Download Texture and Rheology

Texture and Rheology: The
Science of Feeding Individuals
with Dysphagia
Don Tymchuck, MS
President
Med-Diet Laboratories, Inc.
About Med-Diet, Inc.
Don Tymchuck
President
In business 30+ years
Began as R&D lab for medical foods
1. Patents
2. National Dysphagia Diet
Became a Distributor
700+ Items
Currently serving 12,000+ facilities
nationwide
Specializing in Niche, Hard-to-Find Products
Focus on specialty foods and medical diets
Turns too small for distributors
Dysphagia
• Difficulty or inability to chew or swallow
• Usually caused by a disease or injury to nerves
and/or muscles used for chewing or swallowing
• Affects an estimated 12% of hospitalized
patients and up to 50% of long term care
patients
• Treatment may include diet modifications and
restorative and compensatory interventions
Dysphagia
• Can be a symptom or condition of another
diagnosis, i.e. Parkinson’s disease, Multiple
Sclerosis, Amyotrophic Lateral Sclerosis,
Stroke, Huntington’s Disease
• Is diagnosed and managed through
coordinated efforts of Physicians, Speech
Language Pathologists, Occupational
Therapists, Nurses, and Dietitians
“What’s in a name? That which we call a rose
By any other name would smell as sweet”.
Romeo and Juliet, Act 2
“’When I use a word’, Humpty Dumpty said in
a rather scornful tone, ‘it means just what I
choose it to mean – neither more nor less’’
Alice Through the Looking-Glass Ch.6
National Dysphagia Diet Project
• Conceived in 1996 by the Dietetics in
Physical Medicine and Rehabilitation
Practice Group of the American Dietetic
Association
• Task Force Assembled in 1997
– Dietitians, Speech Language Pathologists,
Food Scientists, Industry Representatives
Identifying The Need For Dysphagia
Diet Standards
• A survey conducted by Giel and Ryker :
-Surveyed 71 dietitians in 27 states
-Revealed 40 terms to describe solid
textures and 18 terms to describe
liquid viscosities
Brown, Mills & Daubert Survey on
Liquid Viscosities and Terminology
293 speech language pathologists and 283
dietitians each tested 10 samples of
thickened liquids
29 unique labels were provided for the 10
viscosity levels
Potential for miscommunication among
caregivers was identified based on lack
of common nomenclature.
Conclusions of the Surveys
• Standard terminology describing food
and liquids does not exist
• Properties of foods and liquids that
impact swallowing safety have not been
defined or measured
• Guidelines for diet prescription for
patients with dysphagia have not been
established.
A System Of Standardized
Texture Terminology Has Been
Developed By The Food Industry
Basic Forces of Chewing
& Swallowing
Classifying Food Texture
1. Mechanical
Parameter
Popular Terms
Hardness
Soft, Firm, Hard
Cohesiveness
Crumby, Mealy, Cohesive
Brittleness
Crumbly, Crunchy, Brittle
Chewiness
Tender, Chewy, Tough
Gumminess
Short, Mealy, Pasty, Gummy
Viscosity
Thin, Viscous
Springiness
Plastic, Springy
Adhesiveness
Sticky, Tacky, Gooey
Corey, H. Texture in Foodstuffs, CRC Critical Reviews in Food Technology , p161-198 (1970)
Classifying Food Texture
2. Geometrical
Parameter
Popular Terms
Particle Size
Smooth, Sandy, Gritty,
Particle Shape
Grainy, Coarse, Fibrous,
Particle Orientation
Cellular, Crystalline
3. Other Characteristics
Parameter
Popular Terms
Moisture Content
Dry, Moist, Wet, Watery
Fat Content
Oily, Greasy
Dysphagia Food Texture Terminology
Solid and Semi-Solid Foods
• Adhesiveness
– The work required to overcome the
attractive forces between the surface of the food and
another contacted surface. An example is peanut butter
adhering to the palate
• Cohesiveness
– The degree to which the food
deforms rather than shears when compressed. Often
occurring when a moist bolus is compressed between
the tongue and palate
• Hardness (Chewability) – The force required to
compress a solid food to attain a certain deformation.
Often occurring in biting and chewing prior to shearing.
Dysphagia Food Texture Terminology
Solid and Semi-Solid Foods (cont.)
• Firmness – The force required to compress a semisolid food. An example is compressing pudding
between the tongue and palate
• Fracturability (Biteability) – The force that causes a
solid food to break. An example is biting peanut brittle
with the incisors
• Springiness – The degree or rate that a food returns
to its original shape after being compressed. An example
is a marshmallow being compressed and released
between the tongue and palate.
• Particle Size – The size of individual pieces
Every food can be placed
on a continuum for each
texture parameter
Texture Scale
0
Cohesiveness
Adhesiveness
Jell-O
veg oil
Firmness
(Semi-solid)
Springiness
cream cheese
Biteability
corn muffin
Hardness
25
50
75
vanilla pudding
mallow fluff
oatmeal
whip cream
cheese spread
hot dog
graham cracker
egg white
tapioca pudding
canned peas
orange section
m’mallow
dough
peanut butter
cream cheese
Knox blocks
ginger snap
hot dog
100
peanut brittle
carrot
(Solid)
© 2000 Med-Diet Laboratories, Inc.
hard candy
Food Texture Ratings are Based on
Objective Measurements
1. Mass
2. Length/Distance
3. Time
Measuring Eating Forces
Compression
Adhesiveness
Tensile
Shear
Source: Your Texture Manual for Texture Analysis, Stable Micro Systems, 1997
Fracture
Correlating Human Sensory Scores with
Instrument Readings
Corey, H. Texture in
Foodstuffs, CRC Critical
Reviews in Food Technology ,
p161-198 (1970)
Analyzed Foods Based on NDD Task
Force Recommendations
• ~130 solid and semi-solid foods
• Asked which textural property made it
suitable or unsuitable for each diet level
• Measured and compared those properties
to develop “break points” between diet
levels
6 Major ‘Break Points’ for
Solid and Semi-Solid Food
1.
Adhesiveness – 1 between Level 1 (Pureed) and all
others
2.
Cohesiveness – 1 between Level 1 (Pureed) and all
others
3.
Firmness/Hardness - 1 between Level 1 (Pureed)
and Level 2 (Mechanically Altered); and 1 between
Level 2 and Level 3 (Advanced)
4.
Particle Size - 1 between Level 1 (Pureed) and Level
2 (Mechanically Altered); and 1 between Level 2 and
Level 3 (Advanced)
Dysphagia Food Texture
Terminology: Liquids
Viscosity – The rate of flow per unit force. An example is the
rate at which a liquid is drawn through a straw.
Yield Stress – The minimum amount of shear stress that
must be applied to a food before flow begins. An example is
the force required to get ketchup to flow.
3 Major ‘Breakpoints’ for
Liquid Viscosity
Thin
1
Nectar-like
2
Honey-like
3
Spoon Thick
National Dysphagia Diet: Standardization for
Optimal Care, American Dietetic Association,
pp10-19 (2002)
Cone and
Plate
Viscometer
Dysphagia Diet Prescription
• An attempt to recommend an NDD level based on patients’
swallowing characteristics
• 50 experienced SLP’s were asked to match dysphagia
rating scale levels to NDD diet levels
• A strong correlation between severity rating and NDD was
found using the Dysphagia Outcome and Severity Scale
– Intended as a guideline for NDD recommendation
– Consideration must also be given to other critical
factors
– Diet “prescriptions” need to include recommendations
for solids and liquids
National Dysphagia Diet
• The National Dysphagia Diet Task
Force and the American Dietetic
Association (ADA) published their
recommendations in “National
Dysphagia Diet: Standardization for
Optimal Care” in October 2002
• Recent Survey Indicates that about
2/3 of Healthcare facilities follow
the NDD to some degree
Terminology Guidelines For Liquids
Thin: 1-50 cP
Nectar-like: 51-350 cP
Honey-like: 351-1750 cP
Spoon-thick (pudding) >1750 cP
– Note: different measuring techniques, equipment, temperature
and time will yield different centipoise (cP) readings; measuring
must be performed under precise conditions.
Terminology guidelines for solid foods
• Level 1 – Dysphagia Pureed
– Smooth, cohesive, no lumps
• Level 2 – Dysphagia Mechanically
Altered
– Moist, soft textured foods with some
cohesion
• Level 3 - Dysphagia Advanced
– Nearly a regular diet with the exception of
very hard, crunchy or sticky foods
• Level 4 - Regular Diet
Level 1: Dysphagia Pureed
Pureed, homogenous, cohesive, pudding-like foods. No coarse textures,
raw fruits, raw vegetables, or nuts are allowed. No foods requiring bolus
formation, controlled manipulation or mastication.
Recommended
Avoid
•
•
•
•
•
•
•
•
•
•
•
Pureed or slurried pancakes,
breads, pastries
Cooked cereals with pudding-like
consistency
Smooth puddings, custards, yogurt,
pureed or soufflés
Pureed fruits or mashed bananas
Pureed meats or braunschweiger
Mashed potatoes with gravy, pureed
rice or pasta
Pureed vegetables
Butter, sour cream, cream cheese
Strained gravy, cheese sauce
•
•
•
•
•
Any bread not pureed or slurried
Oatmeal and any dry cereal and
cooked cereal with lumps or seeds
Rice, cookies, cakes, muffins, pies
and pastries
Whole fruits (fresh or canned)
Whole or ground meats, cheese
cottage cheese, eggs
Non-pureed rice, noodles, potatoes
Any vegetable not pureed or
containing seeds
Level 2: Dysphagia Mechanically Altered
Moist, soft-textured, and easily formed into a bolus. Meats are ground or
minced no larger than one quarter inch pieces & are moist with some
cohesion. All foods from level 1 are allowed.
Recommended
Avoid
•
•
•
•
•
•
•
•
•
Well moistened pancakes,
pureed or slurried breads
Cooked cereals or slightly
moistened dry cereals with little
texture (corn flakes)
Cobblers (no seeds/nuts), moist
cakes, “dunked” cookies
Soft drained canned or cooked
fruit
Ground meats with gravy, eggs,
quiche, casseroles w/o rice,
meatballs
Cooked, moist potatoes,
noodles
Soft, well cooked vegetables
•
•
•
•
•
Dry un-moistened breads
Coarse cooked cereal, cereals
with seeds or nuts, dry cereal
Dry cakes and cookies, nuts,
rice or bread pudding, coconut
Dried fruit, fresh or frozen fruit
Dry meats, hot dogs, bacon,
sandwiches, pizza, cheese
cubes
Chips, fries, rice
Corn, peas, fibrous, non-tender
or rubbery vegetables
Level 3: Dysphagia Advanced
Nearly a regular texture with the exception of very hard, sticky or
crunchy foods. Foods still need to be moist and should be “bite-sized”
pieces at the oral phase of the swallow.
Recommended
Avoid
•
•
•
•
•
•
•
•
•
Moist biscuits, muffins, waffles,
soft bread
All moistened cereals
Most desserts except those to
avoid
Canned fruit, soft peeled fresh
fruit
Thin sliced, tender or ground
meat, casseroles, eggs
All starches
All cooked tender vegetables,
shredded lettuce
•
•
•
•
•
Toast, crusty bread, crackers
Extra coarse cereals - All Bran,
Grape Nuts , shredded wheat
Crunchy cookies, sticky candy
Apples, stringy or pulpy fruits
Tough dry meat or meat and fish
with bones, chunky peanut
butter
Potato skins or chips
Raw, crunchy vegetables
Simplified Dysphagia Severity
Assessment System
Based on National Dysphagia Diet
Dysphagia Viscosity
Assessment Flow Chart
Administer
Level 3
Viscosity
Warning
Signs
Yes
Recommend
Spoon Thick
Viscosity
No
Administer
Level 2
Viscosity
No
Warning
Signs
Administer
Level 1
Viscosity
Warning
Signs
Yes
Recommend
Honey-like
Viscosity
No
Recommend
Thin
Viscosity
Yes
Recommend
Nectar-like
Viscosity
Safest
Riskiest
Breaking Points
Level 3: Spoon Thick/Honey-like
Level 2: Honey-like/Nectar-like
Level 1: Nectar-like/Thin
Dysphagia Foods Assessment
Flow Chart*
Administer
Adhesiveness
Sample
No
Warning
Signs
Administer
Cohesiveness
Sample
Warning
Signs
Yes
No
Administer
Hardness
Level 1
Warning
Signs
Yes
Recommend
Puree Diet
Yes
Recommend
Puree Diet
Yes
(Recommend
Mechanically
Altered Diet)
No
Administer
Hardness
Level 2
Recommend
Puree Diet
Recommend
Advanced Diet
No
Warning
Signs
Yes
Recommend
Mechanically
Altered Diet
Administer
Particle Size
Level 2
No
Warning
Signs
Administer
Particle Size
Level 1
No
Warning
Signs
Yes
Recommend
Puree Diet
*Assumes patient is an oral feeding candidate
Conclusion: The chewing and swallowing
capability of every person with dysphagia
could be objectively matched with the
proper diet level using 9 controlledtexture samples
•
•
•
•
•
1 Adhesiveness
1 Cohesiveness
2 Firmness/Hardness
2 Particle Size
3 Viscosity
Food Science Has Developed Many
Tools That Can Aid In Evaluating
And Treating Dysphagia
Videos For Dysphagia Caregivers
(in English and Spanish)
1.
2.
3.
4.
About Thickened Liquids
The Pureed Diet Made Easy
The Mechanically Altered Diet Made Easy
Pleasing Plate Presentations for the
Dysphagia Diet
www.Dysphagia-Diet.com
Booth #1608
Caregiver Videos
www.Dysphagia-Diet.com
Thank you!
Blandin Foundation
University of Minnesota
University of Florida
National Institutes of Health
Sister Kenney Institute
and many more…