Managing Dysphagia Through Diet Modifications

Oropharyngeal swallowing hydrodynamics of thin and mildly thick liquids in an anatomically accurate throat-epiglottis model

Understanding the mechanisms underlying dysphagia is crucial in devising effective, etiology-centered interventions. However, current clinical assessment and treatment of dysphagia are still more symptom-focused due to our limited understanding of the sophisticated symptom-etiology associations causing swallowing disorders. This study aimed to elucidate the mechanisms giving rise to penetration flows into the laryngeal vestibule that results in aspirations with varying symptoms. Methods: Anatomically accurate, transparent throat models were prepared with a 45° down flapped epiglottis to simulate the instant of laryngeal closure during swallowing. Fluid bolus dynamics were visualized with fluorescent dye from lateral, rear, front, and endoscopic directions to capture key hydrodynamic features leading to aspiration. Three influencing factors, fluid consistency, liquid dispensing site, and dispensing speed, were systemically evaluated on their roles in liquid aspirations. Results: Three aspiration mechanisms were identified, with liquid bolus entering the airway through (a) the interarytenoid notch (notch overflow), (b) cuneiform tubercle recesses (recess overflow), and (c) off-edge flow underneath the epiglottis (off-edge capillary flow). Of the three factors considered, liquid viscosity has the most significant impact on aspiration rate, followed by the liquid dispensing site and the dispensing speed. Water had one order of magnitude higher aspiration risks than 1% w/v methyl cellulose solution, a mildly thick liquid. Anterior dispensing had higher chances for aspiration than posterior oropharyngeal dispensing for both liquids and dispensing speeds considered. The effects of dispending speed varied. A lower speed increased aspiration for anterior-dispensed liquids due to increased off-edge capillary flows, while it significantly reduced aspiration for posterior-dispensed liquids due to reduced notch overflows. Visualizing swallowing hydrodynamics from multiple orientations facilitates detailed site-specific inspections of aspiration mechanisms.

Nutritional and hydration interventions for people with dysphagia

Dysphagia (swallowing difficulties) is particularly common in older people and is associated with various health conditions. Dysphagia affects an individual's ability to eat and drink, and can have a significant effect on their clinical outcomes and quality of life. This article explores ways in which nurses can support people with dysphagia to minimise the effects of the condition and enhance their quality of life. The authors examine the role of commonly used strategies such as dietary texture modification and thickened fluids that aim to optimise nutrition and hydration. However, some of the management options for dysphagia do not have a strong evidence base, so nurses should consider whether any dietary restrictions are proportionate and ensure that their benefits outweigh the risks.

Weight Regain after Metabolic Surgery: Beyond the Surgical Failure

Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.

Quantitative Textural and Rheological Data on Different Levels of Texture-Modified Food and Thickened Liquids Classified Using the International Dysphagia Diet Standardisation Initiative (IDDSI) Guideline

Diet modification is a common compensation strategy to promote swallowing safety in patients with swallowing difficulties. The International Dysphagia Diet Standardisation Initiative (IDDSI) guideline provides qualitative descriptions on texture-modified food and thickened liquid. This study aimed to establish quantitative textural and rheological data on different IDDSI levels based on common Chinese ingredients and dishes. Textural and rheological properties of 226 samples of various food textures and 93 samples of various liquid consistencies were obtained using a texture profile analysis (TPA) and viscometer, respectively. The establishment of such quantitative data can be used for future texture-modified food product development and research purposes.

A Review of Factors Contributing to Adults' Adherence to Dysphagia Dietary Recommendations Through an Ecological Lens

PURPOSE

The purpose of this review was to identify the factors affecting adherence to dysphagia dietary recommendations, a necessary contributor to the effectiveness of this compensatory strategy.

METHOD

A rapid review of two electronic databases was conducted in April 2021. Studies were included based on the following criteria: (a) were empirical studies published in English, (b) included data from the adult population, and (c) measured adherence to dietary recommendations. The ecological model and the health belief model were used as frameworks during the analysis process.

RESULTS

The literature search resulted in 930 unique abstracts, of which 14 articles were included based on the final criteria. Across the literature, multiple factors were identified as having an influence on adherence, classified according to three unique levels: the individual (e.g., dissatisfaction), the caregiver (e.g., knowledge), and the environment (e.g., institutional policies and values).

CONCLUSIONS

Improving adherence to dysphagia dietary recommendations is crucial for the effectiveness of those recommendations. As suggested by the current review, increased adherence will require careful attention to the multiple levels of factors that likely play a role, acknowledging the multifaceted nature of this complex behavior. Furthermore, characterizing the multilevel factors that influence adherence can contribute to future theoretical models, which could help guide speech-language pathologists in their clinical practices.

Risk Factors for Dysphagia in Patients Hospitalized with COVID-19

Patients hospitalized with COVID-19 may be at risk for dysphagia and vulnerable to associated consequences. We investigated predictors for dysphagia and its severity in a cohort of patients hospitalized with COVID-19 at a single hospital center. A large level I trauma center database was queried for all patients hospitalized with COVID-19. Demographics, medical information associated with COVID-19, specific to dysphagia, and interventions were collected. 947 patients with confirmed COVID-19 met the criteria. 118 (12%) were seen for a swallow evaluation. Individuals referred for evaluation were significantly older, had a lower BMI, more severe COVID-19, and higher rates of intubation, pneumonia, mechanical ventilation, tracheostomy placements, prone positioning, and ARDS. Pneumonia (OR 3.57, p = 0.004), ARDS (OR 3.57, p = 0.029), prone positioning (OR 3.99, p = 0.036), ventilation (OR 4.01, p = 0.006), and intubation (OR 4.75, p = 0.007) were significant risk factors for dysphagia. Older patients were more likely to have more severe dysphagia such that for every 1-year increase in age, the odds of severe dysphagia were 1.04 times greater (OR 1.04, p = 0.028). Patients hospitalized with COVID-19 are at risk for dysphagia. We show predictive variables that should be considered when referring COVID-19 patients for dysphagia services to reduce time to intervention/evaluation.

Attitudes towards Freshly Made and Readily Prepared Texture-Modified Foods among Speech-Language Therapists, Dietitians, and Community-Dwelling Older Adults

Texture-modified foods (TMFs) are recommended for patients suffering from swallowing difficulties. Given the increasing aging population, the use of TMFs is on the rise. Research to date has focused on the nutritional value, malnutrition indices and healthcare practices in relation to TMFs, but the perception of these diets from a patient and healthcare practitioner perspective has received less consideration. This study explored how currently available TMFs (including Soft & Bite-Sized, Minced & Moist, and puree) are perceived by key stakeholders. Four types of TMFs were consumer tested: freshly made TMFs following foodservice recipes and three types of readily prepared TMFs (commercially packaged, sous-vide and hydrolysed). The selected samples were tested through five focus groups (including nine dietitians, seven speech-language therapists, and five community-dwelling older adults), which involved a sensory rating using a validated 7-point scale meal assessment tool and a semi-structured focus group discussion. Analysis was conducted using quantitative and qualitative approaches. Soft & Bite-Sized meals had significantly higher palatability ratings than others. Sous-vide meals were most suitable for Soft & Bite-Sized texture, while commercially packaged samples were most appropriate for minced moist and pureed meals. Three main themes emerged through content analysis: (1) palatability of TMFs, (2) perceived challenges with the currently available TMFs and (3) key differences in opinion between stakeholders. Freshly made TMFs were more appealing and tastier, whereas readily prepared (pre-cooked, packaged and require reheating) TMFs had a more consistent texture. The texture of all TMFs requires enhancement, particularly in pureed meals. Developing nutritious and safe TMFs for people with dysphagia requires the promotion of active insight exchange between dietitians and speech-language therapists.

A Comparison of Dietary Intake and Nutritional Status between Aged Care Residents Consuming Texture-Modified Diets with and without Oral Nutritional Supplements

Oral nutritional supplements (ONS) are high-energy and protein-rich nutrition drinks that are commonly prescribed to individuals with compromised nutritional status. Aged care residents requiring texture-modified diets are exposed to poor oral intake and malnutrition. This study aimed to investigate the dietary intake and nutritional status of residents consuming texture-modified diets with and without ONS. This multicentre cross-sectional study included 85 residents consuming texture-modified diets (86.0 ± 8.7 y; n = 46 requiring ONS and n = 39 without ONS). A one-day dietary record was completed using a validated visual plate waste estimation method. To determine the adequacy, nutrition intake was then calculated using FoodWorks (Xyris Ltd., Brisbane, Australia) and compared to the recommended dietary intake for Australia and New Zealand. The Mini-Nutritional Assessment Short Form was collected to assess nutritional status. Residents receiving ONS had significantly higher energy, protein, carbohydrates and fat intake than those who did not consume ONS (p < 0.05). No significant differences were found in saturated fat, fibre or sodium intake. With the administration of ONS, residents were able to meet their protein requirement but fell short of their energy and carbohydrates requirements. Both groups had inadequate fibre intake and a high saturated fat intake. A total of 48% of the residents were at risk of malnutrition and 38% were malnourished. Aged care residents requiring texture-modified diets are at high risk of malnutrition as a result of inadequate dietary intake. Administration of ONS may be an effective strategy to optimise nutrition intake.

Best Practice Recommendations for Dysphagia Management in Stroke Patients: A Consensus from a Portuguese Expert Panel

Dysphagia is frequent after stroke, and it increases the risk of respiratory infection, dehydration and malnutrition, resulting in worse outcomes. Different clinical guidelines present recommendations for the assessment and management of dysphagia in stroke patients in a scattered way. These best practice recommendations address seven clinical questions on the assessment and management of dysphagia in stroke patients, gathering the best-updated evidence. A systematic literature review using the PICO strategy was performed. The recommendations draft was then appraised by a multidisciplinary panel of experts (nutritionists, physiatrists, speech-language pathologists and rehabilitation nurses) in a total of 3 Delphi rounds. A minimum of 80% consensus was established, and the final version offers a total of 21 recommendations for use in clinical practice for stroke patients. These clinical recommendations are an overview of the most recent evidence combined with experts’ consensus and translated into clinically relevant statements. In implementing recommendations at the local level, health professionals should identify facilitators and barriers to evidence-based practice within their contexts and determine the best strategies to address local needs. Where the change is needed, initial and continuing training on all recommendations is essential and relevant.

Sensory Profiling and External Preference Mapping of Pre-Thickened Water Products for Dysphagia

Dysphagia is a dysfunction of the swallowing system and thickened beverages are widely prescribed as a treatment. The objective of this study was to determine the sensory characteristics of pre-thickened water products and determine sensory drivers of liking for those types of products. Pre-thickened water products (two starch-based and two gum-based) were tested in both nectar and honey thick versions. Based on product availability, one product was neutral water, and the others were water with lemon flavoring added. The sensory characteristics of the products were evaluated with a highly trained descriptive panel, and the viscosity of the products was evaluated with both the Bostwick consistometer and the line spread test. Previously published consumer data was used to determine preference maps with the descriptive data. All lemon-flavored products had similar flavor characteristics, except the Thick & Easy Clear that had a less lemon-related flavor than the others. After excluding the lemon-related flavor characteristics, all pre-thickened products had similar “base flavor” notes, no matter whether the products were starch-based or gum-based. This contrasts with literature, which reports differences in flavor of thickened beverages prepared using thickening agents. The thickness of the products varied between nectar and honey thickness, but also varied among products that were stated to be at the same level of thickness. External preference mapping showed that both lemon-related flavor and a thinner beverage texture are potential drivers of consumers acceptance of the product, which was expected based on other studies. In conclusion, pre-thickened beverages are good alternatives for self-mixed thickening agents but a standard for thickness should be agreed on and used by manufacturers.

Using Diet to Treat Diseases of Esophagus: Back to the Basics

The esophagus plays a crucial role in oral nutrition and digestive pathophysiology. In addition, diet is now considered an important primary or augmentative therapy in several esophageal disease states. This review highlights common dietary therapies used in treating diseases of the esophagus as well as the underlying data that support such practices. Specially, diet and its relationship to swallowing dysfunction, motility disorders, malignancies, and inflammatory mucosal diseases such as gastroesophageal reflux disease and eosinophilic esophagitis is explored.

Formulation and Cost-Effectiveness of Fluid Gels as an Age-Appropriate Dosage Form for Older Adults with Dysphagia

Dysphagia is associated with increased dependency and treatment costs, whereby patients resort to extemporaneous compounding that may further increase the number of adverse events and medical errors. In the management of dysphagia, increasing the bolus viscosity of medication such as fluid gels can be practiced. This study aimed to prepare and characterize the fluid gels as well as to estimate the cost of using fluid gels and compare it to the conventional practice of extemporaneous preparation of thickened liquid. Fluid gels were formulated using gellan gum and determined for physicochemical characteristics and in vitro drug release profile. The cost-based price of the fluid gel was estimated and compared to the cost of administering standard medication as well as administering thickened liquid using thickening powder. Fluid gels exhibited good physicochemical properties with the viscosity within nectar and honey consistency. A similar dissolution profile to the reference was observed for the 0.5% w/v gellan gum fluid gel and exhibiting the Higuchi release model. The price for 100 mL unit of 50 mg/mL paracetamol/acetaminophen and 20 mg/mL ibuprofen fluid gel was estimated to be about USD2.30 and USD2.37, respectively. A dose of 1000 mg paracetamol and 400 mg ibuprofen fluid gel was estimated to be about USD0.46 and USD0.47, respectively, which is lower than the cost of administering the same dose using extemporaneous thickened liquid. Fluid gels could be a cost-effective formulation for delivering medication in patients with dysphagia and can be developed on a profitable scale.

Olfactory Stimulation Successfully Improves Swallowing Function of Aged Rats through Activating Central Neuronal Networks and Downstream DHPR-RyR-mediated Neuromuscular Activities

Presbyphagia is age-related changes in swallowing function, which imposes a high risk of aspiration in older adults. Considering olfactory stimulation (OS) can influence behavioral activities by modulating neuronal excitability, the present study aims to determine whether OS could improve the swallowing function of aged rats through activating the central neuronal networks and downstream muscular activities participated in the control of swallowing. Aged male Wistar rats received OS by inhaling a mixture of plant-based volatile molecules twice a day for 12 days were subjected to functional magnetic resonance imaging (fMRI) and c-fos, choline acetyltransferase (ChAT) immunostaining to detect the neuronal activities of the orbitofrontal cortex (OFC) and medullary nuclei engaged in swallowing control, respectively. The functional effects of OS on downstream pharyngeal muscle activity were examined by evaluating the dihydropyridine receptor-ryanodine receptor (DHPR-RyR) mediated intra-muscular Ca2 + expression, and analyzing the amplitude/frequency of muscle contraction, respectively. In untreated rats, only moderate signal of fMRI and mild c-fos/ChAT expression was detected in the OFC and medullary nuclei, respectively. However, following OS, intense signals of fMRI and immunostaining were clearly expressed in the orbitofronto-medullary networks. Functional data corresponded well with above findings in which OS significantly enhanced DHPR-RyR-mediated intra-muscular Ca2 + expression, effectively facilitated a larger amplitude of pharyngeal muscle contraction, and exhibited better performance in consuming larger amounts of daily dietary. As OS successfully activates the neuromuscular activities participated in the control of swallowing, applying OS may serve as an effective, easy, and safe strategy to greatly improve the swallow function of aging populations.

How Accurate Are the Consistency Labels Used in Hong Kong? An Objective Study of the Consistency of Thickened Liquids Using International Dysphagia Diet Standardisation Initiative and Consistometric Measurements

OBJECTIVES

The present study objectively examined the consistency (thickness) of labels that are used in Hong Kong for the population with dysphagia using an International Dysphagia Diet Standardisation Initiative (IDDSI) flow test and Bostwick consistometric measurements.

METHODS

Liquids were prepared by thickening water to achieve 4 consistency labels (slightly thick, mildly thick, medium thick, and extra thick) according to manufacturer's instructions, employing 2 types of thickening products that are used in Hong Kong, i.e., starch based and gum based. For each consistency label prepared using each thickening product, the IDDSI flow test and consistometric measurements were obtained and compared.

RESULTS

The results showed that the actual thickness of liquids was highly dependent on the type of thickener (starch based vs. gum based) used. Thickened liquids prepared using the starch-based thickener were generally thinner than the actual value at a lower concentration.

CONCLUSION

Though prepared strictly following the manufacturer's instructions, the thickened liquids fail to faithfully correlate with the standardized norms established according to the IDDSI framework and the objective consistometric measurement using a Bostwick consistometer. Therefore, caution must be exercised when administering a thickened diet following the manufacturer's instructions for patients with dysphagia.

Oral Health Disorders in Parkinson's Disease: More than Meets the Eye

Despite clinical evidence of poor oral health and hygiene in Parkinson’s disease (PD) patients, the mouth is often overlooked by both patients and the medical community, who generally focus on motor or psychiatric disorders considered more burdensome. Yet, oral health is in a two-way relationship with overall health—a weakened status triggering a decline in the quality of life. Here, we aim at giving a comprehensive overview of oral health disorders in PD, while identifying their etiologies and consequences. The physical (abnormal posture, muscle tone, tremor, and dyskinesia), behavioral (cognitive and neuropsychiatric disorders), and iatrogenic patterns associated with PD have an overall detrimental effect on patients’ oral health, putting them at risk for other disorders (infections, aspiration, pain, malnutrition), reducing their quality of life and increasing their isolation (anxiety, depression, communication issues). Interdisciplinary cooperation for prevention, management and follow-up strategies need to be implemented at an early stage to maintain and improve patients’ overall comfort and condition. Recommendations for practice, including (non-)pharmacological management strategies are discussed, with an emphasis on the neurologists’ role. Of interest, the oral cavity may become a valuable tool for diagnosis and prognosis in the near future (biomarkers). This overlooked but critical issue requires further attention and interdisciplinary research.

Texture-Modified Diets, Nutritional Status and Mealtime Satisfaction: A Systematic Review

While the association between dysphagia and malnutrition is well established, there is a lack of clarity regarding the nutritional status and mealtime satisfaction of those consuming texture-modified diets (TMDs). This systematic review summarises and critically appraises the nutritional status and mealtime satisfaction of adults consuming TMDs. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE and Scopus. Nutritional status, mealtime satisfaction and costs were identified as primary outcomes. Eligible studies were grouped according to outcome measurement. In total, 26 studies met the inclusion criteria. Twenty studies evaluated the nutritional status by weight change or using malnutrition screening tools and found the consumption of TMDs correlated with weight loss or malnutrition. Nine studies evaluated mealtime satisfaction, with two reporting poor satisfaction for people on thickened fluids (TFs). Nutrition intervention through adjusting texture and consistency and nutrition enrichment showed positive effects on weight and mealtime satisfaction. The majority of the studies were rated as 'neutral' quality due to the limited number of experiments. TMD consumers had compromised nutritional status and poor mealtime satisfaction. More research input is required to identify promising strategies for improving the nutritional status and mealtime satisfaction of this population. Food services need to consider texture, consistency and fortification in designing menus for people on TMDs to avoid weight loss and malnutrition, and to enhance mealtime enjoyment.

Impact of the Chin-Down Posture on Temporal Measures of Patients With Dysphagia: A Pilot Study

Purpose The chin-down position is a commonly prescribed posture by health care professionals to alleviate the symptoms of dysphagia. Yet, how the technique influences swallowing physiology lacks clarity. Our goal was to examine the impact of the postural technique on patients with various medical conditions and swallowing impairments. Method Temporal and functional measures were examined with videofluoroscopy in the chin-down and neutral head position on 15 patients. Also, timing differences between head positions were examined to determine the presence of improvement during the chin-down posture. Results The primary finding was chin-down posture swallows prolonged the elapsed time between when the prematurely spilled bolus entered the pharynx relative to swallow onset compared to the neutral head position (p = .006). Also, no improvement in airway protection was found when performing the postural technique. Conclusions The chin-down posture may benefit patients with specific swallowing impairments. However, the general use of the technique for all patients who experience swallowing difficulty might be negligent and could potentially have adverse or no effect on patient outcomes. Future studies examining patients with the same pathophysiology are needed to understand the benefit of the chin-down posture based on swallowing impairment.

Texture-Modified Food for Dysphagic Patients: A Comprehensive Review

Food texture is a major food quality parameter. The physicochemical properties of food changes when processed in households or industries, resulting in modified textures. A better understanding of these properties is important for the sensory and textural characteristics of foods that target consumers of all ages, from children to the elderly, especially when food product development is considered for dysphagia. Texture modifications in foods suitable for dysphagic patients will grow as the numbers of elderly citizens increase. Dysphagia management should ensure that texture-modified (TM) food is nutritious and easy to swallow. This review addresses how texture and rheology can be assessed in the food industry by placing particular emphasis on dysphagia. It also discusses how the structure of TM food depends not only on food ingredients, such as hydrocolloids, emulsifiers, and thickening and gelling agents, but also on the applied processing methods, including microencapsulation, microgels as delivery systems, and 3D printing. In addition, we address how to modify texture for individuals with dysphagia in all age groups, and highlight different strategies to develop appropriate food products for dysphagic patients.

Nutritional Intake and Meal Composition of Patients Consuming Texture Modified Diets and Thickened Fluids: A Systematic Review and Meta-Analysis

Texture-modified diets (TMDs) play an important role in ensuring safety for those with dysphagia but come with risks to nutrition and quality of life. The use of TMDs has been addressed with the increasing prevalence of dysphagia in previous decades. However, there is limited literature that investigates the nutrition perspectives of TMD consumers. This review summarises the nutrition outcomes of adults consuming TMDs and thickened fluids (TFs) and identifies the limitations of TMD and TF productions. A systematic database search following PICO criteria was conducted using Cochrane Central (via Ovid), MEDLINE, CINAHL, EMBASE, and Scopus databases. Nutrition intake, meal consumption, adequacy, and meal composition were identified as relevant outcomes. 35 studies were included for analysis. Consumption of TMDs demonstrated a poorer intake compared to regular diets, in particular significant in energy and calcium. Meta-analysis of mean differences showed favourable effects of shaped TMDs on both energy (−273.8 kJ/d; 95%CI: −419.1 to −128.6, p = 0.0002) and protein (−12.4 g/d; 95%CI: −17.9 to −6.8, p < 0.0001) intake compared to traditional cook-fresh TMDs. Nutrition intake was compromised in TMD consumers. Optimisation of nutrition intake was achievable through enrichment and adjusting meal texture and consistency. However, the heterogeneity of studies and the missing verification of the consistencies lead to difficulty in drawing conclusions regarding particular texture or intervention.

Effects of texture properties of semi-solid food on the sensory test for pharyngeal swallowing effort in the older adults

Background

Increasing viscosity can reduce the risk of aspiration into the airway, but excessively thickened food may require more force and effort. We assumed that semi-solid foods with similar viscosities will behave differently in the oropharynx and there might exist the possibility that properties other than viscosity may have clinical relevance. This study aimed to find out the texture of semi-solid foods that affects the effort of pharyngeal swallow in the older adults.

Methods

Nine kinds of semi-solid foods not requiring mastication were selected for texture profile analysis (TPA), and included whipped cream, mayonnaise, soft tofu, mango pudding, boiled mashed pumpkin, boiled mashed potatoes, boiled mashed sweet potatoes, red bean paste, and peanut butter. Hardness, adhesiveness and cohesiveness of each food were measured three times by using the rheometer. A blinded sensory test using a 9-point hedonic scale was also conducted in eighteen older adults people to investigate how much effort was required to swallow food, and how much of the food remained in the pharynx after swallowing. The correlation between texture and sensory outcome was statistically analyzed.

Results

Foods that belonged to the same viscosity category showed different texture values, and the participants also rated different scores respectively. Only adhesiveness among three properties was significantly correlated with the sensory test. (r = 0.882, p = 0.002 for difficult to swallow, r = 0.879, p = 0.002 for sense of residue).

Conclusions

Adhesiveness was the most important property of the semi-solid foods, requiring most efforts in pharyngeal swallow in the older adults. If we select and provide food having low adhesiveness value in the same viscosity category, there might be the possibility to make it easier to swallow in older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01890-4.

Ingredients of Jelly Products Affect Aspiration-Related Pulmonary Inflammation; in an Animal Study

Diet modification is an important intervention in the management of patients with dysphagia. Food entering the airway, same as oral bacterium, causes pulmonary inflammation; therefore, the elucidation of inflammatory responses to different foods is important. This study aimed to investigate the differences in the severity of inflammatory response induced by intratrachial injection of foods with different nutritional components. Two jelly products, the one containing only carbohydrates (KURIN jelly: Isocal Jelly KURIN^®) and the other containing carbohydrates, proteins, and lipids (HC jelly: Isocal Jelly HC^®), were prepared. These jelly products (dilution with saline, 50% volume/volume) and saline, as control, were intratracheally administered to Sprague-Dawley rats at a dose of 1 ml/kg (KURIN group (n = 15), HC group (n = 15), Saline group (n = 15)). At 1, 2 and 7 days after administration, lungs were harvested and histological analysis was performed. The severity of induced inflammation was evaluated using the Acute Lung Injury (ALI) score with hematoxylin-eosin staining, and the expression of IL-1β, IL-6 and TNF-α, markers of airway inflammation, were observed with immunostaining. The ALI score in the HC jelly group was significantly higher than the KURIN jelly group and the Saline group (P < 0.01) at 1 and 2 days after administration, while the ALI score in the KURIN jelly group was higher than Saline group only at 2 day after administration. Numerous positive cells for IL-1β, IL-6 and TNF-α were observed only in the HC jelly group at 1 and 2 days after administration. There were no significant histological differences between the three groups at 7 days after administration. Our data suggests that the severity of inflammation caused by aspiration differs depending on the ingredients of the foods, and the nutrients contained in foods might be considered in dietary management for the patients with dysphagia.

A favorable effect on nutritional status of 12-week tailored texture-modified sous-vide cooking meals in institutionalized elderly women with oropharyngeal dysphagia: an intervention study

BACKGROUND

Dysphagic patients are not always able to meet their energy, micro and macronutrients needs for various causes and therefore are at high risk of malnutrition. The aim of the present study was to evaluate the effectiveness on satisfaction of the meal (by a 10-cm visuo-analogical scale), food intake (by visual estimation of food waste), nutritional status (anthropometric measures, mini nutritional assessment [MNA], vitamin D, B12, folic acid), functional (handgrip) and blood chemistry metabolic parameters of a tailored texture-modified sous-vide cooking meals (TTMSVC), well balanced in macro and micronutrients, in elderly women suffering from oropharyngeal dysphagia at long-term care facilities.

METHODS

A 12-week intervention study was conducted on female elderly subjects affected by oropharyngeal dysphagia of level 3-5. The treated group received TTMSVC with the consistencies standardized using viscosimeter (5000-10000 mP/s). The control group maintained pureed hospital diet.

RESULTS

50 subjects, 25 in treatment group and 25 in control group, with mean±SD age 89.12±4.18 and mini mental state examination (MMSE) 20.58±1.63 were enrolled. The treatment and control groups were similar at baseline. The changes over time between the two groups showed significant differences for food intake, meal appreciation, Body Mass Index (BMI), calf circumference, arm circumference, MNA, prealbumin, albumin, folic acid, vitamin D, ionized calcium, C-Reactive Protein (CRP), Tumor Necrosis Factor (TNF-α), handgrip. Significant positive correlations were observed in the treatment group between the meal appreciation and prealbumin and vitamin D.

CONCLUSIONS

This study demonstrated that elderly dysphagic women at long-term care facilities can eat better and increase nutritional status by eating 12-week tailored appealing TTMSVC.

Frontline Interventions: Considerations for Modifying Fluids and Foods for Management of Feeding and Swallowing Disorders Across the Life Span

Purpose Individuals with dysphagia across the age continuum may require dietary modifications of fluids and foods for safe and adequate oral intake. Considerations of this frontline intervention are presented in this clinical forum dedicated to the discussion of dysphagia. Method This clinical focus article reviews the technical challenges of providing modified fluids and foods across the life span as well as the literature specific to its origins, efficacy, challenges and solutions to standardization, and the methods for ensuring quality service delivery. Conclusion Dietary modification is an often-used method of dysphagia management that presents unique challenges to the clinician for successful application. Speech-language pathologists in clinical practice across all settings must remain dedicated to evidence-based practice as they navigate service delivery of this strategy to individuals with dysphagia across the life span.

Safety and Effectiveness of Early Oral Hydration in Patients After Cardiothoracic Surgery

BACKGROUND

Patients fast after cardiothoracic surgery because of concerns for nausea, vomiting, dysphagia, and aspiration pneumonia; fasting, however, causes thirst, a distressing symptom. To our knowledge, no studies exist to guide hydration practices in this population.

OBJECTIVE

To determine the effect of early oral hydration on adverse events and thirst in patients after cardiothoracic surgery.

METHODS

This study applied a prospective 2-group design in which 149 patients from an 18-bed cardiothoracic intensive care unit were randomized to either usual care (a 6-hour fast) or early oral hydration after extubation. The research protocol involved nurses evaluating patients' readiness for oral hydration and then offering them ice chips. If patients tolerated the ice chips, they were allowed to drink water 1 hour later.

RESULTS

Most patients (91.3%) had undergone coronary artery or valve surgery, or both. Demographic and clinical variables were similar in both groups. No significant between-group differences were found for the incidence of nausea, vomiting, or dysphagia, and no aspiration pneumonia occurred. Significantly more patients with a high thirst level were in the usual care group (81.2%) than in the early oral hydration group (56.5%; P = .002, r2 test). After adjustment for demographic and clinical variables by using logistic regression, early oral hydration was independently and negatively associated with a high thirst level (odds ratio, 0.30 [95% CI, 0.13-0.69]; P = .004).

CONCLUSION

This research provides new evidence that oral hydration (ice chips and water) soon after extubation is safe and significantly reduces thirst in particular patients.

Postintubation Dysphagia During COVID-19 Outbreak-Contemporary Review

The COVID-19 is a global pandemic. Its rapid dissemination and serious course require a novel approach to healthcare practices. Severe disease progression is often associated with the development of the Acute Respiratory Distress Syndrome and may require some form of respiratory support, including endotracheal intubation, mechanical ventilation, and enteral nutrition through a nasogastric tube. These conditions increase the risk of dysphagia, aspiration, and aspiration pneumonia. The data on the incidence and risks of dysphagia associated with COVID-19 are not yet available. However, it is assumed that these patients are at high risk, because of respiratory symptoms and reduced lung function. These findings may exacerbate swallowing deficits. The aim of this review is to summarize available information on possible mechanisms of postintubation dysphagia in COVID-19 patients. Recommendations regarding the diagnosis and management of postintubation dysphagia in COVID-19 patients are described in this contemporary review.

A Comparison of Behavior of Transitional-State Foods Under Varying Oral Conditions

Transitional foods are under-utilized in the adult population as they may provide an opportunity to optimize eating pleasure and nutrition for individuals on a modified texture diet. Yet, little is known about the behavioral properties of transitional foods and no research to date has explored the dissolution of known transitional foods in adults. This study aimed to understand the extent of dissolution of five transitional snacks items in relationship to time, tongue pressure, and amount of saliva. Thirty individuals ages 50 to 88 participated in this study (10 with diagnosed xerostomia). The foods tested included shrimp chips, Baby Mum Mums, the EAT bar, and the Savorease cracker with and without dip. Each test food was placed in the mouth for 5 s or 12 s with or without tongue pressure and then expectorated. Benchtop preparation via the International Dysphagia Diet Standardisation Initiative (IDDSI) protocol was also completed. An IDDSI fork pressure test was then performed on all samples. Significant differences between snacks were found in degree of dissolution, with Savorease crackers dissolving more consistently than all others and Baby Mum Mums dissolving least frequently than all others. Tongue pressure positively influenced the dissolution of some foods, particularly those with decreased rates of dissolution. Differences also existed between testing conditions. Overall, there was a wide variability in degree and speed of dissolution across different transitional foods and testing methods. These findings support the need for individual testing to explore post-oral processing consistency when determining the clinical utility of transitional foods.

Suitability of food in a rehabilitation hospital for patients with neurologic dysphagia

Texture-modified food is a common strategy in dysphagia management for increasing safety of swallowing. It is essential for the patient to receive the prescribed diet based on clinical and instrumental examination of swallowing in order to be able to benefit from rehabilitation and avoid complications. Variations in terminology and definitions regarding texture-modified food and liquids demonstrate the need for international standardized terminology. We aimed to assess suitability of texture-modified diets used at a rehabilitation hospital in terms of the International Dysphagia Diet Standardization Initiative guidelines. A texture-modified main dish was analyzed for 5 days (15 samples of pureed and 10 samples of minced texture) at lunch time by 2 trained assessors using International Dysphagia Diet Standardization Initiative-recommended testing methods. The majority of pureed and minced food samples did not suit the comparable International Dysphagia Diet Standardization Initiative levels. The results underline the need for implementing the International Dysphagia Diet Standardization Initiative guidelines in order to provide an appropriate texture-modified diet for patients with neurogenic dysphagia and support dysphagia management within inpatient rehabilitation.

Dysphagia predicts greater weight regain after Roux-en-Y gastric bypass: a longitudinal case-matched study

BACKGROUND

Weight regain (WR) after gastric bypass is thought to be multifactorial in etiology with behavioral, neurohormonal, and anatomic features playing a role. A significant proportion of patients complain of dysphagia after Roux-en-Y gastric bypass (RYGB) and may have difficulty tolerating solid foods. Our observations suggest that this subgroup of patients compensate for esophageal symptoms by increasing their intake of calorie-dense liquid and soft foods, which can precipitate WR.

OBJECTIVES

We hypothesize that dysphagia predisposes to greater WR than seen in individuals without swallowing symptoms.

SETTING

Single tertiary care referral center.

METHODS

This was a matched-cohort study analysis of prospectively collected data on RYGB patients. All individuals who underwent high-resolution manometry after RYGB were enrolled. Controls were identified via a retrospective analysis of a prospective institutional database. Patients who developed dysphagia were matched with controls, from a subset of 450 eligible controls. Each patient with dysphagia was matched with 4 control patients based on age, body mass index, and time since surgery. WR was defined as an increase of ≥15% from nadir. Χ² and t test (or Wilcoxon rank sum, if applicable) were used for bivariable analysis. Multiple logistic and linear regression were used for multivariable calculations.

RESULTS

Forty-nine patients with dysphagia were included. After matching, there were 196 RYGB controls that did not have swallowing or esophageal symptoms. Controls had similar baseline demographic characteristics and initial weight loss compared with dysphagia cases. WR was common in both groups; however, total WR in those with dysphagia was greater than controls (15.7 versus 11.4 kg, respectively; P = .02). In addition, percent WR in those with dysphagia exceeded that seen in controls (mean 37% versus 25%, P = .003), and more individuals regained 15% of nadir weight (55% of dysphagia cases versus 38% of controls, P = .03) when adjusting for baseline body mass index, age at surgery, and race. Dietary histories suggested that, among those with dysphagia, patients with partial or complete conversion to soft or liquid calories had greater WR than those who adhered to the solid food diet.

CONCLUSIONS

Dysphagia is a risk factor for WR post-RYGB. This is likely due to increased intake of soft or liquid foods that are tolerable in these patients but lead to a positive energy balance and accelerated WR. More than half of patients with dysphagia after RYGB regain significant weight. Screening for and aggressively managing dysphagia in patients before or after RYGB may be warranted to prevent significant WR.

Impact of the Consistency of Food Substances on Health and Related Factors of Residents in Welfare Facilities for Seniors in Japan

The aim of this study is to determine the effect of food consistency on health and related factors among residents in welfare facilities for seniors (n = 227; mean age, 86.2 ± 8.0 years; 78.9% female). Residents who ate regular food had a lower incidence of fever during the 3-month period (p < 0.001) and consumed more calories (1325.97 ± 220.2 kcal) than those who ate chopped (1125.0 ± 256.8 kcal), paste (1122.0 ± 288.5 kcal), and gastric tube food (812.5 ± 150.7 kcal) (p < 0.001). Modifying a resident’s food by making it softer and finer did not reduce the incidence of choking. Logistic regression analysis (backward elimination method) revealed four factors related to eating regular food: vitality index, appetite, number of remaining teeth, and choking frequency. Causal relationships were not obtained because this was a cross-sectional study. The findings of this study suggest that a regular consistency of food positively influences the health of older individuals.

Nutrition Care Management Practices for In-Patients with Dysphagia in Korean Clinical Settings

This study aimed to examine nutrition care management for in-patients with dysphagia and to evaluate knowledge on nutrition care related to dysphagia among dietitians in clinical settings. A total of 554 questionnaires were distributed to dietitians at hospitals located in Seoul and Gyeonggi Province in Korea, and 147 responses were used for data analysis after excluding responses with significant missing data. Study participants worked at general hospitals (37.2%), long-term care hospitals (24.3%), hospitals (19.2%), and tertiary hospitals (11.5%). Prior education and training related to dysphagia was received by 69.9% of the respondents. The percentage of hospitals that had diet guidelines for dysphagia was 68.0%. Dysphagia diets of 2 levels and 3 levels were provided in 55.1% and 34.7% of the hospitals, respectively. Overall 74.7% of the dietitians responded that they provided information on dysphagia diets to in-patients and caregivers, but only 45.7% of dietitians did so in the long-term care hospitals. Among the respondents who used commercial thickening agents, 77.2% used only one type of commercial thickening agent. Patients or caregivers (75.7%) or nurses (34.5%) were reported to modify viscosity of liquid. Dietitians showed low levels of knowledge on nutrition care related to dysphagia (a mean of 5.14 based on possible scores from 0 to 10 points). To promote nutritional consumption and prevent malnutrition and aspiration, hospitals need the standardized diet guidelines, and dietitians should improve their expertise in nutritional care for patients with dysphagia.

Prevalence and Characteristics Associated with Modified Texture Food Use in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project

Purpose: To describe the prevalence and characteristics of modified-texture food (MTF) consumers when applying standard diet terminology.

Methods: Making the Most of Mealtimes (M3) is a cross-sectional multi-site study including 32 long-term care (LTC) homes located in 4 Canadian provinces. Resident characteristics were collected from health records using a defined protocol and extraction form. Since homes used 67 different terms to describe MTFs, diets were recategorized using the International Dysphagia Diet Standardization Initiative Framework as a basis for classification.

Results: MTFs were prescribed to 47% (n = 298) of participants (n = 639) and prevalence significantly differed among provinces (P < 0.0001). Various resident characteristics were significantly associated with use of MTFs: dysphagia and malnutrition risk, dementia diagnosis, prescription of oral nutritional supplements; lower body weight and calf circumference; greater need for physical assistance with eating; poor oral health status; and dependence in all activities of daily living.

Conclusions: This is the first study that used a diverse sample of LTC residents to determine prevalence of MTF use and described consumers. The prevalence of prescribed MTFs was high and diverse across provinces in Canada. Residents prescribed MTFs were more vulnerable than residents on regular texture diets. These findings add value to our understanding of MTF consumers.

Modifying the consistency of food and fluids for swallowing difficulties in dementia

BACKGROUND

People with dementia can have feeding and swallowing difficulties (dysphagia). Modification of the consistency of food or fluids, or both, is a common management strategy. However, diet modification can affect quality of life and may lead to dehydration and malnutrition. Evidence on the benefits and risks of modifying food and fluids is mandatory to improve the care of people with dementia and dysphagia.

OBJECTIVES

To determine the effectiveness and adverse effects associated with modifying the consistency of food and fluids in improving oral intake and eliminating aspiration in adults with dysphagia and dementia.

SEARCH METHODS

We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), the Cochrane Library, MEDLINE via Ovid SP, Embase via Ovid SP, PsycINFO via Ovid SP, CINAHL via EBSCOhost, LILACS via BIREME, ClinicalTrials.gov and the World Health Organization (WHO) Portal on 9 May 2018. We also checked the reference lists of relevant articles to identify any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs published in any language that measured any of the outcomes of interest. We included trials with adults with a clinical diagnosis of dementia with symptoms and signs of dysphagia confirmed on instrumental assessment. We included participants with all types, stages and severities of dementia. Control groups received either no intervention or interventions not involving diet modification or modification to sensory properties of food.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed for inclusion all potential studies identified. Data were extracted independently along with assessment of methodological quality using standard Cochrane methods. We contacted study authors for additional unpublished information.

MAIN RESULTS

No trials on modification of food met the inclusion criteria. We included two studies that examined modification to fluids. Both were part of the same large multicentre trial and included people with dementia and people with or without dementia and Parkinson's disease. Participation in the second trial was determined by results from the first trial. With unpublished data supplied by study authors, we examined data from participants with dementia only. The first study, a cross-over trial, investigated the immediate effects on aspiration of two viscosities of liquids (nectar thick and honey thick) compared to regular liquids in 351 participants with dementia using videofluoroscopy. Regular liquids with a chin down head posture, as well as regular liquids without any intervention were also compared. The sequence of interventions during videofluoroscopy may have influenced response to intervention. The second study, a parallel designed RCT, compared the effect of nectar and honey thick liquids with a chin down head posture over a three-month period in a subgroup of 260 participants with dementia. Outcomes were pneumonia and adverse intervention effects. Honey thick liquids, which are more consistent with descriptors for 'spoon thick' or 'extremely thick' liquids, showed a more positive impact on immediate elimination of aspiration during videofluoroscopy, but this consistency showed more adverse effects in the second follow-up study. During the second three-month follow-up trial, there were a greater number of incidents of pneumonia in participants receiving honey thick liquids than those receiving nectar thick liquids or taking regular liquids with a chin down posture. There were no deaths classified as 'definitely related' to the type of fluids prescribed. Neither trial addressed quality of life. Risk of bias for both studies is high. The overall quality of evidence for outcomes in this review is low.

AUTHORS' CONCLUSIONS

We are uncertain about the immediate and long-term effects of modifying the consistency of fluid for swallowing difficulties in dementia as too few studies have been completed. There may be differences in outcomes depending on the grade of thickness of fluids and the sequence of interventions trialled in videofluoroscopy for people with dementia. Clinicians should be aware that while thickening fluids may have an immediate positive effect on swallowing, the long-term impact of thickened fluids on the health of the person with dementia should be considered. Further high-quality clinical trials are required.

Tongue Shape Dynamics in Swallowing Using Sagittal Ultrasound

Ultrasound imaging is simple, repeatable, gives real-time feedback, and its dynamic soft tissue imaging may make it superior to other modalities for swallowing research. We tested this hypothesis and measured certain spatial and dynamic aspects of the swallowing to investigate its efficacy. Eleven healthy adults wearing a headset to stabilize the probe participated in the study. Both thickened and thin liquids were used, and liquid bolus volumes of 10 and 25 ml were administered to the subjects by using a cup. The tongue's surface was traced as a spline superimposed on a fan-shaped measurement space for every image from the time at which the tongue blade started moving up toward the palate at the start of swallowing to the time when the entire tongue was in contact with the palate. To measure depression depth, the distance (in mm) was measured along each radial fan line from the location at which the tongue's surface spline intersected the fan line to the point where the hard palate intersected the fan line at each timepoint. There were differences between individual participants in the imageability of the swallow, and so we defined quantitatively "measureable" and "unmeasurable" types. The most common type was measureable, in which we could find a clear bolus depression in the cupped tongue's surface. Indeed, with 10 ml of thin liquids, we were able to find and measure the depression depth for all participants. The average maximum radial distance from the palate to the tongue's surface was 20.9 mm (median) (IQR: 4.3 mm) for swallowing 10 ml of thin liquid compared to 24.6 mm (IQR: 3.3 mm) for 25 ml of thin liquid swallow (p < 0.001). We conclude that it is possible to use ultrasound imaging of the tongue to capture spatial aspects of swallowing.

Influence of dental factors on oropharyngeal dysphagia among recipients of long-term care

OBJECTIVE

The study evaluated the association of the sociodemographic, behavioural variables and the oral conditions with the presence of oropharyngeal dysphagia in long-term care older persons.

BACKGROUND

Due to the influence of ageing, swallowing may be altered both in people with natural teeth and in those who have dentures or tooth loss.

MATERIALS AND METHODS

This cross-sectional study evaluated 115 individuals older than 60 years, living in long-term care institutions of the State of Rio Grande do Sul in 2016. The diagnosis of dysphagia happen using a clinical speech evaluation, based on the research of signals and symptoms of alterations during deglutition, and on an oral sensory-motor evaluation. The dental clinical evaluation examined the oral cavity, teeth and dental prostheses, including a Xerostomia assessment. Poisson Regressions with robust variance was calculated were used to estimate crude and adjusted Prevalence Ratios(PR) and their IC95%.

RESULTS

The sample was mostly comprised of older women (67.0%), with more than 81 years of age (44.3%) and edentulous (54.3%). Diagnosis of oropharyngeal dysphagia was verified in 60.9% of the participants. In the final model, older persons who presented no pair (PR=1.52(CI95%=1.02-2.40)) had a highest prevalence of oropharyngeal dysphagia, when compared to older persons who presented 8 to 14 mixed pairs, as well as those older persons who had more complaints related to symptoms of Xerostomia (PR=2.86(CI95% 1.58-5.18)).

CONCLUSION

Institutionalised older persons with a poor oral health condition are associated with a higher prevalence of oropharyngeal dysphagia, as well as with the presence of Xerostomia.

Study on viscosity modification of human and formula milk for infants with dysphagia

ABSTRACT Purpose: to analyze the modification of the viscosity of human milk and infant formula. Methods: three studies were performed to assess the viscosity and effect of time on infant formula with a thickener, at concentrations of 2, 3, and 5%, as well as raw and pasteurized human milk at concentrations of 2, 3, 5, and 7% at 37ºC, for 60 minutes. Rice cereal was used as a thickening agent. The viscosity was evaluated using a Ford Cup-type viscometer, and the samples were analyzed at 20-minute intervals. Significant differences were assessed using the ANOVA test. Results: no significant differences in viscosity were observed over time in concentrations of 2, 3, and 5%. There was a difference in the viscosity between human milk and infant formula, in concentrations of 2% and 5%, 2% and 7%, 3% and 5%, and 3% and 7%, independently of the time intervals evaluated. Conclusion: the findings of this study demonstrate the need for different concentrations of the thickening agent for human milk and infant formula. Rice cereal is a suitable therapeutic option for newborns presented with dysphagia in concentrations of 2, 3, 5, and 7%, due to its effect on the viscosity and flow reduction, provided that the feeding time is considered.

Texture-dependent effects of pseudo-chewing sound on perceived food texture and evoked feelings in response to nursing care foods

Because chewing sounds influence perceived food textures, unpleasant textures of texture-modified diets might be improved by chewing sound modulation. Additionally, since inhomogeneous food properties increase perceived sensory intensity, the effects of chewing sound modulation might depend on inhomogeneity. This study examined the influences of texture inhomogeneity on the effects of chewing sound modulation. Three kinds of nursing care foods in two food process types (minced-/puréed-like foods for inhomogeneous/homogeneous texture respectively) were used as sample foods. A pseudo-chewing sound presentation system, using electromyogram signals, was used to modulate chewing sounds. Thirty healthy elderly participants participated in the experiment. In two conditions with and without the pseudo-chewing sound, participants rated the taste, texture, and evoked feelings in response to sample foods. The results showed that inhomogeneity strongly influenced the perception of food texture. Regarding the effects of the pseudo-chewing sound, taste was less influenced, the perceived food texture tended to change in the minced-like foods, and evoked feelings changed in both food process types. Though there were some food-dependent differences in the effects of the pseudo-chewing sound, the presentation of the pseudo-chewing sounds was more effective in foods with an inhomogeneous texture. In addition, it was shown that the pseudo-chewing sound might have positively influenced feelings.

An Attempt to Improve Food/Sound Congruity Using an Electromyogram Pseudo-Chewing Sound Presentation System

Improving the texture of foods provided during nursing care is necessary to improve the appetite of elderly individuals. We developed a system to vary perceived food texture using pseudo-chewing sounds generated from electromyogram (EMG) signals. However, this previous system could not provide chewing sounds that were sufficiently congruous with foods. Because food/sound combinations that seem unnatural cause individuals to feel uncomfortable with pseudo-chewing sounds, food/sound congruity is important. This research aims to improve the derivation and presentation of pseudo-chewing sounds so as to be able to provide various kinds of chewing sounds. The developed system adjusts the volume of pseudo-chewing sounds that are stored in a digital audio player based on the amplitude of the EMG signal envelope. Using this system, food/sound congruity was examined with two kinds of softened Japanese pickles. Six kinds of pseudo-chewing sounds were tested (noisy chewing sound, EMG chewing sound, and four kinds of actual chewing sounds: rice cracker, cookie, and two kinds of Japanese pickles). Participants reported that food/sound combinations were unnatural with the noisy and EMG chewing sounds, whereas the combinations felt more natural with the pseudo-chewing sounds of Japanese pickles. We concluded that the newly developed system could effectively reduce the unnatural feeling of food/sound incongruity.

The effect of a crunchy pseudo-chewing sound on perceived texture of softened foods

Elderly individuals whose ability to chew and swallow has declined are often restricted to unpleasant diets of very soft food, leading to a poor appetite. To address this problem, we aimed to investigate the influence of altered auditory input of chewing sounds on the perception of food texture. The modified chewing sound was reported to influence the perception of food texture in normal foods. We investigated whether the perceived sensations of nursing care foods could be altered by providing altered auditory feedback of chewing sounds, even if the actual food texture is dull. Chewing sounds were generated using electromyogram (EMG) of the masseter. When the frequency properties of the EMG signal are modified and it is heard as a sound, it resembles a "crunchy" sound, much like that emitted by chewing, for example, root vegetables (EMG chewing sound). Thirty healthy adults took part in the experiment. In two conditions (with/without the EMG chewing sound), participants rated the taste, texture and evoked feelings of five kinds of nursing care foods using two questionnaires. When the "crunchy" EMG chewing sound was present, participants were more likely to evaluate food as having the property of stiffness. Moreover, foods were perceived as rougher and to have a greater number of ingredients in the condition with the EMG chewing sound, and satisfaction and pleasantness were also greater. In conclusion, the "crunchy" pseudo-chewing sound could influence the perception of food texture, even if the actual "crunchy" oral sensation is lacking. Considering the effect of altered auditory feedback while chewing, we can suppose that such a tool would be a useful technique to help people on texture-modified diets to enjoy their food.

Analysis of resources assisting in coping with swallowing difficulties for patients with Parkinson's disease: a cross-sectional study

BACKGROUND

Malnutrition induced by swallowing difficulties (SD) impairs the quality of life and gives rise to SD-related costs in Parkinson's disease (PD) patients. With results of a swallowing difficulty questionnaire and data of resources specifically obtained such as SD-related costs, caregivers, and dietary therapies, this study is to suggest statistically supported ideas for improvements in arrangements for how participants cope with SD and maintain general well-being.

METHODS

We interviewed 237 PD patients. The SD-related costs involved those incurred by the provision of dietary modifications, care oriented foods, alternatives, and supplements. Dietary therapies included rice porridge and commercially available care foods. The relationships between BMI (body mass index) and the severity of SD assumed in this paper as indicators for general well-being and as resources for coping with SD for PD patients were statistically analyzed.

RESULTS

A lower BMI was found in participants eating porridge consistency rice (p = 0.003) and eating porridge rice is significantly related to the severity of SD (p < 0.0001) and PD (p = 0.002). The severity of SD increased with age and PD duration (p = 0.035, p = 0.0005). Outlays for dietary modifications are the lowest reported here (p < 0.004) but the number of participants using dietary modifications is the largest among the SD-related items (n = 58). Eating care foods were reported for 11 older participants (p < 0.0001), most female (10/11). No lower BMI was found in participants eating care foods when compared with participants eating ordinary foods. Dietary modifications were performed by caregivers (OR: 6.8, CI: 3.1-15.2, p < 0.0001) and were related to the presence of children (OR: 3.4, CI: 1.2-11.4. p = 0.024). Older participants commonly live with spouses and children.

CONCLUSIONS

Severe SD is associated with higher costs of coping with SD. A lower BMI is associated with modified foods, mostly eaten to cope with SD. Presence of caregivers and other persons residing with the participants here are related to dietary modifications but not to care food-related costs. Care foods may be effective in preventing malnutrition although the number who are able to cover the added expenses is limited because of the higher prices and shortage of information on the usefulness of care foods.

Fork test: A new simple and reliable consistency measurement for the dysphagia diet

The objective of this study was to validate fork test which is a simple tool to assess the consistency of food. The consistencies of 27 water and thickener mixtures were measured with a viscometer. These measures were then compared to those obtained with fork test to evaluate the validity of fork test. The inter-observer and intra-observer reliabilities of the fork test were assessed with an intra-class correlation coefficient. The viscometer was used to obtain reference values for three categories (0-300 cP, 300-10,000 cP, and >10,000 cP) in order to categorize water and thickener mixtures into grade 1, grade 2, or grade 3 according to the results of fork test. Our results revealed that the fork test showed excellent validity (r = -0.889, p < 0.05), intra-observer reliability, and inter-observer reliability. Therefore, fork test may be used as a practical tool to assess food consistency.

Tongguan Liqiao acupuncture therapy improves dysphagia after brainstem stroke

Tongguan Liqiao acupuncture therapy has been shown to effectively treat dysphagia after stroke-based pseudobulbar paralysis. We presumed that this therapy would be effective for dysphagia after bulbar paralysis in patients with brainstem infarction. Sixty-four patients with dysphagia following brainstem infarction were recruited and divided into a medulla oblongata infarction group (n = 22), a midbrain and pons infarction group (n = 16), and a multiple cerebral infarction group (n = 26) according to their magnetic resonance imaging results. All patients received Tongguan Liqiao acupuncture for 28 days. The main acupoints were Neiguan (PC6), Renzhong (DU26), Sanyinjiao (SP6), Fengchi (GB20), Wangu (GB12), and Yifeng (SJ17). Furthermore, the posterior pharyngeal wall was pricked. Before and after treatment, patient swallowing functions were evaluated with the Kubota Water Test, Fujishima Ichiro Rating Scale, and the Standard Swallowing Assessment. The Barthel Index was also used to evaluate their quality of life. Results showed that after 28 days of treatment, scores on the Kubota Water Test and Standard Swallowing Assessment had decreased, but scores on the Fujishima Ichiro Rating Scale and Barthel Index had increased in each group. The total efficacy rate was 92.2% after treatment, and was most obvious in patients with medulla oblongata infarction (95.9%). These findings suggest that Tongguan Liqiao acupuncture therapy can repair the connection of upper motor neurons to the medulla oblongata motor nucleus, promote the recovery of brainstem infarction, and improve patient's swallowing ability and quality of life.

Pulmonary function in infants with swallowing dysfunction

BACKGROUND

Swallowing dysfunction can lead to recurring aspiration and is frequently associated with chronic symptoms such as cough and wheezing in infants. Our objective was to describe the characteristics of infants with swallowing dysfunction, determine if pulmonary function abnormalities are detectable, and if they improve after therapy.

METHODS

We studied 38 infants with a history of coughing and wheezing who had pulmonary function tests performed within two weeks of their diagnosis of swallowing dysfunction. The raised lung volume rapid thoracoabdominal compression technique was used. After 6 months of therapy, 17 of the infants repeated the tests.

RESULTS

Initially, 25 had abnormal spirometry, 18 had abnormal plethysmography, and 15 demonstrated bronchodilator responsiveness. Six months later test were repeated for seventeen patients. Ten patients had continued abnormal spirometry, two patients remained normal, three patients' abnormal spirometry had normalized, and two patients' previously normal studies became abnormal. Eight of the 17 patients had continued abnormal plethysmography, six had continued normal plethysmography, and three patients' normal plethysmography became abnormal. After 6 months of treatment, eight patients demonstrated bronchodilator responsiveness, of which five continued to demonstrate bronchodilator responsiveness and three developed responsiveness. The remainder either continued to be non- bronchodilator responsive (two) or lost responsiveness (three.) The findings of the abnormal tests in most infants tested is complicated by frequent occurrence of other co-morbidities in this population, including gastroesophageal reflux in 23 and passive smoke exposure in 13 of the infants.

CONCLUSIONS

The interpretation of lung function changes is complicated by the frequent association of swallowing dysfunction with gastroesophageal reflux and passive smoke exposure in this population. Six months of medical therapy for swallowing dysfunction/gastroesophageal reflux did not significantly improve pulmonary function in these infants. Long-term studies will be necessary to determine which of these changes persists into adulthood.