Use of modified diets to prevent aspiration in oropharyngeal dysphagia: is current practice justified?

Abstract

BackgroundAlthough modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach.DiscussionThere is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners.ConclusionThe disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention.

Prevalence, Risk Factors, and Complications of Oropharyngeal Dysphagia in Older Patients with Dementia

“…Recipes were developed to meet patients' needs and to be reproducible at patients' homes, which may improve their clinical outcomes. A pilot study in our hospital suggested a strong therapeutic effect of these diets in OD older patients [14], though we also suggested that there was a need for better quality evidence regarding this promising intervention [43]. Recently, Hospital of Mataró and Fundation Furega developed a full set of menus based on the Mediterranean diet, with 2 textures and 2 caloric/proteic adaptations to increase compliance and the pleasure of eating [42].…”

Assessment and Management of Dysphagia in Acute Stroke: An Initial Service Review of International Practice

“…There is some evidence for the effectiveness of these behavioural interventions [22], but the modification of food/fluid, particularly with thickening agents, is not necessarily indicated as the preferred management by a number of authors. Although liquid bolus modification has been found to have beneficial effects on bolus flow [40], there is evidence that this impact is not consistent [41], and there are ongoing issues around the consistency of the thickening of liquid [42]. More recently, IDDSI [43] and the European Society for Swallowing Disorders [44] have published recommendations to standardize food consistencies.…”

Rheological, tribological and sensory attributes of texture‐modified foods for dysphagia patients and the elderly: A review

“…For these properties to be fully understood, advanced instruments such as texture analysers and rheometers need to be used. Measurements performed on these instruments can provide some insights that would be useful in the design of TMFs as opposed to instrumental swallowing assessment which are reported to bear little resemblance to eating in real life and swallowing ability at mealtimes (O’Keeffe, ).…”

“…Patients with OD are reported to be more likely to obtain a better dietary intake with TMFs rather than with normal foods (Sukkar et al , ). Conversely, a lack of evidence to support the significance of thickened fluids and TMFs in relation to the amount of dietary intake for adults with acute dysphagia has been reported (Foley et al , ; O’Keeffe, ). Kaneoka et al reported the lack of evidence for thickened fluids and TMFs in prevention of aspiration pneumonia in patients with chronic dysphagia (Kaneoka et al , ).…”