These reasons may include:

  • inadequate food and fluid intake following changes to the recommended consistency of food and fluid that is safe to consume as advised by a speech and language therapist
  • inadequate provision of nutritious texture modified food and fluid
  • taking longer to eat a meal therefore a person may lose interest, or the meal goes cold therefore the meal becomes unappetising

What role does a dietitian play in helping people with dysphagia?

Following diagnosis of dysphagia, it is important that a dietitian works closely with speech and language therapists to ensure any nutritional concerns are addressed. As discussed earlier there may be numerous reasons why a person with dysphagia may become nutritionally compromised and identifying these reasons will be key to improving someone’s nutritional intake.

  1. Texture modified diets and fluids

Management strategies for dysphagia can include texture modification of diet and fluids.  The IDDSI framework is a globally developed standardised set of terminology to describe texture modified foods and thickened liquids2.

Depending on the recommendations set out by the speech and language therapist, the degree of nutritional support required will vary. For some individuals they may be able to manage for example 80% of their nutritional intake from texture modified diet but require oral nutritional supplements to provide the deficit. When considering the use of oral nutritional supplements there are several things a dietitian will need to consider:

  • does the person need their drinks thickened?
  • does the person like milk?
  • is the person able to make a drink or do they need a ready to drink version?

Dependent on these factors will determine the type and format of oral nutritional supplement recommended.  It may be appropriate to consider a pre-thickened oral nutritional supplement if the person requires thickened fluids as these products offer a safe solution to ensure that the recommended thickened fluid consistency is received.

Before or alongside the use of oral nutritional supplements, food fortification is usually recommended and is a way of improving the nutritional value of food and can be used in texture modified diets.  For example:

  • Using cream or whole milk instead of water to puree the food
  • Add butter or cheese into food before preparing to the correct consistency e.g. mashed potato
  • Add cream or custard to fruit before it is pureed.

In addition to addressing nutritional concerns, dietitians will also look at the hydration status of an individual.  It is common for people with dysphagia to have inadequate fluid intake which can lead to dehydration.  

The major consequences of dehydration include:

  • Low blood pressure
  • Urinary tract infections
  • Constipation
  • Confusion
  • Dizziness

Maintaining adequate hydration in people with dysphagia can be challenging due to a number of reasons.

Thickened fluids are commonly used as part of texture modification strategies to reduce the risk of aspiration.  However, it is important that the extent to which the fluid is thickened is balanced alongside risk of dehydration, compliance with thickened fluids and the safety aspect for a safe swallow.  This is where collaboration between dietitians and speech and language therapist is essential to ensure the risk of dehydration is minimised whilst also managing the risk of aspiration.

Strategies to reduce the risk of dehydration in people with dysphagia could include the following:

  • Offered flavoured thickened drinks rather than thickened plain water
  • The use of gum-based thickeners over starch-based thickeners may be preferable to improve the visual appeal and palatability of the thickened drink
  • Pre-thickened drinks may play a role particularly if the person also requires nutritional supplementation

2. Provision of safe and nutritious food and drink

Dysphagia management is everyone’s responsibility and once a plan has been outlined about how to manage dysphagia, it is important all key individuals are involved in the plan. Once recommendations are in place for a texture modified diet, it is important that those who prepare and serve the food and drink are aware of these recommendations.. 

Texture modified foods can be self-prepared or ready meals can be purchased.  When preparing homemade texture modified it is important that the preparation of the food is in line with the IDDSI framework descriptors for the recommended level advised by the speech and language therapist.

Summary

Due to the overlap between dysphagia and malnutrition, it is important that speech and language therapists and dietitians work together.  The role of the dietitian in dysphagia management is to ensure adequate nutrition and hydration, particularly when texture modified food and diet recommendations are in place.  This will help to improve a person’s nutritional status, aid recovery and improve quality of life.

References:

  1. Tagliaferri S, Lauretani F, Pelá G, Meschi T, Maggio M. The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals. Clinical Nutrition [Internet]. 2019;38(6):2684–9. 
  2. Cichero JAY, Lam P, Steele CM, Hanson B, Chen J, Dantas RO, et al. Development of International Terminology and Definitions for Texture-Modified Foods and Thickened Fluids Used in Dysphagia Management: The IDDSI Framework. Dysphagia [Internet]. 2016/12/02. 2017 Apr;32(2):293–314.

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