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As full-time speech language pathologists working with adults, we have become increasingly aware of the difficulties some of our patients face with mixed consistency foods (soups, cereal with milk, fruit cups in syrup etc.) As clinicians, we are always trying to balance patient quality of life with safety. Clinically, we see patients who safely consume thin liquids in isolation and solids in isolation but struggle with mixed consistencies, demonstrating increased signs/symptoms of aspiration. Frequently, dietary restriction or modification is recommended, and often we see patients return from instrumental exams with recommendations to avoid mixed consistencies. How do we balance this with our desire to keep patients on least restrictive diets and maintain their quality of life? In an effort to open up this discussion about mixed consistencies, let me share what we’ve found thus far.

Here’s what we know about mixed consistencies:

They are popular

Mixed consistency foods are convenient and comforting, and not surprisingly, very popular among our geriatric patients. Soup was a $4.3 billion market in 2011, with core markets (consumption 20% above average rates) including consumers 65 and over, single person households and single active seniors [1]. Cold breakfast cereal was estimated to reach $10.4 billion in sales by 2016, with core markets (consumption 20% above average rates) including single active seniors purchasing family cereals, and affluent seniors purchasing natural/bran cereals [2]. Anecdotally, we’ve each experienced many patients who rely heavily on these foods for nutrition either in their homes or assisted living residences as well as in skilled nursing facilities. These foods are easy to make, convenient and budget-friendly.

It is important that mixed consistencies are thoroughly assessed during instrumental as well as bedside evaluations, and that we each carefully consider interventions that are helpful.

They are challenging

In a survey of over 100 speech-language pathologists in the state of Ohio, 86% reported having at least one patient on their current caseload with dysphagia of mixed consistencies [3].  Biomechanically, a small study of normal adults by Saitoh et. al (2007), showed that chewing and initial consistency each altered the relationship between food transport and swallow initiation; and that when consuming foods with both solid and liquid phases, a portion of the food commonly reached the hypopharynx well before swallow onset [4]. Saitoh et. al concluded that consuming two-phase foods (with both solid and liquid phases) may increase the risk of aspiration in dysphagic individuals [4]. We have found little information about mixed consistencies in the dysphagic or elderly population in the literature. Kang, Kim, Seo & Seo, 2011, observed continuing abnormal findings in Korean patients with stroke or brain injury during consumption of mixed consistencies (even after they were upgraded to regular hospital diets) following completion of video fluoroscopy [5]. Their findings included the following abnormalities:

  • posterior spillage of liquid prematurely to pyriform sinus in the oral preparatory phase of swallowing (chewing) of solid component
  • laryngeal penetration of prematurely spilled liquid in the oral preparatory phase of solid component
  • subglottic aspiration of prematurely spilled liquid during chewing of the solid component,
  • significant residue in the valleculae or pyriform sinuses

They are relevant for functional treatment

Because of the popularity of mixed consistencies, we need to be thinking carefully as clinicians about how to best manage this difficulty for our patient populations. Clinically, most of our patients do not want indefinite restriction and complete avoidance of an entire food category. This is the easiest suggestion, but I hope it is not our best suggestion.

 MIT-E Spoon: The authors are the creators of a solution to the challenges with mixed consistencies.

Below are the most common compensatory strategies compiled through web-based searching and the OSLHA Mixed Consistencies Member Survey of November 2014 (in no particular order):

  1. Draining liquid from the spoon during meals.
  2. Use of a fork to eat mixed textures.
  3. Thickening broth or milk.
  4. Pureeing mixed consistencies.
  5. Let cereal absorb milk until there is little liquid left.

From a clinical standpoint, we understand these suggestions and have tried several of them. Each strategy has its challenges and may not be beneficial for long-term management of mixed consistency dysphagia. For example, draining liquid from the spoon is subjective and tedious, and requires intact cognition for recall. Use of a fork may give the appearance of confusion or allow food to slip through tines. Thickening and pureeing mixed consistencies creates additional modification, which may cause aversion. Imagine sitting at the dining table with your friends eating chicken noodle soup while you consume a slurried mush that tastes chicken-y. Surely, this is not our best option either! Finally, allowing cereal to absorb milk does not change the fact that the bolus contains two consistencies; and the time it takes to allow proper absorption can be quite subjective. The challenges related to each option and the desire of our patients to eat mixed consistency comfort foods led us to seek adaptation instead of restriction or compensation, and the journey is ongoing.

Mixed consistencies are still mysterious

We are not researchers by title, and are simply practicing SLPs who seek the best outcomes for our patients. This journey for answers has not been entirely exhaustive; we are still learning. We have used whatever resources available to us to help the people we serve make educated decisions and enjoy their mealtimes. We’d love to see more study in the area of mixed consistencies and more evidence for rehabilitation of a mixed consistency swallow. It is important that mixed consistencies are thoroughly assessed during instrumental as well as bedside evaluations, and that we each carefully consider interventions that are helpful. Striving for innovation that is useful, and leaning heavily on a patient-centered approach, our hope is that our loved ones and patients may safely eat REAL soup for lunch with their friends.

Let’s seek ways to include foods instead of removing them, and conquer these mixed consistencies!

Links of interest

MIT-E Spoon: The authors are the creators of a solution to the challenges with mixed consistencies. Check it out here!

About the Authors

Mandi Wilhelm, Megan Ordway and Sara Bouchard are practicing speech-language pathologists in Ohio, currently each working in skilled nursing facilities. They are co-inventors of the MIT-E Spoon for Mixed Texture Eating and run calmslp.com, a resource site for downloadable therapy materials and handouts.

References

  1. Government of Canada. (2012). Soup: American eating trends report. Retrieved from: http://www.agr.gc.ca/eng/industry-markets-and-trade/statistics-and-market-information/agriculture-and-food-market-information-by-region/united-states-and-mexico/market-intelligence/soup/?id=1410083148504
  2. Government of Canada. (2012). Breakfast cereals: American eating trends report. Retrieved from: http://www.agr.gc.ca/eng/industry-markets-and-trade/statistics-and-market-information/agriculture-and-food-market-information-by-region/united-states-and-mexico/market-intelligence/breakfast-cereals/?id=1410083148499
  3. Bouchard, S., Ordway, M., & Wilhelm, M., (Nov, 2014). OSLHA Mixed consistencies member survey.
  4. Saitoh et al. (2007). Chewing and food consistency: effects on bolus transport and swallow initiation. Dysphagia, 22(2),100-107.
  5. Kang, S. H., Kim, D., Seo, K., & Seo (2011). Usefulness of video fluoroscopic swallow study with mixed consistency food for patients with stroke or other brain injuries. Journal of Korean Medical Science, 3, 425-430.

 

2 COMMENTS

  1. The difficulty that many adults with dysphagia have with mixed-texture foods is not at all surprising. If you look at the development of feeding skills in infants and young children, you’ll find that handling multiple food consistencies is the last major skill to develop. Until children are approximately 2.5 years old, they may experience coughing or use the types of compensations described in this article (plus just letting the liquid run out of the mouth!). This reflects the developmental challenge of handling the timing and coordination of emerging oral-motor skills when 2 or more consistencies are involved. Other foods that create this coordination challenge are juicy fresh fruits such as oranges, melons, mangos, and fruits with a peel, pulp and juice (3 consistencies) such as apples, pears and grapes. Spoons with small holes (such as your MIT-E Spoon) have been available for toddlers for more than 20 years as the Sassy Less Mess Spoon. Although designed for young children, this spoon could be very helpful for adults who have motor difficulties with self-feeding.

  2. Hello! Mixed consistencies is something that many overlook. Having identified the appropriate consistency for a patient the reality is making sure every thing they eat and drink is the right consistency is a complex issue for all the reasons raised.

    When you add the fact their everyone has their favourite foods and drinks and complicate it with multiple carers preparing the food and drinks – their is a low low probability a person will ever receive all their foods and drinks at the right consistency.

    It is a massive issue. The answer may be compromise and only offering guidance on what works best.

    What’s important is to raise the issue. By raising it and starting to discuss it a solution can be found. Great article.

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