Why Do We Care About Diet Texture? The Rationale Behind Diet Texture Recommendations

Speaker1:
[0:15] Hi, everyone. I'm Emily.

Speaker0:
[0:18] And this is Eva.

Speaker1:
[0:20] And you're listening to Speech Talk.

Speaker0:
[0:22] We're your research book club so you can do evidence-based practice in practice.

Speaker1:
[0:26] So let's start talking.

Speaker0:
[0:29] Emily, what was exciting that happened for you this week?

Speaker1:
[0:32] I know that I've talked to you guys before about my cart. You know, I just blew into my eye.

Speaker0:
[0:39] Your work cart. Yes.

Speaker1:
[0:42] So I have this work cart and day one, I got it quite as a mouse. Today, it is like I'm pushing a full dumpster through my facility. It's just like all the way down. So my boss was talking to my coworker and I'm trying to like tiptoe through this conversation with my loud dumpster. And I get almost through the door when one of my patients with severe dementia, lots of fluctuations, elbows me and goes, I think you made it out. He's like you made it out unscathed no one noticed it was very sneaky oh i love those highlights

Speaker0:
[1:37] That's so great. I like that he definitely has your side. Like, you could. I was watching. I'm looking out for you. You're good.

Speaker1:
[1:45] Eva, what about you? Tell me this week.

Speaker0:
[1:48] Classic, not fun, fun. I was on holiday. I was on vacation. And so I hadn't been at work. And I came back. And of course, the entire caseload is brand new. I don't know anybody. And I was like oh man it's a heck of a reintroduction you're like okay I have 30 minutes to chart I've got to do all new patients and learn everybody's background then I get into my first patient's room and she's super sweet, and she has the same nickname my mom has and I told her that and she said thank you and I was like I guess you're welcome, we're like talking about you I'm trying to get to know her a little bit. What is something you enjoy doing? She's like, well, I enjoy spending time with my daughter. And I was like, oh, that's really sweet. After a long pause where she's just staring me directly in the eyes, she goes, even though she's a snitch. And I was like, wow, you really mean that, don't you? She goes, mm-hmm. Rough. But you know what? It sounds like they're working through their relationship. So, beautiful.

Speaker1:
[2:56] She loves her even though. That's unconditional love.

Speaker0:
[2:59] That's unconditional love. Exactly. Well, that's fun stuff for today. Before we get into it today, I just want to let you know, we're going to be talking about chewing more than you have ever talked about chewing in your life. We're going to talk about tongues and jaws and swallowing and munching and teeth and all of the parts of eating. So just hang tight because that's what we're doing today.

Speaker1:
[3:24] Eva, so why does that matter? Why does chewing function in all the swallow things? Why do we care?

Speaker0:
[3:31] Why does chewing matter? Why do you modify textures matter? Why do our jobs matter? Why do we show up to work? It all matters because ultimately we're trying to provide the best eating experience for somebody at whatever stage of health and life they're at, right? So we need to really deeply understand, like, what does a healthy chew swallow function look like? How can things vary? What are sort of the diagnostic categories under which we can assess whether or not somebody has problems eating and swallowing? And then what can we do about it, which is usually where we're getting into modified textures. And so it's really important to make sure we understand those two and how they interact with the swallow. So buckle up, everybody. We're about to get down. Emily, you chose today's episode, so I think it's only fair that you introduce it. What are we talking about?

Speaker1:
[4:24] So this week comes to you from our friend, Nicole, and that is by the difficulties that That is explaining to the kitchen staff that we need consistency from them by my own difficulties explaining to staff that we need to have a reason and a list of things that are excluded from specific diets. It matters.

Speaker0:
[4:46] You mean there need to be rules, Emily? This isn't like a free-for-all excitement?

Speaker1:
[4:52] I do not just make random recommendations for the fun of it. There is reasons we restrict certain foods.

Speaker0:
[5:00] So let's talk about it. No, we should just like have a wheel, like spin the wheel. Like what texture do you get today?

Speaker1:
[5:06] You cough too much puree.

Speaker0:
[5:08] Yeah, yeah, yeah, exactly. So that you get, start weighting the wheel.

Speaker1:
[5:12] You look very hungry. Pizza.

Speaker0:
[5:17] You said that you'll want to talk to the supervisor if you don't get a pepsi you get pepsi.

Speaker1:
[5:23] You get two if you leave a good review

Speaker0:
[5:25] That's right that's right five star reviews, Um, not a plug for Scrubs because until we get sponsored, nothing's an official plug, but they have a whole episode in the new season about, um, what it's like to be reviewed as a doctor and like getting stars and needing to like look good on the internet as a medical professional. And I was like, oh, I cut steep.

Speaker1:
[5:50] You know, one time I, my kid's doctor went above and beyond, so I actually left a review and she texted me. Thank you. And I was like, oh, shouldn't this be anonymous?

Speaker0:
[6:04] I want the praise. I didn't know you could review your doctors. I should I should go review my children's pediatricians and thank them publicly because they do a great job. Anyways, why is this from Nicole? What did Nicole say? What did I miss in our group thread?

Speaker1:
[6:17] So Nicole was asking us how we explain dietary textures. What makes a certain dietary texture suitable via ITZY standards? And how can we properly explain that to staff? And it just got me thinking about how all of this actually matters. Why do we take the time out of our day to explain the different levels? Why are we so hard on our kitchen staff and our aides to make sure that our recommendations are being followed through based on these levels?

Speaker0:
[6:52] So as I like to remind people, the ITZY rules are not my rules. They're the ITZY rules.

Speaker1:
[6:58] Yeah.

Speaker0:
[6:59] Because this isn't a me thing. It's an international standardized process thing. Can't wait to get into this discussion right after this break. Music.

Speaker0:
[7:11] Okay, and it's good to be back. Emily, what are we reading today?

Speaker1:
[7:16] Our research is a few articles, but we're going to start off with textural changes by mastication and proper food texture for patients with oropharyngeal dysphagia by Kurichiro Matsutu-Eron.

Speaker0:
[7:31] Yeah, so this article was really great because it basically describes chewing, which obviously we're all really excited about. So basically, right, we eat, we take food in the mouth. Don't put it in your nose unless you have a nasogastric tube. Food in the mouth. You chew it, it mixes a saliva, it breaks down. And that's when our body is like, hey, this is now ready to swallow. And if you've ever swallowed before that moment and you get that really uncomfortable stuck feeling, you know what I'm talking about. So we make our food into this chewy spitty ball and then we push that backwards with our tongue and then our pharynx kind of takes over and we have this pharyngeal stripping wave but we're gonna, keep it in the mouth for now and i feel like that's not an appropriate phrase to keep.

Speaker1:
[8:18] It in the

Speaker0:
[8:18] Mouth and let's just keep it in the mouth all right.

Speaker1:
[8:23] I thought it was interesting, though, reading this article, I learned that mastication isn't just moving the food back and forth, but there's like a rhythm to chewing, right? When we eat, there's a cycle of tightening and relaxing. And the one thing I learned in this is that when we close our jaw, then reopen, we're creating this vacuum that almost helps pull the aroma from food into the nasal cavity to increase the inclusion of those chemoreceptors in the nasal cavity. Wow, I feel like those. meaning smells, the sniffers.

Speaker0:
[8:54] The sniffers. I feel like that was like a very exotic description, like this very romantic tangent.

Speaker1:
[9:00] You just went

Speaker0:
[9:00] On. I feel like we should watch one of those food shows where they're just like these gorgeous up-close, like shots of food that are supposed to make you just, you know, drool. And that should be the voiceover.

Speaker1:
[9:13] Yes. That's probably the problem is that I watch too much Food Network.

Speaker0:
[9:18] And we're creating a vacuum that almost helps pull the aroma. Like my food voiceover.

Speaker1:
[9:26] I know. Aroma is a weird word choice. I don't know why I said that. But the aroma, the smell,

Speaker0:
[9:31] The snuffer. It was poetic. It was romantic. I loved it. Yeah. So basically the tongue movement is then temporal, spatially related to jaw movements, right? So your tongue is moving in relationship to everything else, including your jaw movement. As the jaw moves down, the tongue generally moves forward. And as the jaw closes, the tongue generally moves back. So we kind of have this push-pull with the tongue and this push-pull up and down with the jaw. Those go together. They're synergistic push-pulls, if you will.

Speaker1:
[10:04] Then we go into an antigenetic. Is that the other word? Synergic? Antrenagic? That's not a word.

Speaker0:
[10:11] You know what? Don't.

Speaker1:
[10:15] Don't say that.

Speaker0:
[10:15] We're supposed to sound smart right now. But like, don't push it into words we don't know about.

Speaker1:
[10:21] I'm just excited to have Eva back. And I think that's the problem. And I'm like too jazzed about recording again.

Speaker0:
[10:27] Okay. Wait, wait. But you forgot to mention that this kind of movement is actually overall pretty important for protecting the pharyngeal cavity from food slipping backwards or that posterior spillage. So this kind of like, I'm going to stick with the poetry of your language, this dance of your oral mechanism is really key for also the safety of your swallow. Like all these parts moving together is what keeps your food in your mouth where it should be while it's being chewed up as opposed to slipping backwards or if the soft palate is in the wrong place, like going up into your nose. We don't want anything going into the nasal cavity.

Speaker1:
[11:03] Right. And in that same vein, your soft palate moves in the opposite direction. So when the jaw opens, a soft palate tightens and blocks the nasopharynx. And as the jaw closes, it relaxes. So again, letting air in whenever your jaw is closed, but tightening up to make sure your nose is protected from any food or drinks going up that way.

Speaker0:
[11:28] Yeah, this is a really good review of how all that works.

Speaker1:
[11:33] So if you're not a speech therapist.

Speaker0:
[11:35] Wait, and I just want to say, for those of you who are listening, and for those of you watching but who don't have x-ray vision, as Emily's been talking, I am trying to do it too quietly to myself and make sure that everything is being described correctly. I'm like, jaw open, soft palate, moving, tongue. All right, cool. That is how it works.

Speaker1:
[11:59] But like if it i yes like you can do that and you can feel it but have i ever tested it or thought about it before this article no i like that

Speaker0:
[12:09] And that's always the hard thing about being in the room with your patient is like you give this technical breakdown of chewing, which is usually unhelpful so i don't always do that when you're like explaining dysphagia techniques to people and you're like well this is how your body is supposed to chew and now we're retraining that or we're doing these compensatory strategies because, your body isn't doing those movements. Then they start thinking about their chewing and then they overthink it. And they're like, chewing is the most complicated thing I've ever done in my whole life. I'm like, it does feel that complicated when you think about every movement.

Speaker1:
[12:46] Yeah, don't think, chew.

Speaker0:
[12:48] All of that wonderful anatomy and physiology aside, what does this have to do with the article?

Speaker1:
[12:53] There are specific factors that influence and alter our ability to masticate food. I won't go through all of this, but in general, we're talking dentition or your teeth. Are they connecting? Is there anything missing? the saliva production do you got it do you don't the food property is is it soft moist chewy hard like what are we actually chewing and all of that really does make a difference yeah

Speaker0:
[13:20] I did just have a patient that was like um, minced and moist not because of any issues in coordination with the oral cavity but just dentition she got some loose teeth it hurts to chew what's she gonna don't do. Put her on a soft diet.

Speaker1:
[13:37] And a lot of people really do, like, that's their first thing. I can't chew a pork chop, so I need my food to be softer. Yeah, that makes sense. And then they get their soft food and like, I will rather gnaw on a steak for 30 minutes than eat this cat food. And I say, good for you, sister. Do what you do.

Speaker0:
[13:58] Yes. Or you're like my husband and you have an exposed nerve in your tooth. And so you just chew on the opposite side of your mouth indefinitely. Then one day, reveal it to your spouse, who then goes, go see a freaking dentist. Like, what is wrong with you?

Speaker1:
[14:10] Like your mother-in-law? Like, it's not even like you don't have access. Like, go talk to my mom. Like, what are you doing?

Speaker0:
[14:19] My mother will tell you who to go see. You have to knock on the door in a very special way. So say, what are you here for? You say, I need a cab. Anyways, within that kind of context of like food properties, the importance of like how we physically chew is really important. So even though... Somebody can be getting a harder texture if they can, you know appropriately masticate it and get it down to a puree because at the pharyngeal level all they can do is swallow puree then like great if they can do one bajillion chewing cycles to gnaw up that pork chop, until it's like a soft enough consistency that they can swallow perfect like bully for them good for you uh, the mechanics of the swallow to the point of like this earlier aspect of, our discussion like really matters because analyzing somebody's ability to perform the mastication does impact their overall swallow safety, and so while it feels really really annoying and pedantic and micromanaging to sit there and count someone's chewing with them, yeah it can make a big difference right i try to remind people that I'm like, I'm not watching you chew intently and like touching your chin to like see how often your jaw moves for my own amusement. Right. I promise.

Speaker1:
[15:44] Now, I once counted 175 chews of someone chewing a cheeseburger. It was functional, but it took a long time.

Speaker0:
[15:53] That's so much. I think I would, like, lose track. I'd be like, 23, 25. What did I have for lunch this morning? I mean, what did I have for breakfast this morning? 20, no, it was 17, 18, 19. My counting is not linear.

Speaker1:
[16:10] When we're talking about, I don't know if you said this or not, There was a fly, Eva, so I started to get distracted. But the number of chewing cycles and the chewing duration, both of those were found to increase with the hardness of the food. So the harder the food is, it makes sense, the longer you're going to have to chew it, the longer that chewing cycle is going to be. And if you don't have, again, like Eva, I think you were saying, if you don't have the dentition, it is going to take you longer. So So, yes, our patient might be chewing 175 times, but they didn't cough or choke or die on that piece of cheeseburger. So they did it. It took them a long time, but he was mighty motivated to get through it.

Speaker0:
[16:53] I feel that way about cheeseburgers, too.

Speaker1:
[16:56] They also found that the amount of time that the food is accumulated on the vollecula is also extended with greater food hardness. So you have more food hanging out in your throat for longer periods of time if the food is harder. So if you have a swallowing impairment, that could potentially be more dangerous. So again, it's not for no reason we're talking about the hardness of food. There can be greater risks.

Speaker0:
[17:24] I just have all these memories of my mom coming home for work, like talking about the nuances of like, flossing and like oral care and just being like, uh-huh, uh-huh. And here I am talking on a podcast about the influence of food hardness. I'm like, just like my mom.

Speaker1:
[17:47] So important. Yeah. We all grew up to be our mom.

Speaker0:
[17:50] For better or for worse. I think it's for better. I think I've embraced it.

Speaker1:
[17:55] I know, me too. I've also embraced it. I love my mom. She's crazy, but I love my mom. She doesn't listen to the podcast, so it's fine. It's fine. I try. I ask. I said, will you listen, mom? She was like, it's not my thing. I was like, oh.

Speaker0:
[18:10] Know the hell. She's like, I know myself, and your podcast is not my thing.

Speaker1:
[18:15] I love you.

Speaker0:
[18:17] Okay. We keep meaning to get to the pharyngeal swallow. Let's do it.

Speaker1:
[18:21] But you talked about this a little bit earlier, but the pharyngeal swallow, that is when the food is then leaving your oral cavity and you're initiating the swallow from the back of the tongue down into the esophagus. The timing of the swallow initiation is significantly different for food than it is for a liquid.

Speaker0:
[18:45] And this is kind of one of the overall parts of the article, right? That liquids roughly stay the same in your mouth. There's like you take a sip of water, it's a sip of water the whole way down. But food is inherently transforming texture.

Speaker1:
[18:59] When we initiate a swallow with liquid, most of that liquid is still in your mouth, right? It's not going down to your throat. When you're chewing food, we're chewing, chewing, chewing, and then the food can reach all the way to the molecula before we really initiate that swallow.

Speaker0:
[19:18] When we're talking about food at the oral stage or if it's in the pharyngeal stage, that transition is kind of where the swallow itself gets triggered, right?

Speaker0:
[19:27] Something I found interesting was that your brain has to have this kind of moment where it's like, all right, okay, swallow now. Like all of the muscles now all of a sudden have to like work in sync and move food back. And so for liquids versus solids, we have kind of a different signal. With a liquid, the whole thing sits in your mouth until the moment when you decide to swallow. But with solid foods, the leading edge of the food has already like reached the vollecula. Like it's already kind of down in the entrance of your throat before the full swallow mechanism actually gets triggered. So the researchers have this theory about why this works safely. Their conversation is that your body has to kind of create bolus cohesion, how well it's like holding the food together as a single unit. And that depends on a couple of things, like how small are the bits of food that you're chewing up and how much saliva got mixed in. So when you get that balance just right, the bolus stays intact as a single mass in your throat before and during the swallow. And that's exactly what keeps you from like aspirating stray bits of food into your airway. And like you don't have stuff just kind of like all over your throat and mouth and you're struggling to get it all down. Like we feel food in one mass go down.

Speaker1:
[20:54] I also love this article because they gave us a new term, oral hypofunction. Why I've never thought of this before. I don't know. But they said this is the inclusion of three or more factors, including oral and lingual force, mastication effectiveness, oral hygiene, and oral moisture.

Speaker0:
[21:15] Oral hygiene. Always got to bring it up. Cannot talk about it. And just for the, to break down the longness of that term, oral, obviously, mouth, hypo, below, function is function. So, like, things are not functioning up to par. They use this as like a diagnostic group right that they're like hey if you have those factors that Emily just mentioned that you have like reduced oral, or tongue strength poor mastication poor oral hygiene and reduced oral moisture it's just kind of a way of saying hey you've got this cluster of issues so your mouth ain't really working the way it's supposed to to make sure that you're eating properly.

Speaker1:
[21:59] So then they looked at how do different dietary textures impact swallowing safety? So they evaluated the frequency of aspiration and penetration and furniture residues among different types of food. They didn't use ITZY. They used like a five stage something. This is a Japanese article. But on their scale, five was regular, four is soft, three is puree or mixed. And two is described as like a mixer meal with gelatin.

Speaker0:
[22:35] Okay, so it's kind of like it's not liquid. It's solid but kind of like gelatinous.

Speaker1:
[22:43] It's a liquid.

Speaker0:
[22:44] Gross. I do not like the idea of drinking gelatin, like a straight jelly that's unapetizing to me. Sorry, if you like gelatin, thanks.

Speaker1:
[22:56] If you are personally victimized by this.

Speaker0:
[22:59] By my comments. I know they say don't yuck other people's yums, but I have like a, I don't even just like regular jello. People are like, jello shots. I'm like, another kid. I'm also in my 30s and have two kids. So dental shots are not like a big part of my life anymore.

Speaker1:
[23:18] And then zero is thin. So tested at 121 patients with dysphagia.

Speaker0:
[23:24] Yeah, they got like men, women, different ages, though the average age was like 73, right?

Speaker1:
[23:30] And a bunch of different causes. So some had a CBA, some had... Pneumonia, but they all underwent an MBS. The severity of their dysphagia was determined by using a food intake level scale. And what I thought was very interesting about this study is that they did show patterns among people with dysphagia with specific types of texture food, just as a baseline. So penetration aspiration was markedly more frequent with thin water. Penetration aspiration was also less frequent for extremely thickened water or for the crushed gelatin or jellies. Pharyngeal residue was remarkably lower for sliced gelatin and water than for mildly or extremely thick. And these results suggested that the sliced gelatin was the safest type of food for dysphagia patients, like period. Like across the people, they had these to say.

Speaker0:
[24:37] One, I would have never thought to give in anybody sliced gelatin. Two, while you said the words gelatin and jelly so many times, all I could think was, gross.

Speaker1:
[24:51] Yeah.

Speaker0:
[24:53] I feel like my clinical brain should have been more engaged, but it was less engaged due to my feelings about jelly textured substances. But, you know, you and I have had this conversation about thickening and... One million times, but I just was kind of like, what are we doing here? You know, like thin liquids are often not necessarily the best choice in terms of perfect swallow safety, but it appeals to patient preferences. If you can have good oral hygiene and are just drinking water, it's relatively safe. Like the idea that now we got to start figuring out if we should be giving people crushed gelatin i'm like oh there's so.

Speaker1:
[25:41] I i like the study in general because they talked about these as like blanket kind of statements but you know there's no blanket to cover everything so everything we we do have to take like you said with um a bit of water so

Speaker0:
[25:57] If somebody had that was their absolute safest texture i cannot imagine sending somebody home with that as a recommendation, you must now eat sliced gelatin forever like what no no you can't do that no that's too onerous.

Speaker1:
[26:14] But maybe it makes you a little bit more comfortable trying different foods knowing that these are could be safer for people so if someone's npo and you have jello at your facility and want to see are they masticating and organizing a swallow maybe that's appropriate All right.

Speaker0:
[26:33] Fair. Way to, you know.

Speaker1:
[26:35] Instead of a ice cubes doing sliced jelly.

Speaker0:
[26:41] Way to make it practical. Wow. I was just being out there being negative. And way to bring us back to something practical. I appreciate that, Emily. Thank you.

Speaker1:
[26:52] But the point of this article, too, is the reason I liked it is that there are these patterns. we can see like yes there's more aspiration and things within like there are a reason we have textures but So those are people with known dysphagia. What about healthy people?

Speaker0:
[27:12] Tune in for part two about chewing. Just in quick summary, I know we reviewed a lot about the anatomy and physiology of chewing, probably more than people want to be thinking about if you're listening in the morning when this episode comes out. But again, it's important to understand the mechanics because then when we add in those factors around, the oral hypofunction, such as issues with dentition, saliva production, or complications with food properties. We need to know what those potential impairments are and how they differentiate from a normal swallow function so we can help people compensate or learn strategies to work back towards that. So with that minor summary of what we got into, let's talk about a healthy chew.

Speaker1:
[28:01] So now we're switching into chewing and swallowing patterns for different food textures in Healthy Subjects.

Speaker0:
[28:09] By Karita Kasari et al.

Speaker1:
[28:11] So this study looked at 75 healthy subjects who were in their second year preclinical dental students. All comes back to your mom this time.

Speaker0:
[28:23] I'll tell her to listen to this episode specifically. She too does not listen to our podcast, so mom's all around.

Speaker1:
[28:31] The subjects were asked to prepare five samples of food selected with variants selected with varying textures and flavors including sweet foods such as a mini cup of jelly

Speaker0:
[28:43] Again not my favorite.

Speaker1:
[28:45] Uh one piece of gummy jelly one piece of biscuits

Speaker0:
[28:50] I was like all right now we're done i was like no no no not the trial for me.

Speaker1:
[28:54] They had salty foods such as a slice of original flavor potato crisp and eight medium-sized grains of roasted nuts.

Speaker0:
[29:05] These are the Brits. They say crisp. And by the way, these are all like very specific. There's like grams of jelly in diameter of said chip, plus or minus four centimeters, in case anybody cared. Roasted nuts of plus or minus four grams.

Speaker1:
[29:23] They discuss the variations of hardness, gumminess, and chewiness. Eva, without looking, how would you tease those apart? What do you think? Hardness, gumminess, chewiness.

Speaker0:
[29:38] In lay terminology, and by that I mean how I would describe it to a friend, hardness. I'm like, I don't know, think about eating a jawbreaker. Like, it's hard. Like, can you crack through it? Gumminess I'm thinking of like, a stickiness factor um chewiness, gumminess and chewiness oh god I don't know if I can tease those apart I'm like one of them makes me think of noodles and one of them makes me think of candy like a gummy bear.

Speaker1:
[30:12] No you did so good like yeah hardness was like how much compression you needed on the texture um then they said that gumminess was the energy required to disintegrate a semi-solid food i think that was a weird term but i think of like gumming the food like literally gumminess the gums

Speaker0:
[30:34] And then you gotta come it.

Speaker1:
[30:37] So hard um and finally chewiness is the energy required to chew a food before swallowing so like how many times are we chewing is the chewiness

Speaker0:
[30:50] Okay so we have the actual like metrics are uh force energy and, and duration.

Speaker1:
[31:03] But it's still, they still said energy required to get through them.

Speaker0:
[31:06] Energy required, yeah. You know what? They had to figure out how to define those terms and I'm not going to blame them for the difficulty of that task.

Speaker1:
[31:14] Right.

Speaker0:
[31:15] No, they did good.

Speaker1:
[31:17] So the food sample with the highest hardness was the biscuit. The food sample with the highest gumminess and chewiness value was the gummy jelly. Potato crisp had the lowest hardness and chewiness values while the roasted nuts had the lowest gumminess value

Speaker0:
[31:34] That's so much effort to think about snacks, it's like so uh so extra god research is such a such a bee.

Speaker1:
[31:51] I know that's why we do this so we read it so you don't have to, but you should read along with us. Double check our facts.

Speaker0:
[31:58] So some of the interesting results were that like harder foods took longer to manage at the start of chewing. So before that first swallow, but hardness basically has no effect on the total time it took to finish chewing and swallowing the whole thing. And that's because once you've made it past that first swallow, their main food is like already broken up and mixed in with your saliva. So even though initially we might think of it as a difficult food, in some ways, like if you can get that first swallow down, like you're clear, you're good. And the single biggest predictor of chewing and swallowing patterns wasn't hardness at all. It was, in fact, the gumminess. The gumminess ended up being kind of the tricky one. The gummier the food, the fewer chews and And the less time it took, both at the start and at the end of the sequence. So chewy food. It's a sneaky one. I don't know how you rate food on gumminess before you start that process. You're like, hmm, I know I struggle with gummy foods. How gummy do I think this will be?

Speaker1:
[33:07] I'm glad I didn't have to put them into categories because it is, they are weird categories.

Speaker0:
[33:12] Yeah. Also, just kind of a funny recommendation to be giving people. It's like, actually, you're doing pretty well with hard. It's the gummy things you're struggling with. Don't eat gummy stuff. It's like, oh, okay. Let's come up with that list, I guess. And they did find a statistically significant link between dental pain, chewing cycle count, and swallowing time. So, again, it just reinforces how much food texture and characteristics drive the whole chewing and swallowing process. This is all part of that elaborate eating dance.

Speaker1:
[33:46] So when we apply these normal findings to our oral hypofunction group, they're likely to be a dentulous, right? Or have some kind of dental supplement. They're talking dentures, partial things. So if they don't have an occlusive surface to break down food, then they aren't going to break apart the bolus for cohesion into a swallowable bolus.

Speaker0:
[34:09] Wow, that sounded like such a smart sentence because all of the words had like seven syllables.

Speaker1:
[34:18] Listen, I'm romantic and smart today.

Speaker0:
[34:21] Oh my God, I'm loving it. I mean, the occlusional factor of a surface is not something I ever think about. But yeah, I think basically what you're saying is like, do you have something to chew the food against? You know, and if you don't have that, then it's a lot more work and it's harder to break down your food.

Speaker1:
[34:42] So harder food needs that increase of force to get to normal mastication time. But if we don't have those healthy structures, we're increasing risk of fatigue. If we are fatiguing at the very beginning of our meals because we're going right in for that steak, then we're not going to have any energy left over for our mashed potatoes.

Speaker0:
[35:08] Yeah and some people for them potatoes are the best part.

Speaker1:
[35:15] I feel like in my in my little thing it was uh the the steak was the best part we're diving into the

Speaker0:
[35:21] Steak we're diving into the steak personally i'm pro the steak but you know some people really like potatoes as i say a meat and potatoes kind of girl.

Speaker1:
[35:32] Listen, and if we haven't, and if you think that we haven't beaten this point home enough, we're going to review one more.

Speaker0:
[35:40] We have one more article about chewing because today we're all in on a chewing marathon. All in.

Speaker1:
[35:47] And this one is called, What About Foods? The Influence of Food Texture on Safety, Timing, Kinesmatics, and Efficiency of the Pharyngeal Phase of Swallowing in Healthy Adults. So, healthy chewing. We saw now we're doing healthy swallowing.

Speaker0:
[36:04] And you thought those were part of the same thing. You're wrong.

Speaker1:
[36:08] Wrong. Wrong.

Speaker0:
[36:11] Yeah. So chewing, obviously, oral phase, pharyngeal phase, swallowing. Let's jump into it. So it looked into a small cohort of healthy adults and tracked pharyngeal swallowing across three texture categories, minced and moist, soft and bite size and regular textures basically kind of all of the like slightly more advanced textures, like moderate to advanced.

Speaker1:
[36:36] Mm-hmm.

Speaker0:
[36:37] And what makes it valuable is that it gives us an actual normal range baseline across multiple real textures. So we had just talked about in the last article, what does a healthy chew look like? Now we're talking about, well, how do we define that? What actually is a normal range? So it's not just the standard cracker barium test. They used a cracker round gummy and a raw carrot. Get some veggies in.

Speaker1:
[37:07] I was so like happy when I saw that. A raw carrot. Because it's like, that's like we. I'm not playing. I'm not playing. Like, that is one of the things. If someone doesn't have teeth, they're like, what do you avoid? Carrots, unless they're cooked. But they're like, give it to them raw.

Speaker0:
[37:30] I just love the idea of somebody being like, well, like how serious was it? It's like raw carrot serious. I'm going to start using that as a metric of my seriousness that nobody's going to understand. It's like, how badly do you want to go with raw carrot bed? I have to go to the concert. And so here's a detail that I think is important. Minced and moist textures produce the longest duration for the upper esophageal sphincter opening. So that little ring that helps keep your esophagus closed against food coming back up and into your mouth. Yeah. Regular texture food produced the longest duration for like your larynx opening, your laryngeal vestibule. So it's kind of like literally where your airway is and we don't want food ever going in there, ideally, unless things have gone wrong. And everything for everything else, timing wise, was like roughly comparable across the three textures.

Speaker1:
[38:35] Yeah. And I think that kind of ties back into our first article when we talked about how all of those structures are relaxing because we're chewing. The harder the food is, the more time it takes to chew, you have to breathe while you're chewing. So it makes sense that for the longer time that you're chewing something, that laryngeal vestibule, where your air goes, has to be open for longer amounts of time so you can breathe while you're chewing before that swallow happens.

Speaker0:
[39:07] The micro mechanics of swallowing. Did this like bring up any questions for you?

Speaker1:
[39:13] For me it made me think about like okay so the regular food is taking us longer to choose so we're breathing so we have to coordinate that breathing swallow timing stuff but also like if your airway is open longer does that innately just increase our risk of choking because of those that yeah okay so being open longer

Speaker0:
[39:39] I think what it sounds like you're saying is that which one is inherently more problematic? Like the harder foods cause the laryngeal vestibule to be open for longer. We don't want the laryngeal vestibule to be open for longer periods.

Speaker1:
[39:56] While we have food in our mouth.

Speaker0:
[39:58] While we have food in our mouths, I guess I would want to know before I could answer that, like what is an appropriate amount of time for it to be open without concern? Like it might be open for longer, but. Is that actually an issue that it's open for longer? And I guess that also depends on the swallow impairment in itself or potentially lack thereof. So if somebody's laryngeal vestibule is like sitting open wide for some reason when it should be, but they're like transiting the food completely safely, then like fine. If it's open longer and people are having this really dangerous pharyngeal level swallow, then we're like, no, no, no, no, no, thank you. But then going back to the minced and moist thing where it's like the upper esophageal sphincter is having trouble there. It has the longest transit time. If somebody has food that is just like sitting at their upper esophageal sphincter their ues, and and say their laryngeal vestibule doesn't close properly now we have a different type of problem like in both cases there's potentially just something sitting around waiting to get into the airway which is what we're trying to prevent.

Speaker1:
[41:10] I view the other way as like a positive that the UES takes longer or stays open longer. So it gives you more opportunity for food to move down. So if you're having maybe some esophageal dysphagia issues or maybe timing in general is just hard for your swallow and you need to do something like a set prep to make sure your food is moving good or you have tightness or there's some reason your UES isn't opening, than going to a minced and moist kind of texture might give your swallow a little bit of extra time to clear because it stays open longer just because your brain wants it to.

Speaker0:
[41:58] Got it. Your brain tells it. You know what? I'm realizing I completely misread it. I was thinking that it takes the longest for it to open. Like it was staying closed and the duration until opening was longest. Yeah. That's not what it was. It's that it was actually open for a longer period. Got it. Okay. Completely misread. Got to admit it, but you do it.

Speaker0:
[42:24] There's also something really important we need to discuss. Emily, tell us about bread, because bread is like the bane of everyone's existence, in terms of the IDC scale.

Speaker1:
[42:35] Bread is the the bane of our existence for itsy bread i don't know if i can shout this into the ether loud enough bread is a regular texture yes that bread that bread yes that bread crusty bread yes crusty bread sandwich bread yes it is a regular texture um in the show notes we will link a very nice publication that they talk about bread being a specific choking hazard because there's been multiple cases where people are having bread and it's an increased risk but Bread absorbs moisture, and that moisture expands the texture. That is problematic if your bolus is getting bigger while you're trying to masticate it. It gets bigger. It gets gummier. It gets stickier. Bread is a danger zone. So I know bread is so loving to your soul. It is dangerous.

Speaker0:
[43:42] You love it. Warm with butter and salt. It's the best thing in the world.

Speaker1:
[43:47] Bread can be modified for different textures we've talked about puree bread before we've talked about making puree moist for the minced moist by like something like soaking a cake in milk or applying copious amounts of eva's favorite jelly

Speaker0:
[44:08] I mean i think that the reason bread is just like so horrible is that people when they think about bread they want bread and anything else is like, why would you do that to bread? Why would you soak it in milk? Why would you blend it? Why would you give me something that is the texture of puree, but in the shape of bread? Like it's just nobody. When people want bread, they want bread. They don't want anything else. And I think that's when you have to start telling people, like, if you can't swallow regular texture foods, then you got to just not eat bread because any of the substitutes will deeply sadden you.

Speaker1:
[44:40] So why do we care about food texture?

Speaker0:
[44:43] I don't know.

Speaker1:
[44:45] You do know.

Speaker0:
[44:45] I don't know.

Speaker1:
[44:46] Yeah, you do. You sat through this whole pot episode. You're here with us. Different textures are broken down differently and require different amounts of pressure to swallow. What's happening in your mouth teeth and such have a huge impact on the food cohesion and thus the slipperiness of the bolus to move successfully and smoothly UES opening window is shorter with regular textures than mince and moist, leaving more time or opportunities for potential residue or choking. Maybe. Who knows? Maybe not.

Speaker0:
[45:24] Maybe? Question mark? I don't know. All of this for real, but maybe not.

Speaker1:
[45:27] It could be. Get a swallow study. Who knows? Everybody's different. And people with a known dysphagia show really a wide range of behaviors. And every individual person needs their own swallow study to confidently identify which textures are safe for that person.

Speaker0:
[45:47] But, I mean, man, the whole conversation goes completely out the window when the person who you've been doing all this work for modified diets for, like, doesn't recognize that there's a plate in front of them. And you're like, you know what? Never mind. Never mind. This is not the right moment for this.

Speaker1:
[46:03] What we were looking at with the study from Japan was that moist, heavy textures without being too heavy or chunky moves with the most efficiency across dysphagic patients. Um so ultimately a texture modified diet can be an excellent choice for intermediary texture but it has to match the supported textures

Speaker0:
[46:26] It has to match the patient it has to match whether or not like their stars are aligned and if their astrology sign is in the, sky i obviously don't know a lot about astrology yo somebody told me that people's friendships are blowing up right now because mercury is in retrograde. The worst it's been in decades. So we should all sit with that for a moment and contemplate our lives. Yeah, your dysphagia diet needs to match your patient's sign. That's the underlying key from tonight.

Speaker1:
[46:57] It can only match if our recommendations match what's being put out. So why do we care? Because it matters. There is science behind why these textures make a difference. We have these edsy textures because it changes in your mouth and your throat when swallowing. We care because it's important.

Speaker0:
[47:21] Yeah, it's important. Yeah. And on that note, good night, San Diego.

Speaker1:
[47:27] That's our cue to esophago.

Speaker0:
[47:31] Oh, my God. That was terrible, and I love it.

Speaker1:
[47:38] You've been listening to Speech Talk.

Speaker0:
[47:41] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker1:
[47:47] If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world because as podcasters, our love language is in positive affirmations.

Speaker0:
[47:58] And if you like listening to us, you may like more podcasts from our network, Human Content, like How to Be Patient, Bendy Bodies, Knock Knock High with the Glock and Fleckens, and Psychiatry Boot Camp. If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Speaker1:
[48:23] If you want even more speech talk content, check out our website at speechtalkpod.com, where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker0:
[48:35] We're your hosts, Eva Johnson and Emily Brady.

Speaker1:
[48:38] Our editor and engineer is Andrew Sims.

Speaker0:
[48:41] Our music is by Omar Benzvi.

Speaker1:
[48:43] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker0:
[48:48] To learn about Speech Talks, program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers.

Speaker1:
[48:59] Speech Talk is a proud member of the Human Content Podcast Network.