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The Dysphagia Diet

Difficulty in Chewing and Swallowing

Dysphagia means difficulty with chewing or swallowing food or liquid. To understand how this might happen, it is important to know something about how swallowing occurs. First, food must be chewed thoroughly. Then it is moved to the back of the mouth. From this point on, the process because automatic—it is a reflex that people do not actively control. A blockage or malfunction anywhere in the throat area or in the nervous system controlling swallowing can result in dysphagia.

An important part of the treatment is helping the patient get adequate nutrition, while protecting against complications such as pneumonia from food or liquid getting into the lungs. Obviously, this requires a specialized diet. There are five different diet levels from pureed (level 1) up through modified regular food (level 5). The diets vary in texture and consistency, and are chosen depending on which would be most effective for a specific patient.

Nutrition Facts

These diets are all nutritionally adequate. However, some patient may have difficulty taking enough fluid and food to get all the energy and nutrients they need. In this case, an adjustment to diet or treatment will be required.

Liquids

Fluids are essential to maintain body functions. Usually 6-8 cups of liquid (48-64 oz) are needed daily. For some dysphagia patients, this may present problems because thin liquid can be more difficult to swallow. In this case, fluid can be thickened to make it easier to swallow. However, close monitoring by the dysphagia team is required for anyone drinking less than 4 cups of thickened fluid a day or anyone not progressing to thin liquids within 4 weeks.

Calories

The greater problem for some patients is eating enough calories. The whole process of eating simply becomes too difficult and too tiring. However, calorie and protein intake can be increased by fortifying the foods the patient does eat.

Fortify milk by adding 1 cup of dry powdered milk to one quart of liquid milk. Use this protein fortified milk when making hot cooked creamed soups, sauces, milkshakes, and puddings. Also add margarine, sugar, honey, jelly, or pureed baby food to increase calories.
Add strained baby fruit to juices, milkshakes, and cooked cereals.
Add 1 jar of strained baby meat to soup, such as strained chicken noodle soup. Also add strained baby meats to sauces and gravies, and mix with strained vegetables.
Add juice to prepared fruit, cereal, or milkshakes

Special Considerations

The following are some general guidelines for safe swallowing. Remember that dysphagia patients have individual requirements, so all of these guidelines may not apply to every patient.

Maintain an upright position (as near 90° as possible) whenever eating or drinking
Take small bites—only ½ to 1 teaspoons at a time
Eat slowly. It may also help to eat only one food at a time.
Avoid talking with eating
When one side of the mouth is weak, place food into the stronger side of the mouth. At the end of the meal, check the inside of the cheek for any food that may have been pocketed.
Try turning the head down, tucking the chin to the chest, and bending the body forward when swallowing. This often provides greater swallowing ease and helps prevent food from entering the airway.
Do not mix solid foods and liquids in the same mouthful and do not “wash foods down” with liquids, unless you have been instructed to do so by the therapist
Eat in a relaxed atmosphere, with no distractions
Following each meal, sit in an upright position for 30-45 minutes
To avoid forming a hard crust on the top of a food or around the edges, cook the food in a covered casserole dish. To make soft scrambled eggs, cook the eggs in the top of a double boiler
To keep meat or fish moist, cook in tomato juice or tomato soup
To make pureed meat, first drain soft, cooked meat. Place meat in a food processor or blender to make a paste. Add hot liquid (broth) to the paste and thin to desired consistency.

Dysphagia Level 1: Pureed Foods

Foods in this group are pureed to a smooth, mashed potato-like consistency. If necessary, the pureed foods can keep their shape with the addition of a thickening agent. Meat is pureed to a smooth pasty consistency. Hot broth or hot gravy may be added to the pureed meat, approximately 1 oz of liquid per 3 oz serving of meat.

CAUTION: If any food does not puree into a smooth consistency, it may make eating or swallowing more difficult. For example, zucchini seeds sometimes do not blend well.

Hot Foods	Cold Foods
Pureed meats, poultry, & fish	Pureed cottage cheese
Pureed tuna, ham, & chicken salad	Pureed fruit
Pureed scrambled eggs & cheese	Thickened juices & nectars
Baby cereals	Thickened milk or eggnog
Thinned cooked cereals (no lumps)	Malts
Pureed French toast or pancakes	Thick milkshakes
Mashed potatoes	Ice cream
Pureed parsley, au gratin, scalloped potatoes, candied sweet potatoes	Fruit or Italian ice, sherbet
Pureed buttered or Alfredo noodles	Plain yogurt
Pureed vegetables (no corn or peas)	Smooth & drinkable yogurt
Pureed soups & creamed soups	Smooth pudding, mousse, custard
Pureed scalloped apples	Whipped gelatin
Gravies	Sugar, syrup, honey, jelly
Sauces: cheese, tomato, barbeque,	Cream
white, creamed	Non-dairy creamer
Decaffeinated coffee or tea	Margarine
	Mayonnaise
	Ketchup, mustard

Dysphagia Level 2: Minced Foods

Foods in this group should be minced/chopped into very small pieces (1/8 inch). The flecks of food are similar in size to sesame seeds.

Hot Foods	Cold Foods
Minced meat, fish, poultry	Cottage cheese
Minced stuffed fish	Junior baby fruit
Flaked fish	Semi-thickened juices
Junior baby meats	Nectars
Minced soft cooked, scrambled,	Ripe mashed bananas
poaches eggs	Minced canned fruit
Minced soufflé & omelets	Pineapple sauce
Minced soft French toast	Milk
Minced soft pancakes	Milkshakes
Cooked cereals	Custard
Minced potatoes	Puddings, including rice & tapioca
Minced buttered or Alfredo noodles	Yogurt
Minced vegetables	Fruit ice, Italian ice, sherbet
Creamed soups	Whipped gelatin
Pureed vegetable or alphabet soup	Junior baby desserts
Minced scalloped apples	Sugar, honey, syrup, jelly
Gravies	Cream
Sauces: cheese, creamed, barbecue,	Margarine
tomato, white
Decaffeinated coffee or tea

Dysphagia Level 3: Ground Foods

Foods in this group should be ground/diced into ¼ inch pieces. These pieces of food are similar in size to rice.

Hot Foods	Cold Foods
Ground meat, fish, poultry	Cottage cheese
Ground meat salads (no raw eggs)	Smooth fruited yogurt
Ground Swedish meatballs	Fruit juices or nectars
Scrambled eggs or soufflés	Ground canned fruit
Ground poached eggs	Crushed pineapple
Cooked cereals	Ripe bananas
Ground soft French toast	Lemonade/Limeade (no pulp)
Ground potatoes	Milk
Ground noodles	Ice cream
Ground baked potato (no skin)	Custard
Ground well-cooked frozen vegetables	Puddings or mousse
(no corn, peas, or mixed vegetables)	Fruit ice, Italian ice, sherbet
Ground canned vegetables	Cream
Creamed soups	Non-dairy creamer
Pureed vegetable or alphabet soup	Margarine
Ground scalloped apples	Mayonnaise
Gravies	Ketchup
Decaffeinated tea or coffee	Mustard
Sauces: cheese, creamed, barbeque,
tomato, white

Dysphagia Level 4: Chopped Foods

Foods in this group should be chopped into ½ inch pieces. These pieces of food are similar in size to uncooked elbow macaroni or croutons (small bread cubes).

Hot Foods	Cold Foods
Chopped meat, fish, poultry	Cottage cheese
Chopped Swedish meatballs	Yogurt
Meat salads (ground or flaked meat)	Milk
Flaked fish	Milkshakes
Poached or scrambled eggs	Soft, cold, dry cereal
Soufflés and omelets	Soft bread (if approved by therapist)
Cooked cereals	Fruit juice or nectars
Chopped French toast	Chopped canned fruit
Chopped noodles or pasta (no rice)	Canned fruit cocktail
Chopped cooked vegetable	Pudding, mousse, custard
(no frozen peas, corn, or mixed)	Ice cream
Chopped canned small sweet peas	Fruit ice, Italian ice, sherbet
Creamed soup or vegetable soup	Cream cheese
Chopped potatoes (all kind)	Whipped topping
Gravies	Whipped gelatin
Canned chicken noodle soup	Sugar, honey, jam, jelly
Bacon dressing
Sauces: cheese, creamed, barbeque,
tomato, white
Decaffeinated tea or coffee

Dysphagia Level 5: Modified Regular Foods

Foods in this group are soft, moist, regularly textured foods.

Hot Foods	Cold Foods
Soft, moist meat, fish, poultry	Soft cheeses
Baked fish	Cottage cheese
Meat salads	Cream cheese
Soufflés and omelets	Yogurt
Eggs	Milk
Stuffed shells	Milkshakes
Spaghetti with meat sauce	Cold dry cereals (no nuts, dried fruit)
Cooked cereal	Crackers
French toast or pancakes	Soft breads (no hard rolls)
Toast	Fruit juices or nectars
Noodles or pasta (no rice)	Canned fruit
Potatoes (all kinds)	Ripe bananas
Soft, cooked vegetables (no corn, lima,	Peeled, ripe, fresh fruit
or baked beans	Cakes (no nuts, dried fruit, or coconut
Creamed soups or vegetable soup	Plain donuts
Canned chicken noodle soup	Ice cream
Gravies	Pudding, mousse, custard
Bacon dressing	Fruit ice, Italian ice, sherbet
Sauces: cheese, creamed, barbeque,	Whipped gelatin
tomato, white	Regular gelatin
Decaffeinated coffee or tea	Canned fruited gelatin molds
	Sugar, honey, syrup, jam, jelly
	Cream
	Non-dairy creamer
	Margarine
	Oil
	Mayonnaise
	Ketchup
	Mustard

Dysphagia Thickening and Thinning Agents

Foods can be thickened or thinned to individual requirements. Many foods can be used to change a liquid to a different consistency. The amount of thickening agent needed to reach a certain food consistency varies depending on the food being thickened and on the thickening agent used.

Product	Manufacturer	Phone Number
Nutri Thick	Menu Magic Foods	(800) 732-5805
Frutex	Crescent Foods	(206) 623-7140
Thick ‘n Easy	American Institutional Products, Inc	(717) 569-1866
Thick-It	Milani Foods, Inc	(800) 333-0033 (312) 450-3189
Thick Set	Bernard Fine Foods, Inc	(800) 538-3663
Thixx	Bernard Fine Foods, Inc	(800) 323-3663 (312) 273-4497

Texture/Consistencies of Foods

The following are examples of medium and thick liquids and foods.

Medium (nectar consistency)	Thick (yogurt/pudding consistency)
Eggnog	Cooked hot cereal
Fruit nectars (apricot, peach, pear)	Pudding
Honey	Custard
Thick creamed soups	Gravy
Soft set pudding with added milk	Yogurt (no nuts or fruit chunks)
Tomato juice	Cottage cheese mixed in blender
Buttermilk	Thick malt and milkshakes
Ice cream (no nuts or fruit chunks)
Milkshakes

Dysphagia Thickening and Thinning Agents

How to Thin Liquids

hot milk-based liquids (hot milk or cream) to pureed soups, pureed vegetables, or cooked cereal.
Add other hot liquids (broth, gravy, sauces) to mashed potatoes, pureed, or ground meats, and pureed or chopped vegetables. Butter or melted margarine may also be used.
Add cold milk-based liquids to cream, yogurt, cold soups, pureed fruits, or puddings, and custards

If a food is too thick, add one of the following:

Broth
Bouillon
Gravy
Juice
Liquid flavored gelatin
Melted hot butter/margarine
Milk (hot or cold)
Plain yogurt
Strained pureed soups

How to Thicken Liquids

Add baby rice or commercial thickener to hot milk-based liquids
Add potato flakes, mashed potatoes, or flaked baby cereal to other hot liquids (soups, sauces, gravies)
Add plain unflavored gelatin, pureed fruits, banana flakes, or a commercial thickener to cold liquids
Add potato flakes, mashed potatoes, thick sauces or gravies, canned pureed or strained meat (baby food), or a commercial thickener to pureed soups
Add flaked baby cereal, flavored gelatin, cooked cream of rice or wheat cereal, or a commercial thickener to pureed fruits
Add mashed white or sweet potatoes, potato flakes, sauces, or commercial thickener to pureed vegetables

If a food is too thin, add one of the following:

Baby cereal
Banana flakes
Breadcrumbs
Cornstarch
Cooked cereals (cream of wheat/rice)
Custard mix
Graham cracker crumbs
Gravy
Instant potato flakes
Mashed potatoes
Plain unflavored gelatin powder
Plain sauces (white, cheese, tomato)
Pureed baby food
Saltine cracker crumbs

Dysphagia Recipes

Fruit Shake

In a blender, place 1 ½ cups of fresh, frozen, or canned fruit with 1 cup fortified milk. Mix until smooth.

Fruit Blend

In a blender, mix ¼ apple juice, ¼ cup orange juice, and 1 cup canned peaches or pears. Mix until smooth.

High-Protein Smoothies

In a blender, mix 1 cup fruit-flavored yogurt and 1 cup fortified milk with soft, fresh, peeled fruit or soft, canned fruit, and 1 cup cottage cheese. Mix until smooth.

Cottage Cheese Pudding

Mix together ¼ cup cottage cheese with 3 Tbsp baby fruit. Chill.

Creamed Vegetable Soup

In a blender, add ½ cup strained or very soft cooked vegetable; ½ cup fortified milk, cream, or plain yogurt, 1 tsp margarine; salt, onion powder, and crushed dried parsley flakes to taste. Mix to desired consistency.