Eating is one of life’s greatest pleasures. Is there a major occasion or event in almost any culture that doesn’t include a special meal? Food nourishes both our bodies and our souls, but eating can also lead to a host of problems, including fatal ones. This is a complex and extensive topic. In writing about it and trying to even begin to do some justice to the subject we discovered that there was far too much material to hold the interest of even the most patient reader. This month’s newsletter will cover swallowing difficulties and other mechanical or anatomical issues that can cause problems with eating.

The human body has one or two questionable anatomical design issues. In order to complete a successful swallow food must pass over the opening to the airway (trachea) to reach the tube that conducts food from the mouth to the stomach (esophagus). A small flap, the epiglottis, normally folds down to cover the trachea and protects it from inhalation of foreign material, or aspiration. Successful swallowing also depends on good alignment of the head and neck (Sit up straight, ears over your shoulders, please). There must also be a functioning nervous system and good muscular control of the jaws, tongue and small muscles of the throat for the swallowing mechanism to work as it should.A full set of teeth that are intact and pain free are also helpful, though not strictly necessary.

Dysphagia is derived from the Greek words for bad or disordered eating though the term generally refers to issues that occur during one of the three phases of swallowing. There are many causes and presentations of dysphagia.

Simply talking or laughing while eating can cause food to “go down the wrong pipe”, as Grandma used to say. The inability or unwillingness to sit up to eat can interfere with the essential role that gravity plays in assisting the safe passage of food. Physical deformity or poor posture are often seen in the elderly, individuals with disabilities as well as certain teenagers. This can interfere with the alignment of the trachea and esophagus or the esophagus and the stomach. This can also impair the function of the smaller muscles of the throat that are involved in swallowing. Poor muscular control due to disease or medication side-effects can also contribute to problems with the basic process of a normal swallow. Many medications dry up saliva production making it difficult to lubricate food for a smooth trip to the stomach. Dental problems or the absence of teeth can make it difficult or painful to chew food to the proper consistency.

Mechanical changes in the esophagus can also result in dysphagia. Individuals may be born with an abnormally small esophagus. It may also be damaged or restricted by growths of the organ itself or within the chest such as the lungs, heart, vessels, cervical (ofthe neck) spine, or local lymph nodes. Damage to the esophagus can occur due to long-term exposure to stomach contents if the person experiences reflux. Ingestion of items that damage the esophagus through temperature-related or chemical burns may also cause scarring that restricts the esophagus.

An individual with dysphagia or those assisting in his/her care may be unaware that they suffer from the condition. Signs of dysphagia may include:

• Difficulty controlling items (food or saliva) in the mouth.
• Difficulty beginning a swallow.
• Coughing or choking while eating.
• Wet or gurgly sounding voice during or after eating.
• Using unusual postures while eating such as gulping with the head back (gravity assisted swallow).
• Passage of food or fluids through the nose while eating.
• Complaint of pain or other swallowing difficulty.

Individuals with long term dysphagia my experience frequent bouts of pneumonia, unexplained weight loss and/or meal refusals. One trick used by speech pathologists to detect silent or discrete aspiration is to attach a pulse oxymeter (which measures oxygen content of the blood) to the person’s finger during meals. Individuals who aspirate while eating often experience a decrease in their oxygen levels at this time. This is a daunting list and it may be frightening to non-medically trained caretakers to feel they must recognize and address these issues. But like many problems it becomes simpler to address when taken one piece at a time.

The first individuals to be notified are those with immediate contact with the individual. These would include case managers, nurses or the person’s primary care provider.

First and foremost, train individuals or their caretakers to recognize and report the signs. “Jamie’s always done that and it’s never been a problem,” is a dangerous way of thinking. So is the inability to recognize changes in the person’s eating habits that may be related to a developing problem.

Second, who should be notified and what can be done? This piece has been exclusively about identifying the existence of the problem and less about treatment, which should always be handled by trained professionals. The first individuals to be notified are those with immediate contact with the individual. These would include case managers, nurses or the person’s primary care provider. With significant problems the services of a speech pathologist or gastroenterologist is often needed.

Third, when professionals make recommendations or write orders, follow them scrupulously. Issues with eating can easily and rapidly lead to death with a single slip. If an altered texture diet is ordered train caregivers how to provide it. If the individual has a feeding tube and orders for no food by mouth (or NPO), make sure nobody sneaks in food where it doesn’t belong. This is not an area with a wide margin for error.

Fourth, people with swallowing issues can often improve and return to eating by mouth or to consuming foods and fluids with more challenging consistencies. Return to a more normal style of eating whenever possible should always be part of the person’s personal goals. It is not always possible but it is always desirable and worth the effort. After all, who wants to miss out on a nice big, gooey piece of birthday cake if they don’t have to?

Next month we will look at behavioral challenges as they relate to eating.