Patients' texture preferences can be inconsistent and stubborn. Texture adjustment—grinding or puréeing solid foods and thickening liquids—is a common approach to helping our patients consume food and fluids safely and efficiently. But research suggests that dissatisfaction with altered food is one of the most common reasons why patients don't follow swallowing recommendations (Colodny, 2005), and that consumption strongly correlates to "likeability" (Mills, 2008). So how do clinicians manage these aversions and preferences?
Managing Texture Preferences
Handling texture preferences requires creativity and a coordinated, multidisciplinary effort. And to ensure the solution to one problem doesn't create others, it's important to view a patient holistically. Here are eight practical, holistic strategies for addressing—or avoiding—the pitfalls of texture preferences.
1. Avoid diet changes based on patients' positive reactions to items puréed "by definition."
A patient's willingness to eat a familiar item—such as yogurt or pudding—may not translate into a willingness to eat traditionally non-puréed items in blended form. In addition, you may find that effective bolus manipulation and oral transport with mashed potatoes—a familiar puréed item—is not duplicated on puréed items of unfamiliar flavor or texture, like meats or most vegetables.
2. Include taste in your analysis.
Because most flavor is released when food is chewed, puréed items have less subjective flavor. Puréed foods are typically blended with water, making them less flavorful and depleting nutrients, requiring a patient to consume more to obtain the same calories and nutrition (Castellanos, 2004). Adding butter, salt, pepper, or other seasonings—as they are approved for the patient—may help with acceptance. Sweet is a well-maintained taste into older adulthood, so skewing a diet toward medically allowable sweets may help supplement food intake. Despite the need for a puréed meal, a patient's improved recognition of sweet flavors can prompt better oral initiation—he or she may be able to eat normally textured dessert items.
3. Investigate split diets.
A patient may accept a single puréed item during a meal—especially if you alternate bites of a more normalized texture—even if he or she might reject a fully puréed meal. A single puréed item may help the patient conserve energy and decrease oral dispersion. Patients may tolerate breakfast's traditionally softer food items, even though they cannot tolerate the more varied, coarse items of lunch and dinner.
4. Find liquids in atypical places.
Many patients tolerate thin liquids by spoon, but this method of hydration is impractical, to say the least. However, this tolerance may mean that a patient will tolerate ice cream or gelatin. You might assess the usefulness of the Frazier Free Water Protocol for appropriate patients to allow controlled presentations of unthickened water and facilitate improved hydration.
5. Investigate chopped versus ground meats.
Chopped meats preserve flavor and inherent texture better than ground meats. If your dietary department grinds all meats, consult with the dietary supervisor about a possible adjustment. Patients' principal complaint about ground items is that after a few meals, they all look and taste the same.
6. Train aggressively.
Clinicians should use compensatory strategies—such as protective postures, adjusted presentation, or longer meal times—that might allow the patient to tolerate more normalized textures and achieve better food intake. But sometimes SLPs may find texture alterations more reliable than compensatory strategies, given the large number of personnel in busy medical centers and frequent turnover of staff. But when a change in diet results in a decline in intake, it is best to further explore compensatory strategies.
7. Analyze intake over time.
It is important to determine if a change in texture is tolerated over a period of days or a week. Mechanical soft meats and pureed solids lose their visual and flavor distinctiveness, so patients may feel they are being served the same item repeatedly. A patient who eats 50% of a mechanical soft diet but consumes only 30% of a puréed diet is not better off, even if oral transport seems more efficient with puréed food.
8. Ensure informed decision-making.
If your best effort at establishing oral efficiency and decreased aspiration risk requires a texture modification, and the patient resists to the point of compromised caloric or fluid intake, notify the attending physician and other appropriate team members. We are obligated to communicate all risks to the appropriate personnel, particularly the patient and family, so that fully informed decisions are made regarding hydration, weight loss, and appetite stimulants or supplements.
Doing Our Best by Patients
When we use a comprehensive management approach that takes immediate and long-term effects of interventions and strategies into account, we can be advocates as well as clinicians. If a patient is referred back to us because we haven't addressed all of the patient's needs, we may be frustrated. But it's far worse if they are never referred back to us at all. Analyzing patients' texture preferences helps ensure the interventions we employ don't result in later unidentified risks.