On the Other Side of the Spoon

By Kindred Healthcare
CIS Peter Lam Nov 12 bThere’s more to pureed food than pureed food, and meeting the nutritional needs of patients can range from complicated to downright dangerous. Peter Lam, RD, CFE, of Peter Lam Consulting in New Westminster, British Columbia, addressed the group of attendees at the2014 Kindred Clinical Impact Symposium to talk about how we can better understand patients’ nutritional needs and concerns, and more optimally meet those needs.


Lam started with a reference to the fictional patient, Mary, who has had her NG tube removed and is now on pureed foods. He asked the group to surmise how Mary might feel. To help them better explore this question, Lam asked them to open a plastic bag that had been left on each table. With that, he went through a series of activities designed to allow each attendee to put him or herself in Mary’s shoes. 

  • Participants put two cotton balls inside their lower lips, and then attempted to eat a cracker 
  • They placed a marshmallow underneath their tongues and tried to swallow 
  • They pinched their noses and breathed for one minute through a straw, to demonstrate how it might feel to have an airway occlusion 
  • One partner closed his eyes and the other partner described an image seen on a screen, in order to demonstrate that there are several different ways to describe the same thing, and we may not always understand what patients are trying to communicate about food
CIS Peter Lam Nov 12 cLam explained that as humans age, they go through an extensive period of eating tougher-to-chew-and-swallow foods (after childhood) and then as they get into older age, “we go backwards.”


Standardization of food groups as given to compromised older patients is needed and coming; what is safe in one place is often not safe in others, and as a result, patients have choked.

“A lot of what we have learned has come, unfortunately, from coroners’ reports,” Lam said.

Lam challenged attendees to think about some of the protocols currently in place in their facilities and how these might need modification. He outlined a typical meal that included pureed forms of several types of food, including meat, potatoes, vegetables and pudding, and pointed out that the meal might require a patient to swallow 50 times. For a patient with dysphagia, that can be a real challenge.

Lam provided some strategies, including:

  • Small, frequent meals 
  • Nutrient-dense meals 
  • Food fortification 
  • Mealtime assistance 
  • Protected/ dedicated mealtimes 
  • Oral nutritional supplements 
  • Enteral nutrition
CIS Peter Lam Nov 12 dAs discussed earlier in the symposium with respect to other aspects of care, patient and family goals must be taken into consideration when it comes to nutrition as well.


  • If Mary loves chicken nuggets, but choked when she tried to eat one, is there a way we can get the flavor to her in some other way? 
  • If a patient or his family says, “if I’m going to die, it’s going to be eating beef tenderloin,” do we need to take that into account?

Lam offered a resource to participants as well. The Web site for The International Dysphagia Diet Standardisation Initiative, which aims to develop global standardized terminology and definitions for texture modified foods and thickened liquids for individuals with dysphagia of all ages, in all care settings, and all cultures, provides useful information at www.iddsi.org.