4 Consequences of Dietary Modifications for Dysphagia

Whats the safest diet for this patient?

As dysphagia clinicians, were asked this a lot. Physicians, nurses, and family members all want to do whats best, and preventing aspiration with diet changes seems like a straightforward solution. Unfortunately, its not that simple.

Diet modifications, such as reducing the texture of the foods we provide or thickening liquids, seem like benign interventions, but the fact is that these interventions can sometimes have unintended consequences.

Heres what we know:

1. Thick liquids increase risk of dehydration.

Several studies have documented that consuming thickened liquids increases our patients risk of dehydration.^{1, 2, 3} There is nothing inherently dehydrating about thickened liquidsin fact, most commercial thickeners return almost all of the water back to the bloodstream for bioavailability.⁴

So whats the problem? People drink less! Why?

• They dont like the taste and texture of the thick liquids.

• Theyre full for longer periods of time after consuming thick liquids.

• The thickened liquids are more difficult to prepare.

• In residential facilities, they are often offered liquids less frequently than those who are on regular liquids.

2. Texture modifications are difficult to achieve at home.

Speech-language pathologists often recommend bringing diet texture down to decrease choking risk and compensate for difficulties with oral bolus management. Makes sense, right? The problem is that we dont always think about the burden of texture modification for patients and their families.

When we bring texture down, particularly to a puree level, we need to add fluid. The additional fluids have the potential to dilute the foods caloric and protein densityparticularly for families who are trying to do this on their own without the benefit of commercial kitchens. In fact, texture-modified diets are often lacking in calories, protein, and micronutrients.^{5, 6}

3. Texture modifications often result in reduced intake.

Remember that diluting effect we were just talking about? In addition to reducing protein and caloric density, pureeing food also reduces flavor intensity.

Whats your first thought when you take the cover off that tray of pureed food? Texture-modified diets dont look appetizing and they dont taste good, so its not surprising that people eat less.

4. Dietary modifications have social consequences.

A while back, I ran into the wife of a former patient in the grocery store. We chatted a bit about how things were going at home, and she reported that her husband was doing well overall. He was following his diet modifications, using his strategies, and eating safely and comfortably.

Then she said something that has stayed with me to this day. Our meals are awfully quiet, though. Her husband had to eat slowly and carefully and concentrate on using his strategies. That meant little to no conversation. Dinner used to be our time to share our day, talk about the kids, make our plans, she said. Now theres no talking so he can concentrate on eating.

Food is an important social tool. Its how we celebrate holidays, get together with friends, maintain social relationships, and form new ones. When we recommend texture modifications or thickened liquids, we must remember that were also imposing a degree of social isolation.

So, what is the safest diet? Is it the one that reduces aspiration risk but increases the likelihood of dehydration? Is it the one that decreases choking risk but results in nutritional compromise?

Is dysphagia management more important than quality of life?

There are no easy answers to these questions. We owe it to our clients and their families to have frank discussions about the benefits and risks of the diets were recommending so that they can make informed choices because dietary modifications have consequences.