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Research Article Journal of Nutritional Health & Open Access

Molecular : Transforming Diets for Dysphagia Rebecca Reilly, Farrell Frankel and Sari Edelstein* Department of , Simmons College, USA

Received: November 04, 2013; Accepted: November 14, 2013; Published: December 13, 2013

*Corresponding authors: Sari Edelstein, Department of Nutrition, Simmons College, S-334, Boston, MA 02115, USA, Tel: 617 521-2713; Fax: 617 521- 3002; E-mail: [email protected]

disease, heart disease, multiple sclerosis, and AIDS can present Abstract with dysphagia. In addition, the institutionalized elderly The purpose of our research is to utilize molecular gastronomy population has a high percentage rate of swallowing disorders and the consequence is can lead to undernourishment and dehydration [3]. individualsto improve food with textures dysphagia for todysphagia continue diets, to consume using techniques the necessary such as spherification, gelification, and emulsification. It is important for Diagnostic Considerations: Patient History can be used to enhance pureed diets as more palatable and aesthetically vitamins and minerals to ensure good health. Molecular gastronomy Dysphagia is a common problem among the elderly and evaluation should start with careful history taking, to guide preventappealing. choking Medical and nutrition aspiration. therapy There for is dysphagia quite a range calls of for unpalatable and subsequent diagnostic testing and management. To enable the pureesbeverages that to are be thickenedcurrently atserved prescribed to patients, textures inclusive and consistencies of baby food to health practitioner to make an appropriate clinical evaluation, an and whole blenderized together and served in one large bowl. in-depth, structured clinical history is important. Determining whether the issue is oropharyngeal or esophageal in origin is food taste is one of few pleasures afforded these patients as a result ofMolecular their condition and allows should more replace variety undesirable for many onewith bowl dysphagia, meals still as an important part of patient evaluation. The patient’s symptoms served in elder and healthcare facilities. The results of this research will help determine the cause, whether it is oropharyngeal, suggest that the use of molecular gastronomy in the preparation of esophageal or neuromuscular. Risk factors for esophageal and pureed foods is favorable and rated highly. The implications of this gastric cancers include smoking, alcohol use, and known family history of upper gastrointestinal (GI) malignancy [2]. long-term care facilities, where patient’s are often on pureed diets for dysphagia.research can be extended to nursing home facilities, hospitals and Dysphagia that occurs only during swallowing of solids is more likely to indicate underlying mechanical obstruction, Keywords: Dysphagia; Dysphasia; Swallowing; Blenderized; whereas when both solids and liquids are affected, dysmotility is

Texturized; Medical nutrition therapy; Spherification; Gelification; Emulsification the likely cause. Steps to find the origination of the swallowing Review of Literature difficultyStep 1:are summarizedDefine the presence below [2]: of physical symptoms such as delayed or absent swallow initiation, cough post-swallowing, Dysphagia, is a word meaning disordered eating [1] and nasopharyngeal regurgitation, and repeated swallows to affect pharyngeal clearance, indicate potential oropharyngeal a mechanical obstruction or dysmotility [2]. Swallowing is a dysphagia. physiologicalthe medical term process for swallowing and entails difficulty the following as a result steps: of either Food and liquid are transported from the oral cavity-mouth, into the Step 2: Define the location of symptoms as the throat is more stomach requiring up to 40 pairs of muscles and 8 nerves. The likely to be oropharyngeal in origin and retrosternal region, tongue and saliva work together to prepare food and liquid to which is more suggestive of an esophageal disorder. move to the stomach. Saliva moistens food and triggers the Step 3: Define the duration and progression of symptoms is also important features as chronic stable symptoms suggest doesn’t travel down the trachea into the lungs. See Figure 1 for benign conditions such as peptic strictures. theswallowing swallowing reflex process. which alerts the larynx to close such that food Diagnostic Considerations: Medical Procedures Dysphagia can present in a patient as a feeling of food/ drink sticking or a discomfort either in the throat. Occasionally, regurgitation, aspiration, or even hiccup may be the patient’s requires investigations that can be broadly divided into imaging presenting complaint [1]. Patients with degenerative diseases Accurate identification of the cause of dysphagia generally such as stroke, dementia, Parkinson’s disease, Alzheimer’s and motility assessment. Gastroscopy is typically the first method chosen to exclude an obstructive lesion. Many techniques are Symbiosis Group *Corresponding author email: [email protected] Molecular Gastronomy: Transforming Diets for Dysphagia Copyright: © 2013 Edelstein, S.

may increase the toless serve fluid appetizing,or aspiration yet of proper overly consistencythin or thickened can be liquids, achieved which by incorporating cookingrisk and of pneumoniascience. [4]. Dietary modification

For creating the proper consistency and texture for thedyspahagia National diets, Dysphagia we utilized Diet (NDD)molecular was gastronomy. used as the guidelinesMolecular gastronomy was used to achieve food textures and tastes and

for these textures [5]. Molecular gastronomy utilizes the food intopreparation spheres. techniques Usually a calcium such as bath spherification, can form soft gelification, spheres to and emulsification. Spherification is the transforming of liquid liquid contained in a network. The network is usually of protein appear, such as in tapioca pudding. Gelification consists of a source (egg protein or meat ). In foods, soy noodles and meringues are gels. Figure 1: and many nerves work to receive food into the mouth, prepare it, and Swallowing is a complex process. Some 50 pairs of muscles move it from the mouth to the stomach. This happens in three stages. and one droplets) combined together with a stabilizer (i.e. soy lecithinEmulsification or phospholipids) is the dispersion to prevent of two separation. liquids (one In a foods,liquid 1. moveDuring solid the firstfood stage,around called in the the mouth oral phase,so it can the be tongue chewed. collects Chewing the gravies and salad dressings are commons [6]. food or liquid, making it ready for swallowing. The tongue and jaw The National Dysphagia Diet (NDD), now the national standard food with saliva. Saliva softens and moistens the food to make swal- lowingmakes solideasier. food Normally, the right the size only and solidtexture we to swallow swallow without by mixing chew the- ing is in the form of a pill or caplet. Everything else that we swallow for dietary treatment of dysphagia, accounts for modifications in is in the form of a liquid, a puree, or a chewed solid. customized dysphagia diet recommendation contains two plans: 2. The second stage begins when the tongue pushes the food or liquid food textures, as well as liquids. Based on patient assessment, a to the back of the mouth. This triggers a swallowing response that one for food texture and a second one for liquids. The following NDDsection Foodexplains Texture the NDD levelsLevels for food textures and liquids [5]. andpasses breathing the food stops through to prevent the pharynx, food or or liquid throat. from During entering this the phase, air- calledway and the lungs. pharyngeal phase, the larynx (voice box) closes tightly Level 1: Dysphagia Pureed Diet: 3. The third stage begins when food or liquid enters the esophagus, i. This diet is designed for people who have moderate the tube that carries food and liquid to the stomach. The passage through the esophagus, called the esophageal phase, usually occurs to severe dysphagia, with Poor oral phase abilities and reduced ability to protect their airway with complete supervision the food, but can take slightly longer in some cases, such as when required. swallowingin about three a pill. seconds, depending on the texture or consistency of ii. All foods will have a “soft mashed potato” or pudding- like consistency. Food should be of a mashed-potato consistency, currently available for assessing esophageal motor function, not too runny or liquid. Pureed foods should be properly although manometry and barium swallow remain the most seasoned in the same way as regular foods. A blender or food clinically useful. High-resolution manometry with topography is processor is used to achieve proper consistency. now the new benchmark in assessing esophageal pressures and iii. Food may require additional liquids or thickening during diagnosing conditions such as achalasia and esophageal spasm. preparation to achieve the proper consistency. Commercially- Combining impedance with manometry in assessing bolus transit prepared pureed foods are available as are formed purees, which currently remains a research tool, as is the functional lumen provide a pureed food formed into the shape of the originating imaging probe and high frequency intraluminal ultrasound. The food: pureed chicken formed into a chicken breast or applesauce choice of test depends on the clinical indication and the outcomes formed into an apple slice.

[2]. Level 2: Dysphagia Mechanically Altered: should be interpreted in conjunction with the patients’ symptoms Medical Nutrition Therapy i. Patients with dysphagia need to have diets that are appealing This diet is a transition from the pureed textures to more solidii. textures. Some chewing ability is required. and other nutrients to ensure good health [3]. Another concern Foods are moist, soft-textured, and easily formed into a isand serving modified improperly in texture in prepared order to beveragesget required may calories, contribute vitamins to ground meat, and well-cooked . bolus. Examples include soft canned or cooked fruits, moistened medical complications such as dehydration if patients consume iii.Aside from chopping or grinding meat, little special

Citation: J Nutrition Health Page 2 of 6 Food Sci, 1(1), Reilly, R., Frankel, F., & Edelstein. S. (2013). Molecular Gastronomy: Transforming Diets for Dysphagia. 01. http://dx.doi.org/10.15226/jnhfs.2013.00101 Molecular Gastronomy: Transforming Diets for Dysphagia Copyright: © 2013 Edelstein, S.

preparation is required. All foods must be well-cooked and . Can freeze the molded foods. (Thick & Easy) hard fresh fruits and and other hard foods should be 3. Resource and Puree Appeal-long list of ingredient. avoided. Someone with food allergies could not use this—includes Level 3: Dysphagia Advanced: ingredients such as bread- iii. This diet is a transition to a regular diet. crumbs, dairy and egg plus corn syrup. Claims it gives the iv. THICK &

Foods are prepared to nearly regular textures with the same EASY® textures (Resource as and Puree Appeal) exception v. Foods of very should hard, besticky, moist. or crunchy No special foods. preparation is 4. Thick It® for beverages required. ®) vi. Avoid very dry foods, nuts, seeds, uncooked dry fruits, and tough meats. ModifiedThe challenge corn is how and tomaltodextrin implement (Thick the solution. It Some residents/patients have trouble chewing so their food has to be NDD Liquid Levels blended. This can look fairly unappetizing on a plate. Special

swallow and are very easy to choke on or aspirate into the lungs. texturized blends of potatoes and vegetables are separate from It mayThin be liquids recommended can be very by difficult the Speech for people and Swallowwith dysphagia therapist to the meat or fish. Putting these blends into apt molds, such as a or doctor to use thickened liquids. Over the counter products plate will be accepted more readily. fish one, or a cabbage one to make it look more appealing on the such as “thick-it” are available to thicken liquids to appropriate Methods

issue to consider. Trained staff as well as the appearance and Participants textures. Black, M. (2009) [7] Taste and texture are very personal appeal affect the patient’s willingness to accept the foods. The Participants were chosen using a convenience sample from importance of keeping the patient hydrated and taking in enough the students taking Advanced at Simmons College. calories and nutrients is critical in avoiding complications and improving outcomes from innumerable medical treatments student. Participants were required to complete the dysphagia labParticipants as part of were their all lab female, portion with of the the Advanced exception Food of one Science male The three recommended thickening levels for liquid diets are: [5]. . The sensory tasting was approved by the Simmons i. College Institutional Review Board. with commercial thickeners or purchased pre-thickened to nectar-likeNectar-Medium thickness. thickness- Thin liquids can be thickened Assemble Equipment and Ingredients Assemble Equipment: ii. Honey- Thicker than nectar. Room temperature honey consistency. Commercial thickeners can be used following i. Blender or Food Processor instructions on the packages. ii. iii. Spoon Thick / Pudding-High viscous too thick for a iii. straw. Commercial thickeners can be used following instructions Mixing Bowl on the packages. iv. FoodSyringe Molds or Cookie Cutters iv. Commercial products are available to enhance food v. Tubing preparation for a puree or liquid diet and are among the following: vi. Pastry Bag 1. SimplyThick® water, Assemble ingredients: (preservative) uses xanthan gum as thickener, i. xanthanNectar, gum, honey citric thicker. acid, and Spoon potassium use 2 honey sorbate ii. TexturizedSweet potatoes beef Gelling for liquids (SimplyThick) iii. 2. THICK & EASY® products binds all of liquid in pureed foods with the food pulp, the risk of unbound liquid running iv. MarshmallowsYellow squash down the throat is virtually eliminated. v. Carrots THICK & EASY® food thickeners and Shape&Serve™ are vi. Chicken

type of pure food or THICK & EASY® CLEAR for liquids without vii. Parsley agglomerated, modified food starch that mixes easily with any lumping. viii. Peas For liquids, purees for molding and shaping slurry for cakes, Tomatoes

ix. Citation: J Nutrition Health Page 3 of 6 Food Sci, 1(1), Reilly, R., Frankel, F., & Edelstein. S. (2013). Molecular Gastronomy: Transforming Diets for Dysphagia. 01. http://dx.doi.org/10.15226/jnhfs.2013.00101 Molecular Gastronomy: Transforming Diets for Dysphagia Copyright: © 2013 Edelstein, S.

Noodles v. Fill food molds or use pastry bag to present on plate. Season to taste x. Basil Emulsification: xi. Pesto and parsley garnish xii. ExtraPeanut virgin butter i. Puree 4c fresh basil in a blender xiii. Jelly ii. Whisk together 1 egg yolk, 1/2t salt, 1/2t pepper xiv. Commercial Thickener iii. xv. Food Coloring iv. Combine pureed basil with mixture in a bowl xvi.Pastry bag piping: iii. Insert coupler into the pastry bag and push it through to Slowly drizzle 1/2c extra virgin olive oil whisking to v. the smaller end emulsify mixture vi. Follow same process, substituting basil for parsley to iv. Attach the pastry tip to the pastry bag, making sure Place mixture in syringe and extract sauce onto plate make parsley garnish there are no gaps between the coupler and bag. Special decorative tips may be used for aesthetics. Marshmallow sauce: v. i.

Kink the pastry bag so that mixture won’t pour out the ii. MeltOnce marshmallows marshmallows in a are bowl melted, add water and tip when vi. beingFill the filled pastry bag and tighten vii. iii. the tip onto the plate Squeeze the pastry bag as mixture is pressed out from iv. Place mixture in syringe and extract sauce onto plate Food preparation As an alternative, place mixture in a pastry bag and Gelification of Spaghetti: extractGravy onto Piping plate: i. Fill a large bowl with ice water i. Add gravy to syringe. ii. Use an immersion blender to puree to puree vegetables ii. with ¾ c broth iii. ExtractAs an alternative, onto plate. use pastry bag with narrow tip and iii. Combine puree with commercial starch thickener in a skillet and bring to a boil extractTexturized onto a plate Beef and Chicken: iv. i. Puree meat in food processor or blender v. Attach silicon tubing to the end of syringe Place the mixture in a syringe ii. vi. iii. Add water until meat is a liquid mixture vii. FillPlace the syringe tubing with with tubing the mixture in a bowl from of the ice syringecold water for like consistency 3 minutes Add commercial thickener until mixture is a pudding- iv. viii. v. spaghetti onto a plate. A pastry bag may be used as an alternative Fill meat shaped molds with mixture Fill the syringe with air and press to extract the to a syringe and tube. Season to taste vi. Wait until mixture is firm in molds to plate the food pastry bag and present on plate. Season to taste Spherification: An alternative to using molds is to pour mixture into a Peanut Butter and Jelly Sandwich: Sweet Potatoes, yellow squash, carrots, peas, tomatoes i. i. Pour canned vegetables and water into a blender ii. ii. Strain out liquid into a bowl, leaving cellulose, lignin or Assemble peanut butter and jelly sandwich on a plate water until a pudding-like consistency un-pureed substance in strainer In a separate bowl, mix commercial thickener with iii. iii. serve pudding-like consistency Pour mixture over peanut butter and jelly sandwich and Add commercial thickener until mixture reaches a Results iv. Add food coloring as needed to match natural color of food Sensory testing was performed on the products made in this research. The taste panel (N=60) found the food products to

Citation: J Nutrition Health Page 4 of 6 Food Sci, 1(1), Reilly, R., Frankel, F., & Edelstein. S. (2013). Molecular Gastronomy: Transforming Diets for Dysphagia. 01. http://dx.doi.org/10.15226/jnhfs.2013.00101 Molecular Gastronomy: Transforming Diets for Dysphagia Copyright: © 2013 Edelstein, S.

The molecular gastronomy technique of using a syringe and

wererank betweenpleased with3-5 on the a Likertresults Scale but also (1=not recommend liked all at; more 2=disliked testing meeting the Level 2 NDD guidelines. The pasta can be made using andsomewhat; tasting be 3=neutral; done to achieve 4=liked even somewhat; higher scores. 5=much Additionally, liked). We atubing variety to make of vegetables, pasta results so in colors long strands and taste of pasta may with vary. a texture Adding pesto sauce to the pasta completes the aesthetic appearance dysphagia symptoms. Figure 2 represents a pictorial of the food of the . The array of colors on each plate increases the taste panels consisted of college students who did not exhibit appearance and appeal ratings of the meal. Adding food coloring to foods, especially canned vegetables, increases the appeal and pureesFigure we Guide made as described in the Methods section. can promote eating amongst individuals with dysphasia. i. marshmallow garnish. Texturized beef with gravy piping and sweet potatoes with ii. Overall, participants in the lab find that foods prepared theusing study molecular is that temperaturecuisine are flavorful, of the foods visually is not appealing, monitored. and While the iii.Pureed chicken mold with parsley garnish, peas and Dental soft yellow squash with butterfly carrots. preparingappropriate pureed texture chicken for individuals in a chicken with mold dysphasia. is visually A limitation appealing, of tomatoes. iv. normal temperature of a chicken breast brings the pureed food closerpreparing to resembling the chicken the pureeactual food. at a temperature reflecting the v. Texturized noodles with gravy, beef and pesto sauce. vegetables. Pureed peanut butter and jelly sandwich with side cuisine in comparison to purchasing supplements for individuals Discussion withFurther dysphasia. research Although can explorethe preparation the cost benefitfor molecular for molecular cuisine The results of this study support the use of molecular appetizing and appealing food is potentially evident in an and sensory-appeal of foods for individuals with dysphasia. In increaseis more cumbersome, in the quality the of benefit life for to individuals providing with nutrient dysphasia. dense, ordergastronomy for patients in the withpreparation dysphasia of flavorful,to obtain aestheticallythe required pleasingcalories, Future research investigating the rating for quality of life in vitamins and minerals necessary for ensuring good health, their individuals with dysphasia who eat molecular cuisine as opposed to supplements or unpalatable purees found in many medical institutions is helpful in promoting the use of molecular cuisine i appetizingdiets need to to those be modified. with dysphasia. Molecular The cuisine results offersof this alab means suggest to n hospitals, nursing homes and other facilities. thatcontrol foods the texture prepared and using appeal molecular of foods, so gastronomy that food will techniques, be more Conclusion sensory appeal, lending them to be more appetizing to those with The use of molecular gastronomy can serve as the new dysphasia.such as spherification, gelification and emulsification, have high Following the Level 1 NDD guidelines for food and liquid tastefoundation for more of food sensory-appealing preparation for meals. dysphagia. The Mealsresult can of our be modernized to accomplish both the appropriate texture and proper consistency for those individuals on a pureed food diet. texture, foods prepared using the gelification technique are the appealing food offerings that can encourage patients with project provided positive sensory evaluation (N=60) of flavorful, yet they are formed in molds similar to the shape of the original of life and nutritional well-being. This emerging cuisine can be food.The chicken The presentation and texturized of the beef pureed prepared meats in thisis appetizing lab are pureed, while useddysphagia for improved to eat more medical and enjoy nutrition meals therapy which aids of dysphagia in their quality diets everywhere. NDD. still adhering to the standardized texture guidelines for Level 1

1 2 3 4 5 Figure 2: Appetizing pureed meals using food shapes. 1. Pureed beef with gravy piping and sweet potatoes with marshmallow garnish.

3. Pureed chicken mold with parsley garnish, peas and tomatoes. 4.2. Pureed noodlesyellow squash with gravy, with butterflybeef and carrots.pesto sauce.

5. Pureed peanut butter and jelly sandwich with side vegetables. Citation: J Nutrition Health Page of 6 Food Sci, 1(1), Reilly, R., Frankel, F., & Edelstein. S. (2013). Molecular Gastronomy: Transforming Diets for Dysphagia. 5 01. http://dx.doi.org/10.15226/jnhfs.2013.00101 Molecular Gastronomy: Transforming Diets for Dysphagia Copyright: © 2013 Edelstein, S.

Disadvantages to commercial supplements include reduce the numbers needing to go into care because malnutrition acceptance and cost. Client acceptance may vary, as clients may

supplements.” Some degree of protein and calorie malnutrition can cause confusion and frailty [9].” It is about “Treating older References isperceive strikingly a flavor prevalent described in today’s as “medicinal” healthcare or institutions tasting “like [8]. vitamin people with dignity [9].” 1. Paik, N. (2012). Dysphagia- overview. Medscape. Nutrition can reduce complications and improve outcomes for nearly every medical treatment imaginable – from surgery to 2. Kuo, P., Holloway, R.H., & Nguyen, N.Q. (2012). Current and future cancer treatment to healing of fractures and more. It is possible techniques in the evaluation of dysphagia. Journal of Gastroenterology and Hepatology, 27(5), 873–881. for institutionalized elderly patients with dysphagia to eat better 3. Germain, I., Dufresne, T., & Gray-Donald, K. (2006). A novel dysphagia and appealing oral diet that meets their nutrition needs [3]. diet improves the nutrient intake of institutionalized elders. Journal of the and increase body weight via a diversified, modified in texture American Dietetic Association, 106(10), 1614–1623. Dietary variety has been associated with nutritional status 4. Garcia, J.M., Chambers, E. 4th., Clark, M., Helverson, J., & Matta, Z. in the elderly institutionalized population [4]. The general (2010). Quality of care issues for dysphagia: modifications involving oral fluids. Journal of Clinical Nursing, 19(11–12), 1618–24. of items every day on an à la carte menu. Elderly individuals resident population enjoys and benefits from a wider selection 5. Academy of Nutrition and Dietetics (2009). National dysphagia diet: standardization for optimal care. with dysphagia might be expected to benefit from the same 6. Cazor, A., & Lienard, C. (2012). Molecular cuisine. CRC Press, Taylor and variety. Furthermore, the pleasant appearance and flavor of the Francis Group: New York. modified texture foods (reformed or traditional) has been stated 7. Black, M. (2009). A multi level diet for those with a difficulty swallowing. solutionsas important for forelderly sufficient patients and with nutritionally dysphagia balanced [3]. But food whatever intake. Dysphagia Diet. It is crucial that to find nutritive, varied, and appealing dietary training is offered, it is undermined by the lack of any requirement 8. Understanding and implementing dysphagia diets. (2004). Association of for mandatory accredited training on nutrition or special diets Nutrition and Food Service Professionals. for aides, staff or in home care. “If you can reduce the 9. Valios, N. (2007). Mean cuisine? Community Care, (1672), 34–36. instances of malnutrition in the dysphagia community, you might

Citation: J Nutrition Health Page 6 of 6 Food Sci, 1(1), Reilly, R., Frankel, F., & Edelstein. S. (2013). Molecular Gastronomy: Transforming Diets for Dysphagia. 01. http://dx.doi.org/10.15226/jnhfs.2013.00101