Dysphagia: Nutritional Management and Implications

1. Introduction

Dysphagia is a gastrointestinal dysfunction mainly affecting the upper gastrointestinal system. It may be a symptom of an underlining condition or a primary physiological dysfunction. It involves the pathophysiological dysregulation of the deglutition of foods. Nutritional impairment presents as a strong risk factor, approximately 32% of all dysphagia patients experience malnutrition and negative outcome of dysphagia [1, 2]. Older and infirm people present as having higher risk of developing dysphagia. Due to the limitations in healthcare resources that lead to a lack of assessment and diagnosis of non-communicable disease, developing countries have a higher disease burden. These conditions increase the risk of dysphagia. Stroke, for example, is one of the risk factors of dysphagia. The current evidence suggests that the bulk of stroke burden (80% of all incident strokes, 77% of all stroke survivors, 87% of all deaths from stroke and 89% of all stroke-related disability-adjusted life years (DALYs)) in 2017 was in low- and middle-income countries (LMICs) [3]. Health outcomes related to dysphagia include malnutrition, weight loss, muscle wasting, increased risk of infections and increased length of hospital stay that are linked to dysphagia [4]. These conditions have been clearly documented to influence the quality of life, particularly influencing morbidity and in extremes, mortality risks. These outcomes can be modified with multi-specialty team management, focusing on detailed assessment, accurate diagnosis, individualized interventions, continuous follow-up and personalized adjustments throughout therapy. The treatment of dysphagia is recommended to be comprehensive with the principal goal of nutritional optimization. It is also imperative that research, examination and evidence-based treatment form the platform for the therapeutic management of dysphagia to optimize health outcomes. This chapter aims to examine the current epidemiological context of dysphagia, risks and clinical outcomes of dysphagia. It summarizes the contemporary strategies to diagnose dysphagia and comprehensively examines the contemporaneous standards to treat and manage dysphagia, especially its nutritional requirements.

2. Incidence

Dysphagia is the medical term for an umbrella group of swallowing disorders, which may be structural, neurological or psychogenic, as it affects quality of life and physiological outcomes. Internationally, dysphagia has an estimated prevalence rate of 20% in the general population; however, it disproportionally affects the elderly when compared to young adults and children. The estimates are documented to affect approximately 50–66% of people over 60 years of age [5]. In the United States of America, the number of people affected is lower. The reported prevalence data are one in 17 (6%) adults and similar sources have reported that mean affected age has increased from 46.6 to 48.1 years [6]. Contradictory evidence exists, suggesting that the prevalence data were as high as 16% among Americans [7]. The disparity in the reported prevalence data has been explained by the difference in the subset of Americans sampled, the timing of the studies, the criteria used to define and the tools used to test for dysphagia. While the recorded prevalence of dysphagia in America is only 6% (1 in 17), the rates in Asia are closer to that described for the general international population. Asian prevalence of dysphagia in the geriatric population living in the community ranges from 13.8 to 33.7%, while the international rates of institutional dysphagia were documented to be between 26 and 60% [8]. In South African countries, the prevalence of dysphagia following stroke was 56% [9]. Caution must be exercised when interpreting the prevalence of dysphagia in [9] study. This is due to the use of very conservative measurement/assessment practices they employed in the study to evaluate dysphagia cases in the targeted population. The patient’s history and bedside subjective tests were used as the primary means to diagnose the disease, rather than confirmatory diagnostic and radiological tests. This limited evidence does not fully capture the disproportional disease and disability burden of the continent. Moreover, no current evidence is available on the general prevalence of dysphagia in Africa, which is partly accounted for by the under-resourced healthcare system [10]. However, due to the potential for poor quality of life and increased disease burden associated with dysphagia, urgent and comprehensive healthcare interventions are critical globally, particularly in Africa. Though the prevalence data vary by region, the elderly are predominantly affected and there is a greater concentration of the condition among those who are institutionalized, with hospitalized patients having higher incidence when compared to community-dwelling individuals. This rate balloons when individuals are admitted to tertiary care facilities and nursing homes. In addition to the disproportionate impact of dysphagia on the elderly, it substantially affects more women when compared to men. The current incidence suggests 52.9% females compared with 47.1% of males who were diagnosed with dysphagia. The same study reported an unusual finding with respect to the difference in health-seeking behaviors by gender [7]. They found that older age, male gender, having insurance, having comorbidities and more severe dysphagia symptoms were associated with increased odds for seeking care for dysphagia. In view of the statistics and the impact on functionality, health and maintenance, it is clear that dysphagia affects quality of life and the magnitude of its impact is directly related to early comprehensive multi-disciplinary but individualized care.

3. Definition and classification

Contemporary evidence points to a lack of consensus on the actual levels of population data for dysphagia. The pundits suggest that the dissonance surrounding the statistical evidence rests in the definition, assessment and ultimately diagnosis of dysphagia. To define the condition, it is imperative that the first step be the examination of the normal physiology of deglutition. Swallowing is a process requiring the coordination of a complex series of motor, sensory and psychological activities that are voluntary and involuntary [11]. This complex process begins with lip closure and the formation of the bolus and terminates with the admittance of the bolus through the esophageal sphincter and its subsequent closure [12]. Several authorities have defined dysphagia and definitions recorded include concepts that express a change in the normal physiology and consider that there is a normal structural decline with aging, which predisposes the elderly to dysphagia. One of the most well-defined meanings stems from an articulation of normal swallowing advanced by The International Classification of Functioning, Disability and Health (ICF), which classifies swallowing as “the function of clearing food and drink through the oral cavity, pharynx, and oesophagus (gullet) with an appropriate rate.” They propose that dysphagia is defined as: the difficulty in transferring food from the mouth to the stomach at an appropriate rate [11]. Importantly, dysphagia is a condition that involves the difficulty in the transition of both liquid and solid bolus through the esophagus and into the stomach. It spans both intermittent, transient and chronic forms [13].

Moreover, dysphagia may also be classified as psychogenic. This form of dysphagia is described as lacking structural, organic or physiological cause but is a perception of difficulty swallowing with associated avoidance in swallowing certain foods and liquids. To avoid misdiagnosis, a multi-disciplinary team of medical practitioners should be enlisted and the diagnosis should be suspected in patients with strong psychological history of mental disability, such as paranoia, anxiety and delusions [14]. Organic dysphagia can be classified into two groups, oropharyngeal dysphagia (OD) and esophageal dysphagia. The time and anatomical health impact differs between the categories of organic dysphagia. In oropharyngeal dysphagia (OD), the patient experiences the difficulty immediately upon swallowing. Additionally, the affected patient undergoes physiological abnormalities in the upper gastrointestinal tract due to physical changes, which may include an imbalance in the coordination between the respiratory and nutritional systems [11]. In the elderly, OD is described as being associated with decline in functional capacity, increase in frailty, polymedication and multimorbidity [15]. In the younger population, dysphagia is more likely to be linked with underlying systemic illnesses, such as autoimmune diseases, gastroesophageal reflux disease (GERD) or eosinophilic esophagitis [5]. In the general population, other conditions, such as radiation, peptic ulcer disease, as well as improper esophageal contraction in achalasia, increase the risk of dysphagia (see Figure 1).

Alternatively, esophageal dysphagia occurs moments after swallowing is initiated and is usually described as the perception of food being lodged in the throat. Medical professionals suggest that it occurs when there is difficulty with the passage of solid or liquid material through the gullet, anatomically this is the region between the pharynx and the inlet (esophageal/cardiac sphincter) to the cardia of the stomach [13, 17]. Both forms of organic dysphagia may be caused or affected by structural, neuromuscular, infectious and inflammatory diseases and are broadly classified as mechanical or motility factors. Mechanical factors within the esophagus that predisposes a patient to dysphagia include cancers, strictures, lesions, inflammation and muscular damage and usually only affect the deglutition of solids. Alternatively, motility-related factors include spasms, achalasia and systemic sclerosis and are thought to impair the swallowing of both liquids and solids.

4. Diagnosing dysphagia

The diagnosis of dysphagia is inconsistent and the related prevalence and incidence data are to be interpreted with caution due to the variation within the scientific community with respect to its established definition and defining features. Accurate diagnosis of dysphagia is critical to the acceptance of research findings and the available statistical evidence. Diagnostic accuracy also guides intervention and individualization of treatment. Contemporary evidence points to a multi-team specialist approach in diagnosing the condition. The multi-disciplinary team includes the following professionals; doctors, physiotherapists, speech therapists, rehabilitators, nurses, auxiliary nursing care technicians and some jurisdictions recognize the role of the lactation specialists in diagnosing neonatal and infantile dysphagia [18]. This multi-disciplinary team approach is thought to be effective in identifying nuanced changes, especially with respect to nutrition in at-risk and specific populations [19, 20].

There exist a number of assessment measures that can be employed in the diagnosis of dysphagia and that incorporate standards of history taking, physical assessment and diagnostic tests/procedures. There is scientific consensus that history taking is important in diagnosing and guiding the diagnostic process for dysphagia. Questions concerning the onset, duration and severity of the dysphagia, and a variety of associated symptoms may help to distinguish between the organic forms of dysphagia and guide the need for other diagnostic procedures. In addition to the timing and duration of swallowing difficulty, doctors routinely ask about coughing, weakness, weight loss, heartburn, pain and regurgitation [21, 22]. Contemporary scientists support these seminal views and suggest that most (80%) of all dysphagia-afflicted patients may be diagnosed by detailed targeted history taking [23]. Moreover, scientists suggest that a detailed examination of the respiratory and upper gastrointestinal tract be examined to determine structural factors that may contribute to dysphagia. Each structure in these shared systems should be assessed, as presented in Figure 2.

Data gathered from anamnesis (history taking) will also determine whether the subsequent diagnostic procedure should be an endoscopy, a barium swallow or esophageal manometry. Targeted questions about the onset, timing and severity of swallowing impairments and the associated symptoms such as coughing and breathing may help to narrow the differential diagnosis. Instances of swallowing impairment immediately after ingestion may lead to the suspicion of oropharyngeal dysphagia and the report of challenges with only solid foods may lead to the impression that there may be mechanical impairments (See Figure 3). In some difficult cases, all three diagnostic techniques may need to be performed to establish an accurate diagnosis [21].

• Barium swallow is an imaging study that includes a fluorescent dye to detect structural changes in the mucosal lining of the throat and esophagus. It is often performed first.

• Endoscopy is minimally invasive and provides imagery of the upper gastrointestinal tract using an endoscope camera.

Esophageal manometry examines gullet motility, esophageal musculature and the functionality of the upper and lower esophageal sphincters. This diagnostic evaluation is customarily performed after the barium meal and endoscopic evaluations. North American practice identifies additional diagnostic strategies in evaluation of dysphagia. They include dysphonia assessment, abnormal pharyngeal sensation assessments and water swallow test. These procedures are described as probative and valuable in dysphagia detection but have an overarching caution that they are collectively inconsistently sensitive [24].

There is also a vibrant discourse concerning the application of the bedside water swallow test (BWST) in the evaluation of dysphagia. This procedure is well documented and involves the administration of 10 mL of water to the affected patient and a subsequent medical examination including pulse oximetry. The patient who is found to have a positive test demonstrates most of the following symptoms (Table 1).

The patient receives a numeric score from 0 to 6, where 1 is assigned for every symptom observed. Scores of 0–2 are categorized as normal and 3–6 as being positive for dysphagia [25].

In addition to the described diagnostic procedures and assessments, practitioners may utilize videofluoroscopic swallow study or a fiberoptic endoscopic evaluation of swallowing (FEES) in the evaluation of oropharyngeal dysphagia [23].

In summary, dysphagia diagnosis is dynamic and relies on several processes including history taking, clinical assessment and diagnostic procedures. There is scientific consensus surrounding the value of history taking in diagnosing dysphagia. Furthermore, where history taking is insufficient in determining swallowing difficulties, it is critical in guiding the other investigative procedures that may provide definitive diagnosis. The diagnostic protocols that exist to evaluate impairments in deglutition include barium esophagography, endoscopy and manometry. More expansive evidence has examined the value of the beside water swallow test (BWST) and described the sensitivity of videofluoroscopy. Research authorities also agree that evaluation of dysphagia is critical to support research and population statistics. More importantly, diagnosis contextualizes the disease and provides guidance for dietitians to maintain nutritional wellness.

5. Health impact

In the last 30 years, the prevalence of dysphagia has increased significantly. In North America and United States in particular, the data concerning dysphagia show that prevalence has increased from 408,035 (2.5% of admissions) in 2009 to 656,655 (3.3%) in 2013 [4]. Other sources point to an increase in the incidence of dysphagia increased from 7.14 in 2006 to 15.64 in 2016 in Korea [8]. Dysphagia has several associated health outcomes that impact quality of life. Moreover, there has been a significant general increase in the global burden of illness and disease and related disability over the same period. Support services for dysphagia include a range of specialized resources, such as access to speech therapists, dietary modification tools, support products, caregivers for the patients and community support. Unfortunately, developing low- and middle-income countries have lower access and availability of these resources, which limit the quality of life of people affected by dysphagia in their jurisdiction [10].

The normal physiology of respiration and deglutition shares similar structural sites (pharynx), which may result in pathophysiological changes when either is affected. The evidence suggests that patients diagnosed with dysphagia, who are unable to control the passage of bolus, may not be able to control the opening and the closure of the epiglottis. The movement of the bolus along the esophagus through the cardiac sphincter may have several upper respiratory and gastrointestinal disorders and symptoms. Common respiratory symptoms associated with dysphagia include dysphonia, pneumonia, lower respiratory tract infection (LRTI), aspiration, chronic coughing and wheezing [26, 27]. Conversely, the gastrointestinal symptoms and conditions that may arise as a result of dysphagia include halitosis, belching, globus (perception of food stuck in the throat) sensation, regurgitation, pyrosis (heartburn) and odynophagia. Several of the symptoms arise with incomplete or dysfunctional closure of the lower esophageal sphincter and mechanical (anatomic) features of dysphagia [26]. The consequence of these symptoms leads to iatrogenic and organic malnutrition and/or dehydration where the patient is either medically prohibited from eating normally or has physical impairment that limits adequate dietary intake [23].

Patients diagnosed with dysphagia may also experience increased rates of mortality, rehospitalization and long-term care admission leading to increased risk of concomitant disease and financial costs [23, 28, 29]. Additionally, elderly individuals who experience unresolved chronic dysphagia are often discharged to nursing homes from hospitals rather than their own homes [23]. These circumstances impact the quality of life of the afflicted patients.

Patients with intractable dysphagia with dietary intake less than 50% for more than 7 days often require enteral nutrition or tube feeding to meet nutritional needs. Consequently, these patients may require longer institutionalization to ensure nutritional adequacy [28, 30]. Patients who required tube or enteral feeding may be managed acutely in secondary or tertiary care facilities, such as hospitals and hospices. Stable patients with no additional comorbidities may be discharged home and continue with independent or supported tube feeding in their respective homes. Healthcare workers, in particular nurses and dietitians, are responsible for discharge teaching concerning the management and delivery of enteral nutrition as well as the assessment of the signs and symptoms of the complications, such as diarrhea, constipation, infections, metabolic complications and mechanical complications (dislocation of the tube). The nutritional support for enteral feeding should be based ideally on calorimetric assessments. In under-resourced settings, energy may be computed using a recommendation of 25 kcal/g [30]. The recommendations for macronutrient intake are as follows:

• Carbohydrate intake—4 gm/kg daily with a target serum glucose level below 180 mg/dl.

• Lipid intake—0.7 to 1.5 gm/kg per day.

• Protein (consumed as amino acid in enteral feeds) should be adjusted to 1–1.8 g/kg per day increased from normal 0.8–1 g/kg with an adequate supply of carbohydrate and fat [30].

Other schools of thought suggest that there is significant morbidity risk that may arise as a consequence of dysphagia and may impact both the respiratory and the gastrointestinal systems. They document conditions including aspiration, asphyxiation, and eventually, premature death. Importantly, the authorities described some physiological and pathological changes that increase individual risk of dysphagia, such as loss of muscle mass, changes of the cervical spine, impaired dentition and xerostomia (reduction of saliva production) [11]. In the elderly, aging causes structural changes in the anatomy, such as xerostomia, loss of muscle mass, impairment in dentition and reduction in gastric motility. Consequently, dysphagia risk is higher in older individuals due to the normal structural decline of aging [11].

In summary, the global disease profile has changed in the last two decades. The related disease prevalence and disability burden inequitably affect low- and middle-income countries (LMICs) when compared to developed countries. The quality of life of an affected person worsens with several physiological changes affecting the gastrointestinal and respiratory systems. In order to improve clinical outcomes, healthcare practitioners should include symptomatic management, examination of underlying contributory factors and diagnostic evaluation as part of the strategic management of the condition.

6. Treatment

Dysphagia has been documented to significantly impact the quality of life, health, recovery and healthcare costs. Similar to the diagnostic process, the treatment of dysphagia is a multi-specialty team approach that requires each patient being ordered an individualized nutrition treatment plan. Based on the patient’s health status and physiological needs, varying nutritional interventions may be employed; primarily including dietary adjustments by mouth or tube as shown in Figure 4.

Jukic Peladic et al. [31]. For the best clinical outcomes with nutritional management, texture-modified diets (TMDs) are standardized into levels according to the level of modification and are recommended to be individualized based on the clinical/ functional capacity of the patient. The recommended texture of the diet was classified according to the International Dysphagia Diet Standardization Initiative (IDDSI). The framework consists of eight levels of modification based on liquid viscosity and form adjustment (see Figure 5). The ratings are on a numerical scale from 0 to 7, where drinks are measured from Levels 0 (thin) to 4 (extremely thick) and foods are measured from Levels 3 (liquidized) to 7 (regular) [31].

Dysphagia increases the risk and prevalence of malnutrition in the affected population. Malnutrition occurs in patients affected by dysphagia due to disease-related factors and iatrogenic consequences. Dysphagia impairs the volume and the quality of nutritional intake, leading to calorie and micronutrient deficiencies. Alternatively, therapeutic orders of nil per os (NPO) are often included as part of the treatment to prevent aspiration and related conditions. This treatment option limits dietary intake, which contributes to macro- and micro nutrient deficiencies. Therefore, malnutrition recognition and management are essential for patients with dysphagia. The relationship between malnutrition and dysphagia is cyclical. On the one hand, dysphagia limits dietary intake and increases the risk of malnutrition. Alternatively, malnourished states increase the risk of dysphagia because malnutrition leads to a decrease in fat-free mass including lean mass and striated muscle mass, which include swallowing-related muscles. This is further compounded in the elderly who are likely to experience sarcopenia as a feature of aging. This condition results in global decline in muscle mass and increases the risk of dysphagia development in sarcopenia, especially in the elderly and dependent populations [29]. This demonstrates the direct cyclical relationship between dysphagia and malnutrition. In the first instance, dysphagia restricts dietary intake quality and volume resulting in malnutrition, while malnutrition impairs the strength and functionality of the muscles of the body and in particular those that support deglutition potentiating dysphagia. Texture modification has been practiced as the standard nutritional management strategy for dysphagia; however, there are many associated disadvantages to this therapy. Texture-modified diets (TMDs) have lower nutrient content than regular diets. Both micro- and macro nutrient alterations’ restrictions have been documented as side effects of texture modifications. To modify a regular meal to achieve texture manipulation, chopping, mincing, grinding or blending is done. For some foods, there are adequate fluids including in the product to facilitate the manipulation and the intake. For other foods such as meats, fluid or liquid must be added to achieve the intended viscosity [32]. This results in alteration in the nutrient density dependent on the product used to liquefy the TMD. Consequently, calorie and protein intake was lower in patients receiving a TMD than in patients receiving a regular diet. Dietary analysis comparing textured (regular) and TMD has shown a variation of 400–600 kcal/d and protein difference of 20 g/d between dietary types [32]. Several cross-sectional and retrospective observational studies have reported malnutrition and muscle mass loss in patients on TMDs [29].

Other nutritional deficiencies have been associated with texture modifications. The evidence suggests that modifications closer to 0 or thin on the texturization scale are associated with lower levels of micronutrients where foods that are more viscous are more likely to be nutrient dense. Due to the high risk of iatrogenic malnutrition associated with dysphagia management, the healthcare team must take all precautions to prevent dietary deficiency. Notably, nutrient quality can be preserved and enhanced in texturization with the introduction of nutrient-dense liquids and constituents, such as skimmed milk, egg albumin, protein-based infant cereals and carbohydrate thickeners [32]. It is important that standard recipes and modification standards are recorded and utilized in institutional settings. Both fat-soluble and water-soluble vitamins have been linked to texture modification, including ascorbic acid, retinal, folate, pantothenic acid, tocopherol and cyanocobalamin. These deficiencies, overt and subclinical, may be treated with fortification or supplementation. It is important that nutritional intervention be personalized and target the specific needs of the patient rather than rote practiced therapy with global dietary challenges. It is also imperative a multi-specialty team, including the speech-language therapist, responsible for assessment, the medical doctor for diagnostic and therapeutic orders, the phlebotomist, the occupational therapist, the nurse and the dietitian, participate in a comprehensive management and support of the patient with dysphagia.

Despite the value of detailed initial and ongoing follow-up assessments, there is still no gold standard for nutritional assessment indicators for adult patients with dysphagia [29]. Nevertheless, the value of continuous evaluation cannot be overemphasized in this population for best health outcomes including early detection of deficiency, deviations and improvements to guide individualized adjustments in therapy.

In the multi-specialty team approach to the therapeutic management of dysphagia, all members of the team are valuable at varying points in the management, assessment, diagnosis, intervention, evaluation and referral. Nevertheless, the literature makes reference to a group of specialists who are critical of achieving the best outcomes in dysphagia management. They are especially valuable in the assessment and diagnostic phases of dysphagia management. Speech-language pathologists use various tests ranging from bedside assessment to instrumented swallowing studies to determine specific deficits, the patient’s prognosis and probability of improvement, and the most appropriate dietary modifications and swallow therapies [33]. These professionals are widely available in developed countries; however, they are limited and sometimes non-existent in developing countries. One of the principal collaborative treatments that is instituted is thickened liquids and foods with specific textures to assist in reducing aspiration risk. Medical specialists who treat dysphagia also teach patients rehabilitative strategies, such as maneuvers of the head, neck and chin, capable of promoting safer swallowing [33].

Speech-language pathologists are trained to offer therapy grouped as dietary modifications with mindful eating involving—careful chewing, avoidance of offensive foods, resizing food, eating slowly, minimal liquid intake to soften bolus, including lubricating sauces and smaller bites [33]. The specialists may also offer a second approach that targets swallowing rehabilitation—structural and muscular strengthening of the mouth, tongue and jaw. Additionally, the speech-language pathologists may introduce dysphagia patients to compensatory safe swallowing techniques such as eating upright and specialized techniques such as chin-tuck in stroke patients and head turn technique in patients with unilateral weakness. If patients continue to decline and have a poor response to other strategies, the management team may recommend enteral feed (tube feeding) and in the later phase parenteral nutrition where benefits outweigh risks [33]. Importantly, for patients receiving tube feeding as well as patients receiving modified oral intake, the estimation of energy requirement is integral to the adequacy of their dietary supply. Formulae including the Harris-Benedict and Mifflin St. Jeor are beneficial in determining basal requirements. Additional needs for full support include accounting for stress using the appropriate stress multipliers such as 1.1 or 1.4 for weight loss and cancer weight loss [34]. Enteral formulation is prescribed in patients who have lost the voluntary capacity to swallow or have non-functional upper gastrointestinal structures such as strictures or blockage. In such instances, the insertion is placed below the level of the stricture or blockage. The formula that is used is dependent on nutritional status and underlining or concomitant disease such as having normal levels of glucose in persons with diabetes, high protein and high calorie levels in weight loss. Parenteral nutrition is the last resort that is used in the dietary management of dysphagia and should only be used when benefits of life preservation and restriction of malnutrition outweigh the risk of thrombus formation, sepsis, hyperglycemia, among others [35]. This involves the process of hyperalimentation or the administration of dietary products outside of the gastrointestinal tract in a high volume vein such as the subclavian or jugular veins (see Figure 6). Total parental nutrition is the intravenous administration of nutrients as the sole source of nutrition [36].

7. Recommendations

Dysphagia is a condition, which affects nutritional status, length of hospitalization, financial burden and the risk of infection and primarily includes the structural/mechanical or sensory impairment in the deglutition process. It preferentially affects older persons due to the physiological decline in the gastrointestinal system with more significant disease-related disability in developing countries. Community-based dysphagia has lower recorded prevalence when compared to institutional-based levels and global incidence is recorded to be one in every five adults. There is a strong link between dysphagia and malnutrition where the relationship is characterized as vicious and cyclical. There are a range of assessment strategies including history taking, bedside assessment of the clinical presentation and a variation of diagnostic procedures including imagery, manometry and fluoroscopic assessments. For best outcomes, a multi-specialty team approach is advised. While medical therapies, such as withholding food (NPO), excision and correction of strictures and physical blockades, are valuable, a significant element of the management includes therapeutic nutritional care principally involving texture modification. Though this is the primary care strategy, there are several associated poor outcomes including micro- and macro nutrient deficiencies.

Given this context, it is essential that nutritional optimization and health maintenance serve as the main goals of therapy. Therefore, the recommendations for care should include:

1. Detailed and continuous physical assessment from multiple members of the healthcare team to accurately diagnose and track improvements or deterioration in the nutritional and health status of the patient

2. Prescription and administration of texture-modified diets based on the assessment findings at admission and modified throughout care based on improvements or physiological decline

3. Formulation of the dietary offerings in keeping with an established dietary standard and with as little modification as individually required for the patients

4. The inclusion of nutrient-dense texturized constituents, such as skimmed milk, egg albumin thickeners, infant cereals and carbohydrate thickeners, to preserve macronutrient and micronutrient nutritional status

5. Biochemical assessments of the patient to direct meal fortification and micronutrient supplementation, especially targeting fat miscible and water-soluble vitamins, such as ascorbic acid, pantothenic acid, tocopherol, folate and cyanocobalamin.

6. Continuous physical assessment and targeted nutritional assessment are essential to guiding the need for tube feeding or enteral nutrition or in the event of failed attempts of artificial or parenteral nutrition.

These strategies along with research and evaluation of current evidence are essential to guide the most strategic and beneficial approach to nutrition and therapeutic optimization in dysphagia.

8. Conclusion

The impact of dysphagia ranges from mild symptoms such as coughing and wheezing to severe symptoms such as malnutrition, aspiration, pneumonia and death. Due to the implications and the variations of presentation, diagnostic procedures should be guided by symptomology and detailed history taking. Following diagnosis, health care is primarily focused on nutritional management. The nutrition therapy should be individualized and patient centered to promote optimal health recovery and outcomes. The main nutritional support includes texture modification where the greatest modification should be offered to the patient with the most severe swallowing challenge and the least modification to the patient with the least significant swallowing deviation. The healthcare team should institute the highest level of nutrition support to promote nutritional adequacy with the inclusion of thickeners that have higher macronutrient values and micronutrient supplementation. Furthermore, continuous patient assessment using biochemical and anthropometric tests is critical to optimizing nutritional status and for early intervention where deficiencies exist. Cost-benefit analysis is important in determining the need for enteral and parenteral nutrition support for patients with the most severe forms of dysphagia.