Dietary Modifications for Swallowing Issues

This is the fourth article in the series on Swallowing Issues. The following information is taken from the ALS Manual on Swallowingand Adjusting to Swallowing Disorders. Since Kennedy's Disease (SBMA) has bulbar related issues, there could come a time when swallowing and choking becomes an issue. I hope you find this information helpful.

On a personal note: Since excessive phlegm and swallowing issues appeared nine months ago, I have noticed a decline in my weight because I have to be careful what I eat and how I eat. Some meals take close to an hour to finish. 

Modified Diets and Mealtime Compensations

The purpose of modifying the consistency of food or liquids is to compensate for swallowing difficulties you might be experiencing. Altering the consistency to a more appropriate texture will help reduce energy expenditure during feeding, chewing, and swallowing. This will allow you to conserve energy throughout the day and experience less fatigue during mealtimes. Eating foods that require minimal chewing and moistening foods with sauces and gravies helps to reduce mealtime fatigue and eating duration.

In the throat, there are two sets of naturally occurring “pockets” that can catch foods, especially if the muscles involved in swallowing are impaired or weakened. Oftentimes this causes a sensation of “food sticking” or residue in the throat. You may feel the need to swallow an additional time in order to pass the residue and alleviate the sensation of food sticking. Moistening foods with sauces or gravies can serve as a lubricant and ease the passage of the food through your throat during swallowing and may reduce the likelihood that the materials will get stuck in the pockets in your throat.

Taking smaller bites and sips of food and liquid respectively may make it easier to control the food during the swallow. Additionally, alternating a sip of liquid every one to two bites of food may help to push the food materials down to your stomach. If medications become difficult to swallow whole, most can be crushed and taken with a tablespoon of yogurt/pudding or provided in liquid form (consult your physician or pharmacist for verification). Four different levels of modified diets are reviewed in Table 3.

Usually, individuals with safe swallowing do best eating a mechanical soft diet. This requires less chewing during the oral preparatory and oral phases of swallowing. Some people, however, may require a more restricted diet if their swallowing is deemed unsafe.

Coughing, choking, or difficulty swallowing may occur even with the use of mealtime compensations and dietary modifications. At that time, it may be beneficial to undergo a Modified Barium Swallow study to determine the safest diet consistency and safe swallowing recommendations.

Using Thickeners

The purpose of thickening agents or thickeners is to make regular liquids thicker (more viscous) and slow the flow rate of the liquid material during swallowing. Recall that swallowing occurs in less than 2 seconds. During this time over 26 pairs of muscles and 5 different cranial nerves need to coordinate and move in a complex pattern to protect the airway and direct the ingested materials towards the esophagus (food pipe) and away from the windpipe.

Adding a recommended thickening agent to liquids allows the swallowing system greater time to coordinate and protect the airway because the thicker liquids move at a slower speed, and in some individuals allows greater control of liquid material during swallowing (Table 4).

Like the levels of solid food modification, there are also different levels of thickening for liquids. Thickeners come in powder (starch based) and gel form and can be added to many of your favorite drinks to make them safer and more manageable. Your SLP will provide you with information on how to thicken your fluids to the recommended consistency. Some examples of brands of thickening agents are, Nestle® Resource Thicken Up, Simply Thick, and Thick-It.

Coughing or throat clearing during or directly after drinking liquids is a sign of aspiration.

Table 3: Dysphagia Diet Levels and Appropriate Foods to Eat

Food Diet Level	Examples of Food in This Level
Level 1: Pureed	• Pudding • Pureed oatmeal, breads, meats • Hummus • Pureed fruits and vegetables
Level 2: Mechanical Soft	• Scrambled eggs • Meatloaf • Well-cooked vegetables • Pancakes • Mashed potatoes • Canned/cooked soft fruits
Level 3: Advanced	• Bread slices • Muffins • Moistened cereals • Pasta, casseroles • Baked potatoes • Soft/ripe fruits • Fish
Level 4: Regular	No Food Avoidances or Restrictions

Table 4: Thickening Liquids

Nectar-Thickened Liquids	• Liquid is a consistency slightly thicker than water • Does not contain fruit nectar or nectar flavoring
Honey-Thickened Liquids	• Liquid resembles the consistency of honey at room temperature