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Dysphagia Diet
5 Levels Difficulty In Swallowing Diet
Purpose
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.
Special Considerations

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.

  • Maintain an upright position (as near 90 degrees as possible) whenever eating or drinking.
  • Take small bites -- only 1/2 to 1 teaspoon at a time.
  • Eat slowly. It may also help to eat only one food at a time.
  • Avoid talking while eating.
  • When one side of the mouth is weak, place food into the stronger side of the mouth. At the end of the meal, check the inside of the cheek for any food that may have been pocketed.
  • Try turning the head down, tucking the chin to the chest, and bending the body forward when swallowing. This often provides greater swallowing ease and helps prevent food from entering the airway.
  • Do not mix solid foods and liquids in the same mouthful and do not "wash foods down" with liquids, unless you have been instructed to do so by the therapist.
  • Eat in a relaxed atmosphere, with no distractions.
  • Following each meal, sit in an upright position (90 degree angle) for 30 to 45 minutes.
Level 1
Puréed Foods
 
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.

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

Sample Menu
Level 1
Breakfast
Lunch
Dinner
  • orange juice 1/2 cup
  • cream of wheat
    1/2 cup
  • scrambled eggs with cheese 1/2 cup
  • decaffeinated tea
    1 cup
  • whole milk 1 cup
  • non-dairy creamer
    2 Tbsp
  • ketchup 1 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 2 tsp
  • pineapple juice
    1/2 cup
  • puréed beef 3 oz
  • gravy 2 Tbsp
  • mashed potatoes
    1/2 cup
  • puréed fresh broccoli 1/2 cup
  • apple sauce 1/2 cup
  • decaffeinated coffee
    1 cup
  • non-dairy creamer
    2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
  • puréed turkey barley soup 3/4 cup
  • puréed Hawaiian chicken 3 oz
  • mashed potatoes
    1/2 cup
  • puréed spinach
    1/2 cup
  • frozen yogurt 1/2 cup
  • decaffeinated tea
    1 cup
  • non-dairy creamer
    2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
This Sample Diet Provides the Following

Calories

1657

Fat

61 gm

Protein

92 gm

Sodium

2590 mg

Carbohydrates

198 gm

Fiber

3163 mg
Level 2
Minced Foods

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

Sample Menu
Level 2

Breakfast

Lunch

Dinner

  • orange juice 1/2 cup
  • oatmeal 1/2 cup
  • scrambled eggs with cheese 1/2 cup
  • decaffeinated tea 1 cup
  • whole milk 1 cup
  • non-dairy creamer
    2 Tbsp
  • ketchup 1 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 2 tsp
  • pineapple juice 1/2 cup
  • minced beef 3 oz
  • gravy 2 Tbsp
  • mashed potatoes 1/2 cup
  • minced fresh broccoli
    1/2 cup
  • applesauce 1/2 cup
  • decaffeinated coffee
    1 cup
  • non-dairy creamer 2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
  • puréed turkey barley soup 3/4 cup
  • minced Hawaiian
    chicken 3 oz
  • mashed potatoes 1/2 cup
  • puréed spinach 1/2 cup
  • frozen yogurt 1/2 cup
  • decaffeinated tea 1 cup
  • non-dairy creamer 2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
This Sample Diet Provides the Following

Calories

2022

Fat

80 gm

Protein

111 gm

Sodium

2992 mg

Carbohydrates

231 gm

Potassium

4182 mg
Level 3
Ground Foods

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

Sample Menu
Level 3

Breakfast

Lunch

Dinner

  • orange juice 1/2 cup
  • oatmeal 1/2 cup
  • scrambled eggs with cheese 1/2 cup
  • decaffeinated tea 1 cup
  • whole milk 1 cup
  • non-dairy creamer
    2 Tbsp
  • ketchup 1 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 2 tsp
  • pineapple juice 1/2 cup
  • ground beef 3 oz
  • gravy 2 Tbsp
  • mashed potatoes 1/2 cup
  • cooked spinach 1/2 cup
  • applesauce 1/2 cup
  • decaffeinated coffee
    1 cup
  • whole milk
  • non-dairy creamer 2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
  • puréed turkey barley soup 3/4 cup
  • ground Hawaiian
    chicken 3 oz
  • mashed potatoes 1/2 cup
  • ground fresh broccoli
    1/2 cup
  • frozen yogurt 1/2 cup
  • decaffeinated tea 1 cup
  • non-dairy creamer 2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
This Sample Diet Provides the Following

Calories

2022

Fat

80 gm

Protein

111 gm

Sodium

2992 mg

Carbohydrates

231 gm

Potassium

4182 mg
Level 4
Chopped Foods

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

Sample Menu
Level 4

Breakfast

Lunch

Dinner

  • orange juice 1/2 cup
  • oatmeal 1/2 cup
  • scrambled eggs with cheese 1/2 cup
  • decaffeinated tea 1 cup
  • whole milk 1 cup
  • non-dairy creamer
    2 Tbsp
  • ketchup 1 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 2 tsp
  • pineapple juice 1/2 cup
  • chopped beef 3 oz
  • gravy 2 Tbsp
  • mashed potatoes 1/2 cup
  • chopped fresh broccoli
    1/2 cup
  • applesauce 1/2 cup
  • decaffeinated coffee
    1 cup
  • non-dairy creamer 2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
  • turkey barley soup 3/4 cup
  • chopped Hawaiian
    chicken 3 oz
  • mashed potatoes 1/2 cup
  • cooked spinach 1/2 cup
  • frozen yogurt 1/2 cup
  • decaffeinated tea 1 cup
  • non-dairy creamer 2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
This Sample Diet Provides the Following

Calories

2097

Fat

82 gm

Protein

113 gm

Sodium

3213 mg

Carbohydrates

243 gm

Potassium

4201 mg
Level 5
Modified Regular Foods

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

Sample Menu
Level 5

Breakfast

Lunch

Dinner

  • orange juice 1/2 cup
  • oatmeal 1/2 cup
  • cheese omelet
  • toast 1 slice
  • decaffeinated tea 1 cup
  • whole milk 1 cup
  • non-dairy creamer
    2 Tbsp
  • ketchup 1 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 2 tsp
  • jelly 2 tsp
  • pineapple juice 1/2 cup
  • hamburger on bun 3 oz
  • steak fries 1/2 cup
  • green beans 1/2 cup
  • applesauce 1/2 cup
  • decaffeinated coffee
    1 cup
  • whole milk 1 cup
  • non-dairy creamer 2 Tbsp
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
  • ketchup 2 Tbsp
  • turkey barley soup 3/4 cup
  • Hawaiian chicken 3 oz
  • mashed potatoes 1/2 cup
  • fresh broccoli 1/2 cup
  • frozen yogurt 1/2 cup
  • decaffeinated tea 1 cup
  • non-dairy creamer 2 Tbsp
  • saltine crackers 6
  • margarine 1 tsp
  • salt 1/4 tsp
  • sugar 1 tsp
This Sample Diet Provides the Following

Calories

2851

Fat

120 gm

Protein

129 gm

Sodium

4062 mg

Carbohydrates

327 gm

Potassium

4609 mg