Purees That Please, Purees That Please, Part 1Part 1

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Review Date 3/11 G-1559Contributed by Judy Schlager, RD, LD

•Choosing the correct diet:– Must individualize– Goal: Rehabilitate to the highest

practical level of the dysphagia diet progression

– Must use collaborative effort to reach decision

– Must have careful swallow evaluation by a qualified therapist

The Dysphagia Diet

National Dysphagia Diet (NDD) 1—pureed:•Pureed, homogenous, and cohesive foods•Pudding-like foods•No coarse textures, raw fruits or vegetables, nuts, etc•All foods requiring bolus formation, controlled manipulation or mastication are excluded

Dysphagia Diet Progression

NDD 1—pureed:•Rationale: This diet is designed for people who have moderate to severe dysphagia, with poor oral phase abilities, and reduced ability to protect their airway•Close or complete supervision and alternate feeding methods sometimes are required

Dysphagia Diet Progression (cont’d)

The pureed diet has only one purpose:•To enable the patient/resident to ingest adequate nutrition in comfort and safety•Modification is in texture only•Further modifications merely impose further complications

The Pureed Diet

NDD 2—mechanically altered:•Foods are moist, soft textured, and easily formed into a bolus•Meats are ground or minced, not larger than ¼ pieces—still moist with some cohesion•All foods from Level 1 are acceptable at this level

Dysphagia Diet Progression

NDD 2—mechanically altered:•Rationale: This diet is a transition from the pureed textures to more solid textures•Chewing ability is required•Textures are appropriate for individuals with mild to moderate oral and/or pharyngeal dysphagia

Dysphagia Diet Progression (cont’d)

NDD 2—mechanically altered:•Assess patients for tolerance to mixed textures•Expect that some mixed textures are tolerated in this diet

Dysphagia Diet Progression (cont’d)

NDD 3—dysphagia advanced:•Foods are of nearly regular textures, with the exception of very hard, sticky, or crunchy foods•Foods still are moist and in bite-size pieces at the oral phase of the swallow

Dysphagia Diet Progression (cont’d)

NDD 3—dysphagia advanced:•Rationale: This diet is a transition to a regular diet•Adequate dentition and mastication are required•Textures of this diet are appropriate for individuals with mild oral and/or pharyngeal phase dysphagia

Dysphagia Diet Progression (cont’d)

NDD 3—dysphagia advanced:•Assess patients for tolerance of mixed textures•Expect that mixed textures are tolerated on this diet

Dysphagia Diet Progression (cont’d)

NDD 4—regular:•Any solid texture food•All beverages are included

Dysphagia Diet Progression (cont’d)

For dysphagic diets:•Puree consistency should support straw when placed in center of food•Foods are dense in relation to volume•Temperatures are cold or hot, not tepid•Thicken liquids PRN•Textures uniform—no combined textures•Smooth, not sticky•Foods to avoid—seeds, nuts, crunchy foods

Characteristics of Pureed Foods

Foods must form a cohesive bolus:•Use sauces and gravies•Avoid rice, cottage cheese, and ground meats without sauces or gravies•Liquids usually are thickened

Foods for Dysphagic Patients

Properties of starch thickeners:•Pregelatinized and agglomerated to instantize•Only the water portion of the item is thickened•Normal metabolism reverses the thickening process, thus releasing the water to make it available for hydration

Commercial Thickeners in Liquids

Properties of gum thickeners:•Indigestible in upper gastrointestinal tract•Low susceptibility to enzymatic hydrolysis•High water-binding capability•Good fiber source•Good bulk for colon

Commercial Thickeners in Liquids (cont’d)

Facility thickened:•Advantages:

– For use with all liquids– Less costly

•Disadvantages:– Unsafe=lumps– Inaccurate measuring=inconsistent

results– Constant training of staff members– Risk of fines because of improper

viscosity levels

Facility-Thickened vs Prethickened Liquids

Prethickened:•Advantages:

– Safer=no lumps– No staff training

•Disadvantages:– More costly– Not all necessary liquids available– Flavors sometimes not as good as with

facility-thickened liquids

Facility-Thickened vs Prethickened Liquids (cont’d)

For thickened liquids:•Thin=1−50 centipoise (cP)•Nectar-like=51−350 cP•Honey-like=351−1750 cP•Spoon thick=>1750 cP

Viscosity Borders and Ranges