Being discharged from a hospital or rehabilitation facility can be an overwhelming process. This is especially true if your Speech-Language Pathologist (SLP) and medical team have prescribed a modified diet due to difficulty swallowing (dysphagia). Diet modifications are implemented to prevent choking and avoid food getting stuck in the mouth, throat, and/or esophagus (the food tube to the stomach). This article provides a comprehensive overview of the Dysphagia 2 diet, also known as the mechanically altered diet, offering guidelines, practical advice, and addressing common confusions.
Understanding Dysphagia
Dysphagia is a medical term that describes difficulty swallowing. It can affect people of all ages and can be caused by various factors, most often neurological diseases. During swallowing, more than 30 nerves and muscles must work together smoothly to move food from the mouth to the stomach. If these finely coordinated processes are disrupted, swallowing disorders can occur. Warning signs of dysphagia include an inability to swallow food properly and choking while eating.
The Importance of Dysphagia Diets
People with dysphagia have a very high chance of experiencing aspiration, which is the accidental ingestion of food or liquid into the bronchi and lungs. Aspiration can cause pneumonia and mediastinitis, with an increased risk of death. To avoid such problems, doctors prescribe dysphagia diets for patients. Following a dysphagia diet is the most important rule for a person with dysphagia. After all, if you follow it, the risk of aspiration and pneumonia disappears.
Introduction to Dysphagia Diet Levels
There are several levels of dysphagia diets to avoid bad consequences of this illness. It is a so-called modified diet that examines the patient’s medical and physical limitations. It may include various degrees of textural modification.
Level 1: Pureed Diet
The level 1 dysphagia diet is based on a puree-like consistency of food and is one of the most critical aspects of facilitating the swallowing process. Mashed vegetables, fruit puree, mashed meat or fish, and liquid or semi-liquid dishes are the main components. Besides, during this dysphagia diet, you should pay attention to the consistency of drinks. Research has shown that consuming liquids with a nectar-like consistency is better. These can be fruit juices without pulp, milkshakes, or fatty soups. But remember that it’s essential to avoid too-liquid drinks. So, at this level of the disease, you should consume purees of the right consistency.
Read also: Understanding Dysphagia Diets
Level 2: Mechanically Altered Diet
At this level, the diet is even more limited. After all, swallowing at this stage has more complications than at the first stage. Foods in the level 2 dysphagia should have a smooth, homogeneous consistency. It should be free of pieces. Such food helps prevent food from stopping in the esophagus and makes it easier to swallow. Also, dysphagia food consistencies should be thick, not spilling, and hold together well. It makes it easier to reduce the risk of aspiration. Homogenized foods and gel-like food can be helpful. And remember one important rule: avoid sticky or slippery foods. At this level of dysphagia diet, such food is dangerous.
Level 3: Advanced Texture Diet
The third level is the most severe. At this level of dysphagia, the swallowing function is severely impaired. So, the main idea of the diet is to avoid foods with a rough texture. Such products can get stuck or create obstructions in the esophagus. Boiled or steamed vegetables, lean meats, and soft fruits are recommended. Smashing the food well to a puree or cutting it into small particles is necessary.
What is the Dysphagia 2 Diet?
A Level 2 National Dysphagia Diet includes only moist, soft foods. Regular foods need to be changed to make them easier to chew and swallow. You need to have some chewing ability to eat these foods.
The Dysphagia Diet Level 2 fits into the NDD which consists of 4 levels. These levels are pureed (level 1), mechanical soft food or mechanically altered (level 2), advanced textures (level 3), and regular (level 4).
Dysphagia diet level 2 is not a smooth, consistent texture and can provide increased variety from a pureed diet. Food may look prettier on level 2 and the texture can provide mental stimulation that is missing from a pureed texture.
Read also: Safe Eating with Dysphagia
Key Characteristics of Level 2 Foods
- Moist: Mech soft foods should always have extra moisture added to them or on the side. This can be in the form of sauce (bbq, dressing, marinara, etc.), gravy, butter or any other option that tastes good with the food you are preparing.
- Soft: The easiest foods to swallow are typically soft that require minimal chewing.
- Textured, but not Homogenous: Level 2 foods are NOT homogenous. They have texture to them. They may be finely minced or chopped or soft cooked and smashed through a fork. The food can be added to a food processor and pulsed until the pieces are very small.
Preparing Foods for the Dysphagia 2 Diet
Preparing the right dysphagia food consistencies involves thoroughly crushing and modifying the texture of meals. Doctors consider texture-modified food for each person individually. Thus, the approach to preparing is different for everyone. But all doctors have the same goal, which is to achieve a consistency that allows patients to swallow food safely. Here's how to prepare food during a dysphagia diet:
- Smash the food to a smooth texture. You can use a food processor and a mixer for this.
- To make swallowing more manageable, divide your food into smaller portions. It will reduce the strain on your swallowing muscles.
- If the consistency is puree-like, you can add nutritious ingredients to improve nutrition. For example, add melted butter or sauce.
IDDSI Framework and Level 5
Your healthcare provider may also explain the International Dysphagia Diet Standardization Initiative (IDDSI). The IDDSI contains 8 levels, from the thinnest liquids and foods to the thickest. Foods from the National Dysphagia Diet level 2 diet are on IDDSI level 5.
The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness.
IDDSI Testing Methods are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature).
Liquids and the Dysphagia Diet
Your healthcare provider will tell you how thick your liquids need to be. This depends on your ability to swallow. For the IDDSI system, liquids are levels 0 through 4. Your healthcare provider will tell you if which liquids you can have. Liquids can be thickened, if needed, with thickeners, flour, cornstarch, or potato flakes. Foods that are liquid at room temperature should also be thickened.
Read also: Understanding Dysphagia Diets
Types of Liquids
- Thin liquids: These liquids take little or no effort to drink. Examples include water, non-fat milk, no-pulp juice, coffee, tea, and soft drinks.
- Slightly thick liquids: A little more effort is needed to drink these liquids.
- Nectar-thick liquids: It should take some effort to drink the liquid through a straw.
- Honey-thick liquids: Should be difficult to drink through a straw.
- Pudding-thick liquids: Need to be eaten with a spoon. You should not be able to drink them through a straw.
Foods to Avoid
You may be having difficulty with regular foods like meats, breads, dry-hard textures, and crumbly-dry foods. You may be having difficulty chewing to break down your foods to make them safe to swallow. Avoid foods that are dry or rough. It includes cookies, nuts, or bread. They cause aspiration very quickly.
Bread can cause an especially high risk for choking. Breads may feel soft, but they require a lot of chewing and oral processing. People tend to swallow bread before it is really processed in the mouth or “swallow-ready.” Bread can stay in a sticky ball in the throat and actually completely block your airway.
Tips for Eating with Dysphagia
- Divide meals into smaller portions and eat slowly.
- Change the consistency of some foods to make them easier to swallow.
- Avoid foods that are dry or rough.
The "Minced & Moist" Approach
You may do best with foods that are actually very soft and minced (chopped up to particle sizes of 4mm in width and no longer than by 15mm in length). Food should be moist and cohesive and NOT sticky or crumbly. You want foods to stay together in the mouth while you are chewing and forming a cohesive ball of food (bolus). If you are unable to chew up your food to make it swallow ready and if you get food stuck in your throat, a minced, moist, slippery, and cohesive food may be safer. When the food is minced small, it is already essentially swallow-ready. Small amounts may stay in a pocket in your throat if they are moist and cohesive. Alternating liquids and solids can be helpful. If you have dry mouth, you may need especially moistened foods to make them slide down better. You may need to get creative with sauces, gravies, and condiments. Applesauce, guacamole, hummus, and olive oils make good additions to add moisture in healthy ways.
Per the IDDSI recommendations, minced foods should be cut into food particle sizes of 4mm wide and no more than 15 mm long which can be easily swallowed without much chewing. Overall, this diet may be good to reduce fatigue that may occur in trying to eat a full regular meal. It is so important, however, to ensure that the food has added moisture built in to the recipe. When we mince up the food we are increasing the surface area. That can lead to these particles drying out. Therefore, the diet is called Minced & Moist for a reason.
The Problem with Older Terminology
The term “mechanical soft” is very old, as it came before any attempt in 2002 to standardize dysphagia diets into the NDD format. “Mechanical soft” has no approved or agreed upon definition, and each facility has their own “homegrown” descriptions. Some facilities lack of definitions and protocols all together! “Mechanical soft” has never been an official diet for people with dysphagia, and there is no evidence to support its use. Fortunately, now the International Dysphagia Diet Standardisation Initiative or IDDSI.org has standardized diet labels, descriptions, rationales for the level, and testing methods to place foods into individual levels.
Prior to IDDSI, we were never speaking the same language of dysphagia diets. It was the wild-west. If your facility is using any of these old diet terms, please ask them for an updated dysphagia diet framework that is standardized. Watch out for OLD terminology that has no clear definition.
Nutritional Considerations
Eat a variety of healthy foods. Eat 6 to 8 small meals each day to get enough calories and nutrients. You may need to take a multivitamin and mineral supplement if you do not get all the nutrients you need.
Importance of Moisture
When we mince up the food we are increasing the surface area. That can lead to these particles drying out. Therefore, the diet is called Minced & Moist for a reason. These old diet terms may have meant the same thing. We don’t know! The new diet label of “Minced & Moist” tells it all. The labels are very descriptive and easily translatable into all languages. Meats are ground-up or minced but with extra gravy or sauce. You want the pieces of meat to stay together in a cohesive ball. All foods within this diet can form into a moist-cohesive ball in your mouth and slide down your throat easily. (For examples: If you make risotto, make sure to have lots of sauce to prevent it from being crumbly. Moist and cohesive foods stay together while you try to chew them and move them around in your mouth.
A New Method of Text-Modified Food Management
To present a new method of text-modified food management for patients with dysphagia that integrates the idea of food exchange. On the basis of the recommended intake in the Expert Consensus, the design of the texture-modified food incorporates the concept of equivalent food exchange. Five categories of standard portions were established, the standard portion of staple foods, milk should be used instead of water during preparation, and carbohydrate components (dextrin) should be added so that each portion provides approximately 200 Kcal of energy. The standard portion of meat, protein components (90% whey) should be added to provide approximately 14 g of protein and 150 Kcal of energy per portion. Two types of standard snacks are recommended, each serving provides 250 Kcal of energy. Vegetables and fruits provide 70 Kcal and 90 Kcal of energy.
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