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Interview with Dr. Diana Miranda on the occasion of World Food Day

20 de October, 2023

Today is World Food Day. We share an interview with Dr. Diana Miranda, a nutritionist and coordinator of the nutrition team at CNS – Campus Neurológico, about the importance of proper nutrition and the relationship between dysphagia and nutritional status.

Could you give an overview of the importance of proper nutrition for patients with dysphagia and how the nutrition consultation is highlighted at CNS – Campus Neurológico?

Diana Miranda (DM) – Dysphagia consists of difficulty in chewing and/or swallowing food and/or liquids. We know that dysphagia is common in neurological diseases such as Parkinson’s disease and other parkinsonisms, and Alzheimer’s disease and other dementia syndromes. Undiagnosed and unmanaged dysphagia has various consequences for the patient, such as respiratory infections, unintentional weight loss, and dehydration. Due to the close and well-studied relationship between nutritional status and the presence of dysphagia, we understand the need for a multidisciplinary approach in which the speech therapist and nutritionist are fundamental to minimize the impact of these difficulties on health. The Nutrition Consultation at CNS aims to assess dysphagia and define strategies to reduce its impact on the patient’s health, while also evaluating the nutritional status and developing a personalized meal plan for each patient based on their specific difficulties to treat and/or prevent nutritional imbalances.

What are the most common nutritional challenges faced by patients with dysphagia and how does CNS deal with them?

DM – One of the situations we most frequently observe is related to difficulty in chewing hard and dry solid foods such as meat, bread, biscuits, etc., leading patients to either eliminate them from their usual diet or take longer to complete a meal or even not finish it. An important consequence can be a decrease in daily food intake and an overall unbalanced diet that can lead to unintentional weight loss and malnutrition. Regarding hydration, the occurrence of choking when drinking water or any other liquid can trigger a significant decrease in fluid intake and lead to dehydration. It is common for the patient not to realize this or not to value it, as these difficulties gradually develop. It is important to understand that each patient is unique and should be individually evaluated. The role of family members and caregivers in early identification of these situations is crucial, as it allows timely intervention that ideally prevents deterioration of nutritional and health status. The challenge for the nutritionist is to strike a balance between adequate nutritional intake, the need to adapt the consistency and texture of foods, and respect for the patient’s preferences, contributing to maintaining the pleasure of eating. Additionally, when dealing with neurodegenerative diseases, we know that we are dealing with an elderly population, which represents an additional challenge.

What are the recommended nutritional strategies to improve the quality of life of patients with swallowing difficulties and enhance safety and satisfaction during meals?

DM – I would say the first step is to conduct a formal evaluation with a specialized professional as soon as the main warning signs are identified. After diagnosing dysphagia, it is important to establish which strategies that patient needs to implement to ensure that mealtime and hydration are safe. The nutritionist’s role, armed with this information, is to evaluate the nutritional status, determine individual nutritional needs, and develop a meal plan that will guide the composition of each meal of the day. Therefore, to ensure the success of any nutritional intervention, personalizing all our recommendations to each patient’s habits, tastes, and dietary and hydration preferences is fundamental. For example, we know that avocado is a nutritionally rich fruit and useful for weight loss situations, but if the patient does not like avocado or does not have financial or local access to it, they will certainly not consume it. From the beginning, some beliefs should also be debunked, one of which is the idea that anyone with dysphagia has to switch to “eating porridge” – not all dysphagia patients need to adapt the texture and consistency of foods, and even when there is a need, it does not mean that purees and porridges are the best option to safeguard meal safety.

What are the innovations or specialized approaches being adopted at CNS to help patients with dysphagia maintain an adequate diet?

DM – In hospitalization, the first meal at CNS is always accompanied by a speech therapist and a nutritionist to detect possible alterations that require specialized intervention from one (or both) areas. The approach to dysphagia is not exclusive to the speech therapist and nutritionist; it is multidisciplinary, and all professionals involved, such as nurses, occupational therapists, doctors, medical assistants, and restaurant staff (cooks, kitchen helpers, and cafeteria assistants), play a crucial role. At CNS, we try to provide as much variety of food options for each meal, taking into account each patient’s particularities and needs. Our approach does not end with the discharge from hospitalization, and all patients are recommended to maintain regular follow-up for nutritional reevaluation and adjustment of strategies as needed.

What is the importance of raising awareness about dysphagia and promoting healthy eating in people with neurological diseases? How does CNS promote this awareness?

DM – Dysphagia symptoms can manifest in various ways and have different impacts, so raising awareness among all potential stakeholders involved in feeding these patients should be a priority for any institution that hosts them. In this regard, one of CNS’s missions is to train healthcare professionals in various topics related to neurological diseases, where concepts related to nutrition and dysphagia are also addressed. Educating and involving formal or informal family members and caregivers is equally important, and there are also various training sessions for caregivers. The main training event exclusively dedicated to nutrition and dysphagia is the “Nutrition Course for Caregivers of people with neurological diseases” which has been held annually. In this course, we address, in a multidisciplinary team, key points about nutrition in these diseases, the main difficulties, and warning signs. The practical component challenges participants to “get their hands dirty” and prove that it is possible to provide adequate, safe, and attractive nutrition. This course also represents a moment of sharing doubts and experiences. The feedback has been very positive.

How does CNS work with patients to develop personalized meal plans?

DM – The patient is the central piece in nutritional intervention, contributing firstly to establish its objectives (whether in terms of weight or the amount of liquids to ingest per day, for example). These objectives should be defined together with the nutritionist, respecting both their preferences and clinical recommendations for their case. The patient is a fundamental partner in defining the meal plan outlined to achieve these same objectives. All their tastes, preferences, eating habits, and main current problems should be taken into account, respecting their individuality. The Nutritionist acts as an intermediary between scientific evidence and its practical and realistic translation into the food options for each meal of the day, and in the case of dysphagia, these should take into account possible adaptation needs. (Practical example: the patient’s favorite breakfast is a “galão” (latte) and buttered bread, but due to their dysphagia, it will not be a safe option. The nutritionist can suggest milk soups made with the “galão” and the bread moistened in milk or replace the bread with a softer option like milk bread or sandwich bread. This way, the patient maintains the usual base they like and makes the meal safer.)

How does CNS – Campus Neurológico plan to expand or further improve nutrition consultation services in the future?

DM – In the future, we would like to make more patients and caregivers aware that this consultation exists and is truly useful, providing more moments of education and dissemination in the general community, with free screenings and awareness actions, and to other healthcare professionals. The attending physician is an essential vehicle for identifying these patients and referring them. In 2024, we will have another edition of the Nutrition Course.

How can patients and families learn more about dysphagia-adapted food options?

DM – In an era where we have access to so much information, it is important to ensure that this information is credible and technically correct. My main recommendation is to seek individualized guidance from a specialized healthcare professional and always ask when in doubt; there are no “silly” questions.

In your opinion, what are the benefits of being followed in a nutrition consultation?

DM – From the range of cases that have been/are being followed in this consultation, we can observe improvements in the nutritional and hydration status of patients, greater peace of mind for their families and/or caregivers in the face of current difficulties, as well as support for the attending physician in decision-making moments such as considering the placement of an alternative route for feeding and hydration.

What message would you like to leave on this World Food Day?

DM – I would like to remind everyone that nutrition is, throughout life, a fundamental aspect for health and prevention of non-communicable diseases and that there is no completely right or completely wrong pattern; it should be a varied, complete, and balanced pattern framed in an active and conscious lifestyle. In various disease situations, it plays a scientifically proven important role and should be guided by health professionals properly qualified for this purpose. In neurological diseases in particular, adequate nutritional follow-up throughout its evolution contributes to a better quality of life for the patient and their caregivers.