Dysphagia is a very serious symptom of many different diseases and
neurological problems such as stroke, Parkinson’s disease and Alzheimer’s
disease to name a few. Dysphagia is a difficulty in swallowing and many
complications can arise if proper precautions are not met. Therefore, it is
important to understand what dysphagia is and how it may occur. It is also
important to understand how dysphagia can be treated on a nutritional level
with a modified diet.
Dysphagia is defined as a difficulty in swallowing or the inability to move
foods or liquids easily down the throat to the esophagus. It is a symptom that is
caused by many different disorders some of which include Parkinson’s disease,
Alzheimer’s disease, and stroke. People who have dysphagia experience pain
while swallowing and in some cases they may not be able to swallow foods or
liquids. To be able to better understand what dysphagia is and how it affects a
person, the swallowing process must be understood. In order to move food from
the mouth to the stomach, 50 muscles are used (NIDCD, 1998). The swallowing
process involves three stages. During the first stage of the swallowing process,
the “tongue moves the food around in the mouth for chewing” (NIDCD, 1998).
According to the NIDCD (1998), “Chewing makes the food the right size to
swallow and helps mix the food with saliva. Saliva softens and moistens the
food to make swallowing easy”. Once the food is prepared, swallowing is the
next stage. This is when the “tongue pushes the food or liquid to the back of the
mouth, which triggers a swallowing reflex that passes the food through the
pharynx” (NIDCD, 1998). Also, during this stage, the larynx closes tightly and
breathing stops to prevent food or liquid from entering the lungs. Once the food
passes from the mouth through the pharynx, the third stage begins. During the
third stage the food or liquid enters the esophagus. It takes only about three
seconds for the food to pass through the esophagus (NIDCD, 1998). If there is
any implication in the swallowing process, this is when dysphagia may occur.
Dysphagia can be classified into two different classes, oropharyngeal and
esophageal. How dysphagia is classified depends on where it occurs. In
oropharyngeal dysphagia, difficulty in “emptying material from the oropharynx
into the esophagus” (Merck, 2007) occurs. Oropharyngeal dysphagia can occur
from muscular disorders or neurologic conditions such as stroke, Parkinson’s
disease or muscular dystrophy among many others. In this condition, “patients
complain of difficulty initiating swallowing, nasal regurgitation, and tracheal
aspiration followed by coughing” according to Merck (2007). Many conditions
can result from oropharyngealdysphagia that is serious. Coughing or choking
can result from the food entering the wrong pipe which can result in “poor
nutrition or dehydration, aspiration or embarrassment” (Mayoclinic, 2008).
Aspiration is very serious and results from food entering the airway instead of
the esophagus. Choking and coughing can result from aspiration and the risk for
pneumonia or other lung problems developing is great (Mayoclinic, 2008).
Symptoms of oropharyngeal dysphagia include: coughing during or after eating
or drinking, extra effort needed for chewing, food or liquid leaking from the
mouth or getting stuck in the mouth, recurring pneumonia or chest congestion
after eating, weight loss, dehydration and weakness and a voice that sounds
gurgled or wet during or after eating or drinking (Mayoclinic, 2008).
The second classification of dysphagia is esophageal dysphagia. This can
occur from a motility disorder or mechanical obstructions. In this condition, it is
difficult to pass food down the esophagus. According to Mayoclinic (2008),
“foods or liquids “stick” in the chest or throat and sometimes come back up”.
Some conditions which lead to esophageal dysphagia include gastroesophageal
reflux disease (GERD), esophageal tumors or cancer or esophageal strictures
There are many healthcare professionals involved in the diagnosis and
treatment of dysphagia. In order to diagnose dysphagia a speech language
therapist uses a bedside swallowing assessment. Other tests are also used such
as the fiber optic laryngoscopy. In this test, the healthcare professional will look
down the patients’ throat with a lighted tube (NIDCD, 1998). A video
fluoroscopy test can also be performed in which a video is taken of a patient
swallowing to view the different stages of swallowing (NIDCD, 1998). An
endoscopy test can also be used in which barium is added to different foods with
different textures. The patient will consume the food and will be monitored on
their ability to swallow the different foods (Mayo Clinic, 2008). A treatment plan
is created after the outcomes of the different tests are evaluated. Treatment can
involve changing the way in which the patient swallows or their diet. Exercises
which help strengthen the muscles involved in swallowing can also be used to
Altering the diet is important for people with dysphagia. The National
Dysphagia Diet (NDD) was founded to help establish a “standard terminology
and practice applications of dietary texture modification in dysphagia
management” (McCullough, Pelletier & Steele, 2003). The NDD classifies foods
according to eight different textures. There are three levels in the NDD in which
different consistencies of foods are used at the different stages. The first level,
NDD-1, is also called “Dysphagia Pureed”. The foods that are allowed in this
diet consist of “foods of “pudding-like”” consistency that are smooth or pureed
with no lumps” (Nelms, Sucher& Long, 2007, p. 439). NDD-1 requires very little
chewing for people with limited chewing ability. Foods that would not be
allowed in the NDD level one diet include foods such as “gelatin, fruited yogurt,
peanut butter, unblenderized cottage cheese, scrambled, fried or hard cooked
eggs (Nelms, p. 439). An example of a meal on this diet could consist of pureed
pork chop, mashed potatoes, pureed green beans and pureed cake.
The next level in the National Dysphagia Diet is called “Dysphagia
Mechanically Altered” or NDD-2. This diet consists of foods that are “moist and
soft textured such as tender ground or finely diced meats, soft cooked vegetables,
soft ripe or canned fruit, and some moistened cereals” (Nelms, p. 439). This diet
includes some chewing for people who can tolerate moderate chewing. Foods
that are not recommended for this diet includes “bread, dry cake, rice, cheese
cubes, corn, and peas” (Nelms, p. 439). A sample menu for this diet could consist
of diced chicken, cooked carrots, mashed potatoes and a banana.
The third stage of the National Dysphagia Diet (NDD-3) is called
“Dysphagia Advanced”. This diet includes “regular foods except very hard,
sticky or crunchy items. Bread, rice, cake shredded lettuce, and tender, moist
meats are allowed” (Nelms). This diet is for patients with more chewing ability.
Foods that would not be allowed in NDD-3 include “hard fruit and vegetables,
corn skins, nuts and seeds” (Nelms). An example of a menu for a Dysphagia
Advanced diet could consist of a chicken breast, baked potato, squash and a
frosted sugar cookie.
In the National Dysphagia Diet, different levels for liquids are also used.
There are four classifications for liquids. The first level is thin, in this level all
liquids are allowed such as “water, ice, milk, milk shakes, juice, coffee, tea,
carbonated beverages, frozen desserts and gelatin” (Nelms, p 439). The next
levels are nectar-like, honey-like and spoon-thick or pudding-like. Thickening
agents are used to reach the desired consistency of the liquid. There are many
different products such as Thicken Up, Thick Set and Thick-it. The labels on
these packages contain instructions on how much thickener should be used to
reach the desired consistency.
In order to properly treat dysphagia it is important to understand what
dysphagia is and how it can occur. Difficulty in swallowing can cause
malnutrition and other problems such as aspiration, if the proper diet is not
followed. Therefore, the National Dysphagia Diet is used and the level that will
be used will be based on the level of swallowing ability. From a nutritional
perspective, it is very important that a proper modified diet is used.
Dysphagia. (2007, October).Merck. Retrieved from the Merck website:
Dysphagia. (1998). National Institute on Deafness and Other Communication
Disorders.Retrieved from the NIDCD website:
McCullough, G., Pelletier, C., Steele. (2003, November 4). National Dysphagia
Diet: What to Swallow? American Speech-Language-Hearing
Nelms, S., Sucher, K., Long, S. (2007). Nutrition Therapy and Pathophysiology.
Thomson Brooks/ Cole
Swallowing Problems. (2008). Mayo Clinic. Retrieved from the Mayo Clinic