Solving the ‘Goldilocks’ Problem of Swallowing Disorders

In the fairy tale of Goldilocks and the three bears, a little girl struggles to find a bowl of porridge that is not too cold or too hot but just right. Patients with swallowing disorders face a similar dilemma when it comes to the consistency of their food – if it is too thick, they will have difficulty getting it down; if it is too thin, their muscles cannot control the movement and they choke.

But now, help is at hand for Hong Kong patients thanks to the work of Dr. Karen Chan Man-Kei, Director of the Swallowing Research Laboratory in the Faculty of Education, and her collaborators, the Hong Kong Council of Social Service and the Centre for Nutritional Studies at The Chinese University of Hong Kong.

Drawing on international efforts to standardise food consistency guidelines for what is called “care food”, she has affirmed the approach and adapted the guidelines for local patients and their carers, be they home-based or in nursing homes. The output includes a book and website that explain clearly, in traditional Chinese, the nine levels of food consistency based on the International Dysphagia Diet Standardisation Initiative (IDDSI). There are also recipes for each level, tailored sections for different stakeholders such as nursing homes and food manufacturers, and how-to videos on the website.

“There was not a comprehensive guideline available before to teach people how to do this, but we knew there was a need,” Dr. Chan said. “We often heard from carers that they were anxious about food preparation – how should I prepare it? Is the food and drink I prepare at the right level?  

“They know the consequences if they don’t prepare the food well because their loved ones will choke in front of them.”

An earlier study by Dr. Chan on how carers prepared food found there was reason to be concerned. “The carers were very consistent in preparing thickened drinks, but they were consistently wrong. The drinks were too thick. But after 20-30 minutes of training, they immediately prepared it to the right level,” she said.

The number of people affected by this issue is not small. Dr. Chan’s research shows about 60 per cent of elderly residents in nursing homes are on modified diets as well as about 40 per cent of frail elderly receiving day care services. 

Swallowing difficulties can arise in people of any age due to brain damage from things such as stroke, dementia, Parkinson’s disease, or cancer and cancer treatments, which affects muscle control. The extent of swallowing difficulty can vary from patient to patient, hence the need for the nine levels. For example, level five food is minced finely enough that food particles are smaller than the space between the tongs of a fork. Level three liquids drip slowly through the prongs of a fork and leave a residue.

Dr. Chan said the aim of their project has been to not only help carers prepare food properly, but to show that modified diets can be more than just purees – hence the inclusion of cooking guidelines for 45 foods and 17 recipes at each level. The book and website were also launched in a restaurant that supports elderly employment and that prepared food at different levels of consistency for the media. “We wanted to send the message that care food can come in different shapes and sizes and be appetising,” she said.

Dr. Chan plans to work directly with more nursing homes and hospitals to support them in implementing the guidelines in their kitchens. She hopes within the next few years that they will all be on the same page on food consistency and that food manufacturers and restaurants will start offering care foods at different levels.

“The social enjoyment of mealtime can come back to these patients when we have a whole community supporting care food,” she said.