ESPEN Congress Gothenburg 2011Finestone et al,2001,Vivanti et al, 2009) Fluid content from foods...
Transcript of ESPEN Congress Gothenburg 2011Finestone et al,2001,Vivanti et al, 2009) Fluid content from foods...
Dietary treatment in Dysphagia
Marjory Macleod
ESPEN Congress Gothenburg 2011
Assessment and treatment of dysphagia – What is the evidence?
Dietary treatment
in
Dysphagia
Marjory Macleod
Advanced Dietetic Practitioner
33rd Congress of Clinical Nutrition & Metabolism
ESPEN, Gothenburg 3-6th
September 2011
Outline of Presentation
Current dietary interventions
Current challenges
Strategies for improving Nutrition
Hydration
Ethical Issues
3 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011
Current Dietary Interventions: Management and Aims
Maximise health and well being
(Burton et al, 2011)
Minimise the risk of under-nutrition and dehydration (Flintsone et al, 2001)
Minimise risk of aspiration pneumonia (Perry & Love 2001)
Maintain oral nutrition (Burton et al, 2011)
Texture Modified Diets (TMD) are the foundation of dysphagia management
4 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011
Dietary management of dysphagia aims to:-
Current Dietary Interventions: Dietary Management
Texture modification (Rothenberg et al, 2007,Germain et al ,2006, Garcia & Chambers
2010)
Fluid modification (Butt and Lamb, 2005, Garcia et al, 2005)
Education and Training (Ginocchio et al, 2009, Dune, 2008, Garcia, 2008)
Interdisciplinary management (Dyer, 2003, Nazaro, 2009)
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Current Dietary Interventions: Texture Definitions
Rheological properties Objective measures (National Dysphagia Task Force ,2002)
Subjective evidence for
foods and fluids (UK food textures ,2011, UK fluid, 2002,
Irish Nutrition & Dietetic Institute, 2009,
Atherton et al, 2007)
Rheological properties Objective and sensory
methods (Wendin et al, 2010)
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Current Dietary Interventions: Modified Diets -Soft/Minced/Mashed
Examples:
flaked fish in sauce
stewed apples
custard
Foods easily mashed with a fork require
very little chewing.
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Current Dietary Interventions: Modified Diets - Thick and Thin Puree
Food that has been pureed or has puree texture. Can be poured.
Tinned tomato soup
Food that has been pureed or has puree texture.
Can hold its own shape on a plate, can be piped layered or molded. Can be eaten with a fork no chewing required.
Mousse
Smooth fromage frais
Sieved mashed potatoes 8
Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011
Current Challenges: Texture Descriptions
Soft
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Current Challenges: Variety
sweet potato,
potato powder
breadcrumbs
Bread and potato
can be adapted for
most TMD.
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Current Challenges: Snacks
Fruit
Nuts
Crisps
Sweets
Biscuits
Sausage rolls/pastries
Sandwiches
Cake
Cake and custard
Smooth yoghurt
Normal Snacks TMD
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Current Challenges: Preparation
Achieving smooth
puree
Moulded foods
Commercially
prepared TMD
foods 12 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011
Current Challenges: Separation
Some pureed foods are not stable!
Beef stew Carrot
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Current Challenges: Stabilisation
Food Products
Nutritional Products
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Current Challenges: Nutritional Inadequacies
Energy (Wright et al, 2005, Nowsen et al, 2003)
Protein (Wright et al, 2005, Nowsen et al, 2003)
Micronutrients (Lengyel et al, 2008)
Fluid (Finestone et al, 2001)
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Strategies: Nutrition - Food Fortification & Enriching Normal Diet
Small/frequent meals (Taylor & Barr, 2006)
Nutrient-dense meals (Lorefalt et al, 2005)
Mealtime assistance (Wright et al, 2008)
Food fortification (Adolphe et al, 2009)
Oral Nutritional supplement (Baldwin & Parson, 2004)
Enteral Nutrition (Nice 2011, Foley et al, 2008)
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Strategies: Nutrition - Food Fortification & Enriching Normal Diet
Protein
adding extra skimmed milk
powder to milk
Adding extra egg to mashed potatoes/puddings
Adding cheese to potatoes, soups and savoury dishes
Oral nutritional supplements especially for dysphagia
Energy
Adding double cream to soups,
mashed potatoes, sauces or desserts
Adding butter or margarine to vegetables, pasta, scrambled egg or in cooking
Adding jam/honey/syrup to breakfast cereals or puddings
Adding glucose or glucose polymers to drinks and foods
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Strategies: Fluid Texture Modification – Consistency Definitions
Consistency
UK / US
Description
Examples of naturally thick
fluids
Syrup
/ Nectar
Can be drunk through a
straw/cup if preferred. Leaves
thin coat on back of spoon
Strained thick
smoothie,
e.g. Innocent UK
Custard
/ Honey
Cannot be drunk easily through
a normal straw.
Can be drunk from a cup
Leaves thick coat on back of
spoon
McDonald’s
milkshake
Pudding
/Spoon
thick
Thickened to stage that needs
to be taken from a spoon
Thick custard
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Strategies: Fluid Texture Modification – Understanding Thickeners
STARCH
Particles expand like a balloon
capturing the fluid
Can be added to hot or cold
drinks
Less effective water binding
than gum
Starchy/grainy flavour and
texture
Metabolism and water
absorption in the small intestine
More prone to chemical
reactions with base fluids
Starch/grainy flavour and
texture**
GUMS
Interact with liquid by forming “nets”
that trap liquid
Hot liquids may need to be cooled
then re-heated
Excellent water binding properties.
More stable
Metabolism and water absorption in
the large intestine
Sensory perceptions slick/oily
flavour and texture**
**(Lotong et al, 2003, Pellier C, 1997, Matt et al,2006)
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Strategies: Fluid Texture Modification – Consistency Challenges
Achieving fluid viscosity (Goulding & Bakheit, 2000, Garcia et al, 2010)
Effect of time on viscosity (Garcia et al, 2008,2005, O’Leary et al 2011)
Saliva (Hanson et al,2011)
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Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011
Strategies: Fluid Texture Modification – Achieving Hydration
Patients requiring thickened fluids are less
likely to meet fluid requirements (Finestone et al,2001,Vivanti et al, 2009)
Fluid content from foods (Vivanti et al, 2009)
Standard protocols for mixing (Queensland Health Dietitians, 2007, Anderson, 2008)
Pre-thickened drinks (Wheelan, 2001)
Free fluid (Panther, 2005, Garon et al,1997)
Enteral Hydration (Vivanti et al, 2009)
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Beneficence Benefit and risks
Justice
Respect for autonomy Advanced decisions/
end of life wishes
Non-maleficence Avoidance of harm-
physical/psychosocial
Disease trajectory/
expected outcome
22 Dietary Treatment in Dysphagia, Marjory Macleod, 33rd Congress of Clinical Nutrition & Metabolism, ESPEN, Gothenburg 3-6th September 2011
Strategies: Ethical Issues
Summary
Evidence exists to support TMD
Nutrition and hydration is very often compromised
Consistency may not always be achieved.
MDT/Interdisciplinary management.
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References
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