Unit 4 - Food preparation (e-book)

4.1 General characteristics of the texture modified diets

The preparation and adaptation of the ingredients and texture of the food consumed daily is essential in the case of people with dysphagia. This process is essential for the improvement of their nutritional and health status.

The extent to which the food and beverages should be adapted depends on the grade of difficulty of dysphagia, as well as the ability for mastication and oral processing.

The diet recommended by SLT is the safest to eat based on the current swallowing ability and should be followed at all times.

4.1.1 Dangerous textures of food

There are some types of food that can pose a particular risk to people with swallowing difficulties if not processed correctly. There are also other foods that are particularly difficult to modify in texture and should therefore be avoided.

• Mixed consistency foods 
• Food that contains husks 
• Foods with a fibrous or ‘stringy’ texture
• Fruit or vegetables with thick skins, seeds or pips 
• Crunchy and crumbly items 
• Hard foods
• Bread

Figure 1. Food that can pose a particular risk to those with swallowing difficulties (Source: designed by Canva Pro).

4.1.2 Texture modified food

Texture modification is done to improve the quality and safety of foods for people with dysphagia. The term texture-modified foods (TMF) refers to foods with a texture that is softer, softer or smaller in size than it would normally be. It is obtained by physical or chemical modification to reduce the risk of choking.

The level of food texture adaptation depends on the severity of dysphagia.

Figure 3. Infographic about dangerous textures in dysphagia (Source: designed by Canva Pro)

Infographics available for download on the training platform (https://indeed-project.org/)

4.2. Classifications and levels of standardization texture modified food

Modification of food texture and liquid thickness, without compromising the nutrient supply to ensure good health, is essential in the treatment of dysphagia.

The International Dysphagia Diet Standardization Initiative (IDDSI) Framework

The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 – 4, while foods are measured from Levels 3 – 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness.

Figure 4. IDDSI classification of Foods and Drinks in 8 levels (https://iddsi.org/framework/)

Level 0: Thin

• Flows like water

Level 1: Slightly Thick

• Thicker than water

• Requires a little more effort to drink than thin liquids

Level 2: Mildly Thick

• Flows off a spoon

Level 3: Liquidiz ed/ Moderately Thick

• Cannot be piped

• Cannot be eaten with a fork because it drips slowly

Level 4: Pureed/ Extremely Thick

• Cannot be drunk from a cup because it does not flow easily

• Does not require chewing

• Falls off spoon in a single spoonful

Level 5: Minced and Moist

• Can be eaten with a fork or spoon

• Can be scooped and shaped

• Adult, equal to or less than 4mm width and no longer than 15mm in length

Go video: IDDSI Food Level Testing (Level 5 Minced and Moist)

(Source: Dorset HealthCare University NHS Foundation Trust, 2020)

Level 6: Soft and Bite-Sized

• Can be eaten with a fork, spoon or chopsticks

• Can be mashed/broken down with pressure from fork, spoon or chopsticks

• Paediatric, 8mm pieces (no larger than)

• Adults, 15 mm = 1.5 cm pieces (no larger than)

Go video: IDDSI Food Level Testing (Level 6 Soft and Bite-sized)

(Source: Dorset HealthCare University NHS Foundation Trust, 2020)

Level 7: Easy to chew or Regular : Normal

Go video: IDDSI Food Level Testing (Level 7 Easy to Chew)

(Source: Dorset HealthCare University NHS Foundation Trust, 2020)

4.3 Ingredients and thickeners to modify the texture of food

Changes in food textures and viscosity (thickness) of liquids can be achieved by reducing particle size and/or using different ingredients known as thickeners.

Thickeners used in diets for dysphagia can be obtained from different sources.

Hydrocolloids

The name comes from “Hydro” which means water and “colloids” that means glue.

Hydrocolloids are used in the diets of people with dysphagia because they have characteristics that allow them to easily modify the texture, increasing the viscosity, fluidity, water retention, firmness and softness of foods and beverages. For example: gum arabic, guar gum, konjac glucomannan, agar, carrageenan.

Figure 5. Starch-based thickeners (Source: CADIS Huesca)

Starch-based thickeners

Starches are obtained from tubers and cereals and have the ability to thicken foods. They are cheap and readily available, but have some disadvantages. They must be used in large quantities, which affect the flavor (starchy taste), color and nutritional value of the food.

Figure 6. Thickeners agents

Commercial thickeners

Commercial thickeners may contain starch or starch derivatives, gum hydrocolloids or combinations of different type of hydrocolloids.

It is useful to follow the manufacturer's instructions, but it should be noted that their behavior is different in each food/drink. Different types of hydrocolloids and concentrations will result in different textures and viscosities.

Figure 7. Commercialized modified starches jars (Source: CADIS Huesca)

Proteins

Some proteins from animal origin are gelling properties (ability to increase their thickness).

Proteins with this gelling capacity can be found in bones, skins and tendons of animals (gelatin), skins of fish (gelatin), milk (caseinates and whey proteins), eggs (egg white proteins) and chitin shells of Crustaceans (chitosan).

Egg proteins (white egg proteins) are used due to their gelling and emulsifying properties. They modify the nutritional value, taste, color and texture of the products.

Figure 8. Proteins food with gelling properties
(Source: CADIS Huesca and Canva Pro)

Practical exercises to apply the theory.

In this exercise we will become aware of the importance and characteristics of different thickeners.

Materials: Cooked green beans, cooked potato, wheat flour, hard-boiled egg.

Exercise: We will prepare four crushed products using a blender:

- Green beans.

- Green beans and potato.

- Green beans and a spoonful of wheat flour.

- Green beans and hard-boiled egg.

Try the different preparations separately and answer the following questions:

Is the texture the same or different between them? Which one do you like and dislike the most?

Do you notice different flavors between the elaborations? Reflect on each of them.

Figure 9. Infographic about thickeners (Source: designed by Canva Pro)

Infographics available for download on the training platform (https://indeed-project.org/

4.4 Modification of the viscosity of liquids

4.4.1 To learn how to thicken liquids

Thin liquids are those that move very fast in the mouth such as:

• Water

• Milk

• Fruit juice

• Soft drinks

• Tea

• Coffee

Figure 10. Liquids with different viscosities (Source: designed by Canva Pro)

This makes them more complicated to handle in the mouth and, therefore, they are often associated with choking episodes in dysphagia giving more health problems for people with dysphagia. In these cases, it is necessary to use thickening agents to aid safe consumption.

4.4.2 What can you use to thicken liquids?

Modified corn starch, xanthan gum, guar gum and Tara gum (alone or combined) are common thickeners to increase the viscosity of the fluids.

Figure 11. Commercial food thickeners (Source: CADIS Huesca)

How to thicken liquids

 Figures 12. Tips to prepare thickened beverages. (Source: Nutricia)

It is useful to follow the manufacturer's instructions for the commercial thickener used. However, it should be noted that the final thickness and characteristics are different depending on the beverage used.

Some tips for preparing thickened beverages:

Figures 13, 14, and 15. Tips to prepare thickened beverages (Source: Nutricia)

Testing Methods for use with the IDDSI Framework

Drinks and other liquids

Go video: IDDSI Flow test

(Source: IDDSI, 2020)

4.5 Modification of the texture of solid foods

Introduction to texture modification of solid foods

The degree of modification of the textural characteristics of solid foods will depend on the characteristics and specific requirement of each person. They will be established by a speech therapist.

To assure optimal nutrition and safety when adapting solid foods, two approaches can be done:

1. Reduction of the portion size but with increased caloric and nutrient density. Applying specific techniques and equipment for food preparation (cutting, chopping, mincing, mixing with liquids, pureeing, ….).

2. Modification of the consistency or texture through the reduction of the particle size and pureeing and/ or with the use of specific thickeners. Mixing the food with different thickening agents (starches, gums, flour, proteins….) and flavouring agents.

Testing methods for identifying levels in the IDDSI framework

Spoon Tilt Test

Go video: Video IDDSI Spoon Tilt Test. Level 4 Extremely Thick

(Source: IDDSI, 2020)

Fork Pressure Test and Spoon Pressure Test

Go video: Video IDDSI IDDSI Fork Pressure, Fork Drip, Spoon Tilt, Chopstick, and Finger Tests - Level 5 Minced & Moist

(Source: IDDSI, 2020)

Chopstick test and Finger test

 Go video: IDDSI Fork Pressure, Chopstick, and Finger Tests - IDDSI Level 6 Soft & Bite Sized

(Source: IDDSI, 2020)

4.6 Techniques and equipment

4.6.1 Cooking techniques

Boiling. It consists of placing food in a pot of very hot (boiling) water and holding it for a period of time until it is fully cooked.

Stewing. It is a form of boiling, but the difference is that the liquid does not need to boil during cooking, so it needs a cooking time of even hours.

Braising. It shares the same type of cooking in liquid as the stewing but before the stew the ingredients are fried a little with oil.

Roasting. Roasting or baking. It consists of introducing food into an oven and cooking it at high temperatures with dry heat.

Steaming. One of the best culinary techniques you can learn is the art of steaming. It preserves flavor and nutrients.

Gelation. Cooking procedure where a food or liquid is converted into a gel by adding an ingredient with this capacity, some of these ingredients are gelatin, agar agar, xanthan gum or others.

Figure 16. Cooking techniques (Source: designed by Canva Pro)

4.6.2 Equipment

The elaboration of texture-adapted foods can be done at home with basic tools.

Pots, pressure cookers, steam cookers and frying pans

Microwaves and ovens

The refrigerator and the freezer

Cutlery

Figures 17 to 20. Pot, Pressure cooker, Steam cooker and Frying pans (Source: designed by Canva Pro)

Figures 21 to 24. Microwave, oven, Refrigerator and Cutlery (Source: designed by Canva Pro)

To adapt the texture.

Blender, food processor and Thermomix.They are the most economical, have an adequate capacity to grind a few portions of food and are simple to use.

Figures 25 to 27. Arm blender, Food processor and Thermomix (Source: designed by Canva Pro)

Cooking tools, moulds and other accessories: piping bag, stainless steel piping nozzles, measuring spoons, moulds, Sieve, scoop, squeeze Bottle, scale and other culinary utensils

Figures 28 to 36. Piping bag, stainless steel piping nozzles, scoop, measuring spoons, Sieve, scale, squeeze Bottle and moulds (Source: designed by Canva Pro)

4.7 Hygiene and food safety in dysphagia

4.7.1 Importance of hygienic preparation of food

Hygienic preparation and serving of food is especially important for those people suffering from dysphagia. Unsafe food affects particularly infants, young children, elderly and the sick.

All actions applied to food preparation must take special care to avoid foodborne illnesses caused by biological, chemical or physical hazards.

Figures 37. Hygienic preparation of food (Source: obtained from Canva Pro)

4.7.2 Food Health hazards (Types of contamination)

A food hazard is agent in a food with the potential to cause adverse health effects. There are 3 types of hazards in food: biological, chemical or physical.

Biological hazards

Microorganisms such as bacteria and viruses are the most common type of food contamination and the agents involved in outbreaks of food-borne illness.

Chemical hazards

There are chemical contaminants that appear naturally in food and some others added during the processing. Chemical contamination can lead to acute poisoning or long-term diseases, such as cancer.

Figure 38. Chemical hazards (Source: obtained from Canva Pro)

Physical hazards

Physical contamination occurs when objects such as stones, bones, wood, plastic, needles, human or animal hair, dirt, metal, glass, jewelry, fingernails are found in food. Finding this objects may cause illness or injury to the person.

Figure 39. Physical hazards (Source: obtained from Canva Pro)

4.7.3 Correct food hygiene

Personal hygiene

A ll food handlers must be aware that high standards of personal hygiene are important.

• Wear clean outer clothing and hair and beard restraints

• keep their fingernails short and not wear any jewellery

• Food handlers should use gloves of food handling utensils or papers to handle ready-to eat-food.

Figure 40. Wash hands (Source: obtained from Canva Pro)

Safe food handling

Go video: Safe food handling

(Source: Ministerio de sanidad, 2012)

These are “Five keys to safer food”, which were developed by WHO to educate safe food handling behaviors to all consumers and food handlers.

Figure 41. Keys to safer food (Source: Food Safety - World Health Organization (WHO))

Storing food

Food storage should be aimed to keeping nutritional, sensory and hygienic quality.

A use-by date on food is about safety. This is the most important date to remember. After the use-by date, don't eat, cook or freeze your food.

The best before date, sometimes shown as BBE (best before end), is about quality and not safety. The food will be safe to eat after this date but may not be at its best.

Go video: Correct storage of food (Source: Ministerio de sanidad, 2012)

Go video: Correct storage of food

Chilling food

Chilling food properly helps stop harmful bacteria from growing.

Figure 42. Chilling food (Source: obtained from Canva Pro)

Freezing food

A freezer acts as a pause button - food in a freezer won't deteriorate and most bacteria cannot grow in it.

Defrosting your food

When you take your food out of the freezer, it's important to defrost it safely before cooking or eating it. Don't defrost food at room temperature.

Figure 43. Defrosting your food (Source: obtained from Canva Pro)

Avoid cross-contamination

Cross-contamination is the transfer of harmful bacteria to food from other foods, cutting boards, and utensils if they are not handled properly.

(Source: Ministerio de sanidad, 2018)

4.8 Preparation of texture modified recipes

The procedure for the preparation of texture-adapted foods is, in most cases, the same as for non-adapted foods. The main differences in this procedure usually occur once cooked and before serving. It is at this moment, when most of the elaborations must undergo a texture modification process using some type of food processor.

Steps to develop texture adapted recipes:

1. To know the characteristics of the food

2. Cook the food with the usual procedure of the recipe

3. Separation of the parts of the preparation for its adaptation in texture and subsequent plating.

4. Texture modification. Use of robots or knives/scissors to modify food texture.

5. Validation of the particle size and characteristics of the dish.

6. Plating process.

Figure 45. Infographic about Steps to develop texture adapted recipes (Source: designed by Canva Pro)

4.9 Texture adapted recipes

2-4 People

Ingredients

2 spoonful butter

2 tablespoons of cornmeal

One finger missing from 1 glass of hot water

2 pieces of string cheese (Cecil cheese or cheddar cheese)

Figure 46. Muhlama. Web nefis

How to prepare.

1. Start by heating a frying pan and melting the butter.

2. Add the corn flour and fry it for 2-3 minutes over high heat.

3. Add the boiling hot water and stir until it comes back to a boil and the mixture has a pudding texture.

4. Add the cheese cut in small pieces and mix until melted.

5. Keep on low heat until the butter rises to the surface and then remove from heat.

How to adapt it in texture

As it is a semi-fluid texture, it could be consumed at all levels of texture-adapted diets.

But in the mash type (level 4 of the IDDSI) it should be prevented from sticking in the mouth. To do so, we would add more water than indicated in the recipe.

Avocado Toast

2-4 People

Ingredients

2 avocados

3 tablespoons olive oil

1/2 tablespoon salt

4 slices of whole wheat bread

Image 47. Avocado Toast. Cookie and kate Web

How to prepare.

1. Toasting the bread slices with the toaster

2. Place the ripe avocado in a bowl, remove the seeds and skin, add the olive oil and salt and mash with a blender.

3. Spread the mixture on the toast

How to adapt it in texture

This recipe can be consumed by IDDSI levels 6 and 7.

To adapt it in texture to levels 4 and 5, the avocado smoothie could be used but the bread would have to be adapted.

For level 5 it would be necessary to chop the bread into small and homogeneous pieces with the help of scissors or a food processor.

To adapt it to level 4 it is necessary to introduce it in a robot and to grind it adding water until obtaining a homogeneous and thick texture like that of a pudding. It is important that it is not too thick so that it does not stick in the mouth and not too liquid so that it is difficult to handle in the mouth.

Note: usually bread is difficult to adapt in texture because it sticks or loses its flavor. If it is not essential for the recipe it is preferable to remove it or replace it with another food.

Important note: if you want to prepare another type of healthy toast, follow the same steps:

1º grind completely until you obtain a homogeneous and spreadable texture of the ingredients that will be used in the toast.

2º Grind the bread on the other side. It is important to obtain the right levels

Purus varškės apkepas/ Silk curd cake

Image 48. Silk curd cake. La Maistas Web

2-4 People

Ingredients

500 grams of curd

4 eggs

80 milliliters Milk

30 grams butter

4 tablespoons semolina (or rice flakes or oat flakes)

2 tablespoons sugar (or honey or other favorite sweetener)

Some bread crumbs

How to prepare.

1. Mix the semolina and milk in a bowl and let it hydrate.

2. Mix the butter with the sugar until stiff.

3. Separate the egg whites from the yolks and add the yolks and curd to the butter and sugar mixture beating until smooth.

4. Beat the egg whites so that they become a white foam.

5. Mix all the above ingredients together carefully integrating them.

6. Grease a mold and sprinkle with the bread crumbs and pour the contents.

7. Bake in oven at 220°C until it rises. Then reduce the heat to 200 degrees. It takes about 30 minutes to bake.

How to adapt it in texture

This recipe can be consumed by IDDSI levels 6 and 7.

To adapt it in texture to level 5 it is necessary to mince it with the help of a fork or food processor.

To adapt it to level 4 it is necessary to introduce it in a robot and grind it adding milk until obtaining a homogeneous and thick texture like that of a pudding. It is important that it is not too thick so that it does not stick in the mouth and not too liquid so that it is difficult to handle in the mouth.

Spanakopita

Image 49. Spanakopita. My Greek Dish Web.

4 People

Ingredients

How to prepare.

1. Preheat the oven to 200*C (390*F) with fan.

2. Melt the butter and, with a pastry brush, generously butter a 30x35 cm (11x12") baking pan and, one by one, place the filo sheets into the pan. The first ones covering the base and the rest crumpled in an elongated accordion shape in the pan.

3. Drizzle the remaining butter over the top of the folded filo dough in the pan.

4. Bake in the highest part of the oven for 20 minutes or until the filo is golden brown and crisp.

5. Meanwhile, in a bowl beat the 4 eggs, the 2 egg yolks and the sugar until fully integrated.

6. Add the vanilla, baking powder, milk, heavy cream and salt and continue mixing until smooth and even.

7. When the phyllo dough sheets are ready, remove them from the oven and pour the contents of the bowl, spreading them well throughout the dough. Sprinkle light brown sugar on top.

8. Lower the heat to 180* C and bake for another 20-25 minutes.

9. When done, remove from the oven and let cool slightly.

10. Sprinkle with powdered sugar and cinnamon before serving.

How to adapt it in texture

This recipe can be consumed by IDDSI levels 6 and 7 if cut into pieces.

For level 5 it would be necessary to chop it into small and homogeneous pieces with the help of scissors or a food processor.

To adapt it to level 4, it is necessary to introduce it in a food processor. If necessary, add milk to grind it until a homogeneous and thick texture similar to that of custard is obtained. It is important that it is not too thick so that it does not stick in the mouth and not too liquid so that it is difficult to handle in the mouth.

Resources

Cichero, J. A., Steele, C., Duivestein, J., Clavé, P., Chen, J., Kayashita, J., ... & Murray, J. (2013). The need for international terminology and definitions for texture-modified foods and thickened liquids used in dysphagia management: foundations of a global initiative. Current physical medicine and rehabilitation reports, 1(4), 280-291.

Sungsinchai, S., Niamnuy, C., Wattanapan, P., Charoenchaitrakool, M., & Devahastin, S. (2019). Texture modification technologies and their opportunities for the production of dysphagia foods: A review. Comprehensive reviews in food science and food safety, 18(6), 1898-1912.

Stading, M. (2021). Physical properties of a model set of solid, texture‐modified foods. Journal of texture studies.

https://www.ruh.nhs.uk/patients/services/clinics/speech_and_language/documents/High_risk_foods.pdf

https://www.uhn.ca/PatientsFamilies/Health_Information/Health_Topics/Documents/Pureed_Foods_for_people_with_Dysphagia.pdf

https://www.albertahealthservices.ca/assets/info/nutrition/if-nfs-dysphagia-soft-diet.pdf

https://dietitiansaustralia.org.au/wp-content/uploads/2015/04/A3_Aus-Standards-Food-and-Fluids-Poster-Check-2.pdf

https://www.ndr-uk.org/uploads/pdf/701461926596.pdf

https://iddsi.org

https://www.lybrate.com/topic/dysphagia-diet#food-items-you-can-easily-consume

https://iddsi.org/framework/food-testing-methods/

https://indeed-project.org/