Grandpa Daeng* was bored with congee, but he had no choice because he does not have teeth to chew. Fortunately, his grandchildren came across a book titled 46 Food Recipes That Help To Train Swallowing based on the IDDSI (International Dysphagia Diet Standardisation). These special recipes helped Daeng enjoy his meals again. Two of his favourite dishes from the book are Szechuan soup and mushy rice with pork stew.
In collaboration with the Thai Dietetic Association, Varanya Techasukthavorn, a dietitian lecturer at the Department of Nutrition and Dietetics at the Faculty of Allied Health Sciences, Chulalongkorn University, teamed up with four other dietitians to create the book.
People who need these recipes have difficulty swallowing. Varanya explained these people include patients suffering from brain and neurological conditions, stroke, or head and neck cancer and side effects caused by treatment. Due to their conditions, they have to consume soft or mashed food. Additionally, elderly people whose physical health has declined with age easily choke or get food stuck in their throats. Many of them do not have healthy teeth making it difficult for them to chew and swallow food.
"There was a patient who sent messages to facebook.com/happytoswallow. She was afraid of swallowing because food would get stuck in her throat. The patient was stressed and worried. This stress can lead to depression and social isolation," Varanya said.
"I recommended she go to a hospital and consult a physiatrist or an occupational therapist who could assess her chewing and swallowing ability. Some patients feel pain, experience choking or have to repeatedly try to swallow their food while eating. Meanwhile, some patients can consume soft food, but others cannot and they have to eat pureed food instead. When swallowing becomes increasingly difficult, loss of appetite can eventually lead to malnutrition, causing weight loss and negative effects on their health," said Varanya.
Thais may not be familiar with dietitians. Varanya, who earned her master's in Dietetics from Deakin University in Australia and has worked as a dietitian for almost a decade, explained they are similar to nutritionists, but they focus on food for patients. Dietitians have to be present with doctors during ward rounds so that they can assess a patient's condition. They co-ordinate with cooks to design food specifically tailored to each patient's need.
Varanya also runs facebook.com/happytoswallow, which provides information about dysphagia -- difficulty or discomfort in swallowing -- and different kinds of food to consume. Many followers often send her messages and ask for recipes, so Varanya worked with four other dietitians to design nutritious recipes for people with dysphagia. To survey feasible dishes, dietitians created an online questionnaire which received 150 responses from all kinds of occupations -- nutritionists, dietitians, occupational therapists and physiatrists.
Rad na muu num (fried noodles with pork and vegetables in gravy) and tofu custard in ginger syrup for dysphagia patients.
From the survey results, the team selected the top eight to 10 dishes, including kai palo (stewed egg), khao man gai (chicken with rice), khao rad khaprao (rice with pork and basil leaves), tom yum goong (spicy prawn soup) and fak thong pad kai (stir-fried pumpkin with egg).
They also listed 80 dishes they wanted to create. However, after working on some dishes and experiencing failure, they eliminated those that did not work. The final selection of 46 is divided into eight levels from 0 to 7, following the framework of International Dysphagia Diet Standardisation which describes food textures and drink thickness. Drinks are categorised as thin (0), slightly thick (1), mildly thick (2), moderately thick (3) and extremely thick (4). Food is classified as liquidised (3), pureed (4), minced and moist (5), soft and bite size (6) and easy to chew (7).
People who cook these dishes have to test the food and beverages by using a fork or syringe to check the appropriate level before serving patients. The book includes detailed guidelines for testing the texture and thickness of food and drinks.
People who cook for dysphagia patients have to test the food.
All 46 dishes were selected based on three criteria.
"First, they must have nutritional value. Protein, carbohydrates and fat are the essential priority since they are the primary source of nutrition. Vitamins and mineral salt are of lesser priority. Secondly, the texture of each dish must match IDDSI levels in the book," said Varanya.
"The dishes should not include spicy condiments such as pepper and wasabi because they can cause patients to choke. The last criterion is that the taste and appearance must be appealing. One of the dishes we eliminated was kluay buad chee [cooked banana in coconut milk] due to its unattractive appearance and unusual taste," she explained.
The names of the dishes on the menu sound similar to regular dishes, but most of them are blended to ensure easier swallowing for patients. For example, in the chicken rice menu, the chicken meat is boiled and blended to a minced and moist consistency (level 5). Cucumbers are replaced with cucumber jelly to suit the texture requirement.
The target readers of 46 Food Recipes That Help To Train Swallowing are healthcare professionals and caregivers. One thousand hard copies of the book were published and given away to those who had reserved them. Anyone else who wants the book can download the e-book version at thaidietetics.org (in Thai).
The recipes require cooking skills because the foods and beverages need to be prepared at appropriate levels for patients. However, the book has received positive feedback, especially from caregivers.
"It was difficult to follow recipes in the beginning, but once people learned how to prepare the dishes, they could easily cook them. Patients need this kind of food and their children and grandchildren, who are caregivers, take great effort to ensure their loved ones have a proper nutritious meal. When we learn about their determination, it inspires us to continue our work," the dietitian said.
After reviewing the book of recipes, Varanya plans to add more information for a possible second edition.
"People have requested more details, such as blender speed and time. Throughout our repeated cooking experiences, we learned many tips. For example, in level 5, the dish rad na moo num (fried noodles with pork and vegetables in gravy), the noodle and pork should not be allowed to soak in the gravy for longer than 30 minutes as it can alter the food texture. We also want to provide tips for the ingredient selection," she explained.
Despite already having 46 dishes, there are still requests for more. Varanya suggests that people should follow facebook.com/happytoswallow. On special occasions like festivals or Chinese New Year, a dietitian will share new recipes on the page.
Rad na moo num is categorised as level 5 (minced and moist) on the International Dysphagia Diet Standardisation.
Varanya is currently working on developing an instant food product which will be easy for elderly people to prepare by themselves.
"In Japanese supermarkets, there are large sections of instant food products for elderly people. It inspired me and I hope to see similar sections in our supermarket. One of the dietitians in our team is working on an instant rad na dish since it is popular," said Varanya.
"Our survey shows that when people are sick, they prefer having dessert over regular meals. Desserts provide more calories and can easily contribute to increased protein intake. In August, we will launch a high protein strawberry pudding which can be consumed as a snack between meals as well."
* Not his real name
Tofu custard in ginger syrup.
