JCPSLP Vol 20 No 3 November 2018

Nutrition, swallowing, mealtimes: Recipes for success

What’s the evidence? Can bread ever be compatible with a texture modified diet? Julie A.Y. Cichero and Peter Lam

S peech pathologists working in aged care are often asked to consider food items that are not typically included on dysphagia diets to address issues related to weight loss and patient compliance. There has been much debate about bread in this context, given that bread is a staple of the western diet. This edition of “What’s the evidence?” investigates the request for bread on a Minced & Moist diet. It uses an evidence-based approach to determine why bread is a choking risk, what factors increase that risk and under what circumstances bread could be included on a texture modified diet. It draws on Speech Pathology Australia’s Code of Ethics asking clinicians to balance client safety with autonomy of choice. Clinician scenario You are a speech pathologist working in private practice and have received a call from the dietitian at one of the aged-care facilities you visit. Mrs Jones is an 83-year-old lady with dementia, dyslipidaemia, osteoporosis, history of falls, reflux, a recent gastrointestinal bleed and previous history of stroke resulting in dysphagia. She was referred to you when she was first admitted to the centre and your assessment indicated she would be safest on Texture B Minced & Moist Food and Moderately Thick fluids. The dietitian tells you that Mrs Jones has lost more than 10% of her body weight and is at risk of malnutrition. He is looking at all possibilities to increase her intake and would like to include bread and sandwiches in her diet. He is aware that bread and sandwiches are not allowed on a Minced & Moist diet because they pose a choking risk, but the patient is asking for sandwiches and the centre is getting pressure from her family as well. Reflection/response Weight loss and malnutrition are problems often noted in aged care with prevalence from Australian studies showing that as many as 41.6% of residents are moderately malnourished, and 8.4% are severely malnourished (Banks, Ash, Bauer, & Gaskill, 2007). Not surprisingly, individuals who rely on texture modified diets have been shown to have reductions in total energy intake and key micronutrients when compared to people who have a normal textured diet (Dunne & Dahl, 2007). Modified diet texture is significantly associated with overall malnutrition (< 0.001), poor dietary intake history (< 0.01), anorexia ( p = 0.02) and weight loss history of the previous two weeks ( p = 0.007) (Hugo, Cockburn, Ford, March, & Isenring, 2016). When looking at a balanced diet, energy

comes predominantly from three macronutrients: protein (15–25%); healthy fats (20–35%) and carbohydrates (45–65%) (NHMRC and New Zealand Ministry of Health Nutrient Reference Values, 2017). Carbohydrates, such as those found in bread, are an essential part of our diet, providing much needed energy and fibre. The Australian Dietary Guidelines (NHMRC, 2013) recommend that women over the age of 70 years should have three serves of cereal fibres per day, giving examples of a single serve as: one slice of bread, one crumpet or English muffin and other examples. The dietitian’s concerns for this lady are well founded, with malnourishment in older adults being associated with: increased hospital admissions; reduced quality of life; and increased incidence of pressure ulcers, falls, hip fractures, and mortality (Isenring, Banks, Ferguson, & Bauer, 2012). As noted above, there are valid reasons to seek changes to dietary intake; however, the question is whether including bread in this lady’s diet is the best solution. Death associated with choking on food is also of significant concern. The Australian standardised terminology and definitions for texture modified foods and fluids, endorsed by Speech Pathology Australia and the Dietitians Association of Australia (Atherton, Bellis-Smith, Cichero, & Suter, 2007) recommend only gelled bread on a Texture B Minced & Moist diet. Although the Australian standards for texture modified foods and thickened fluids are currently in place, you are aware that Australia is transitioning to adopt the International Dysphagia Diet Standardisation Initiative (IDDSI) framework on 1 May 2019. On review of the IDDSI framework, you find that Level 5 Minced & Moist similarly excludes regular, dry bread (Cichero, Lam, Steele, Hanson, Chen, Dantas … Stanschus, 2017). Published national guidelines in the field guard also against including regular bread on a Minced & Moist diet. The Code of Ethics (Speech Pathology Australia, 2010) provides further weight to how we approach this case. Seeking to respect the rights of our clients to self- determination and autonomy must also be balanced with seeking to prevent harm. Although many people are familiar with food choking risks for children, it may be surprising to learn that the rate of death related to choking on food is seven times higher for people over the age of 65 years than it is for children aged 1-4 years (Kramarow, Warner, & Chen, 2014). Further, Kramarow et al. (2014) found that three conditions were most strongly associated with death by choking on food in older individuals. These were a diagnosis of dementia, Parkinson’s disease, or pneumonitis.

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology