When Diane Wolff’s 85-year-old mother was diagnosed with a swallowing disorder in 2010, the prognosis seemed dismal, at least when it came to diet. “Everything had to be pureed, and I couldn’t find anything ready-made for her that tasted good. It was institutional, like dog food,” Wolff remembers.
But pureed food was the only option, as it is for many people with swallowing disorders.
The medical term for difficulty swallowing is dysphagia. It occurs when an underlying condition — such as a stroke, neurological disorder (Parkinson’s disease, for example), surgery or weakened muscles due to aging — throws a monkey wrench into the body’s complicated swallowing process.
Swallowing requires the coordination of many nerves and dozens of pairs of muscles. They enable us to chew food, push it to the back of the throat, close the vocal folds to keep food from going down the airway, and move food into the esophagus and then the stomach.
Problems at any point along the way may show up as obvious symptoms, such as coughing or gagging during a swallow, a sensation that food is stuck in the throat or chest, pain with swallowing or drooling. Other symptoms may be harder to pin down, such as heartburn or hoarseness.
No matter what the symptom, the risk is serious. “When swallowing is compromised, liquid or food may get into the airway and lungs and cause a person to choke or develop pneumonia,” says Bonnie Schaude, a speech and language pathologist with the Shepherd Center in Atlanta.
Weight loss, malnutrition and dehydration may also result from not being able to eat or drink enough.
Diagnosis and Treatment
Doctors (called otolaryngologists) determine which part of the swallowing process isn’t working by using a special imaging test that allows them to see what’s happening inside your mouth and throat as you eat or drink. They can also watch what happens when you swallow by looking into the throat with a long, flexible tube that has a light and video camera at the end of it (called an endoscope).
Once there’s a diagnosis, the doctor and speech and language pathologist determine a treatment plan. It can range from surgery to enlarge the throat (if that’s the problem) to exercises to strengthen the muscles in the mouth and eating strategies such as using smaller eating utensils. “Smaller amounts of food can help the patient as they eat. Problems can occur when they increase the volume,” Schaude notes.
One of the main strategies for anyone with a swallowing problem is using a dysphagia diet:
— Mild dysphagia requires only that a person avoids very hard, sticky or crunchy foods (like pretzels, apples or marshmallows) and takes small bites.
— Moderate dysphagia requires soft, moist textures that are easier to push to the back of the throat. “Chewing can be fatiguing when the muscles are weak. Therefore, moist foods are easier to swallow,” Schaude says. Those types of foods include cereals softened in milk, ground meat softened in sauce, cooked fruits and vegetables without skins or seeds, fish and casseroles.
— Severe dysphagia may require pureed food. “It’s a pudding-like texture that’s easier to hold in the mouth and swallow,” Schaude explains. “You have to avoid raw, course textures that require you to chew and manipulate the food.” Just about any type of food can be pureed in a food processor or blender, as long as a small amount of liquid is added to it.
Drinks are also taken into consideration for people on a dysphagia diet. Someone who has difficulty swallowing thin liquids may need to add a xanthan gum thickener to drinks, soups or even ice cream to change the liquid to the consistency of nectar or honey, which is easier to swallow.
Dysphagia Diet Challenges
Sticking to a dysphagia diet can have a negative effect on quality of life. “Eating is cultural,” Schaude points out. “Gatherings often center on food, drink and socializing with others. When patients can’t eat the same food, there can be an emotional component with negative outcomes. People with dysphagia may develop depression, socialize less, eat less and feel they’ve lost their independence.”
Loss of interest in food and social withdrawal are common, Schaude notes, when pureed (often bland) food is necessary.
Wolff knew the risks for her mother. As her caregiver, she took on cooking duties from day one. “I wanted to get variety and flavor into her so she didn’t feel like she was stuck eating oatmeal for the rest of her life,” Wolff says.
But keeping pureed food flavorful wasn’t easy. “It’s basic food chemistry,” Wolff says. “When you puree it you’re increasing the surface area of the food, so it loses flavor.”
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Secrets of a Puree Chef
Wolff began a quest to create delicious, nutritious food that her mother would want to eat — and was still safe for her. “I read everything. I spoke to dietitians, speech and language pathologists, primary care physicians and the certified nursing assistants who actually assisted with the feeding,” she says.
She also began experimenting in her kitchen, taking apart and reconstructing foods one layer at a time — from turkey dinners to banana cream pie (her mother’s favorite). “I tried pureeing a piece of pie, but the crust went soft. So I figured out how to thicken the whipped cream, make banana pudding and puree the crust, then put it in three layers to simulate a banana cream pie,” she says.
Another breakthrough came when Wolff realized the secret to keeping dishes flavorful was in the liquid you add to it. “Sauce is the medium of flavor. If you’re blending cooked fish,” she explains, “you put it in the food processor and slowly add a little lemon butter sauce and then add thickener, until there’s a pudding consistency.”
— Fibrous or stringy foods, such as turkey thighs, don’t puree well.
— Steaming vegetables and pressure-cooking rice keeps them moist, more flavorful and full of nutrition when later pureeing them.
— Allowing diners to see the cooked food before it’s pureed and take in the aroma of the foods helps engage the senses and add to the enjoyment of the meal.
In time, Wolff was serving her mother pureed chicken Marsala, meatloaf, crab cakes, stuffed mushrooms, braised greens, ginger carrots and even salmon in puff pastry.
Advice for Others
Wolff’s mother passed away in 2013. But during her last years, her appetite was so hearty that her doctors encouraged Wolff to share her puree recipes.
She wound up writing “Essential Puree: The A To Z Guidebook,” which she considers an emergency response manual and cookbook to help caregivers set up a puree kitchen and figure out what to put on the table. A series of books followed, offering recipes to puree everything from holiday meals to game day food for tailgates (yes, you can puree miso maple-glazed baby back ribs).
It’s a long way from the dismal diet outlook Wolff’s mother faced initially. “But there’s no reason why you can’t eat a wide variety of healthy foods and have your favorites,” Wolff says. She’s sure her mother would agree.
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