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Why do Savorease snacks fit into the early ALS diet?

Eating is one of the most important pleasures of life that is often taken away from a person with progression of ALS.  When food preparation and the dining experience becomes a struggle for the ALS sufferer, and can lead to eating anxiety and reduced quality of life. It can be an emotional struggle for the family as well.  Understanding the distinct challenges with ALS can allow caregivers to find the right food solutions to bring comfort and energy to their loved one. 

 

ALS presents with a unique risk of unwanted weight loss for three distinct reasons:  

  1. Dysphagia – difficulty swallowing from bulbar weakness
  2. Hypermetabolism – imbalance between calories consumed and an increase in metabolic demand. 
  3. Increased time to eat secondary to weakness of muscles of chewing

 

Dysphagia: 

In short, the definition for dysphagia is difficulty swallowing. For ALS this presents as a difficulty in moving food from the mouth through the pharynx and into the esophagus. Weakness of chewing muscles as well as tongue muscles impairs the ability  to close the lips and break apart the food to safely swallow. 

 

The 5 stages (Burgos et al., 2018) of swallowing changes are: 

  1. Normal eating habits
  2. Early eating problems such as chewing difficulty
  3. Softened foods and texture modified diet
  4. Need for tube feeding 
  5. Nothing by mouth

Often a presenting symptom of ALS, dysphagia will ultimately be experienced in the majority of ALS patients with bulbar onset, as the condition progresses. The degeneration of bulbar neurons manifests as difficulty in chewing, oral preparation, the time required to complete a meal and dysphagia (Burgos et al., 2018).This leads to longer eating times, and softening of food texture or thickening of liquids. Minced moist and puree foods, and difficulty in self-feeding can affect the social aspect of food sharing at meal times (Shune, Moon, & Goodman, 2015) The rapid decline often noted can be hard to adjust to and can lead to frustration, fear of coughing or choking, reduced appetite, food refusal and caregiver burden.  In fact, fear of choking and increased eating time related to dysphagia can lead to 15% fewer calories consumed than recommended (Miller et al., 2009, Kasaraski et al., 1996). 

Hypermetabolism: 

About 50% of patients wtih ALS  are hypermetabolic. This could be due to increased breathing work, and other factors that are not well established yet. This can put the ALS patient at risk of unwanted weight loss and discussion with the dietitian would help in determining options to reduce this risk. 

Nutritional status: 

It has been shown (Kasarskis, et al, 1996) that ALS patients consume only 84% of the required calories.  Malnutrition, lower BMI, weight loss, and body composition can all affect survival time with ALS. Malnutrition will accelerate progression of the disease. Oral nutritional supplements are often used to minimize weight loss.  High fat or high carbohydrate supplements have been studied with varying results (Dorst et al, 2013; Silva et al, 2010). A ketogenic diet of high fat and high protein has been shown in limited studies to prolong survival in ALS animal models ( Zhao et al. 2006, Dupuis e t al, 2004, Fergani et al., 2007) and in patient studies (Kim et al., 2020).  Further research is needed.  

As the disease progresses, enteral nutrition through a percutaneous endoscopic gastrotomy (PEG) tube can be used to support caloric needs (Mazzini et al., 1995). It has been recommended to place a PEG when the patient has early documented weight loss. The PEG tube does not eliminate oral feeding but helps to stabilize body weight if necessary, and support administration of medication and fluids.  In later stages of the disease total parenteral (through an IV) nutrition might be necessary. 

 

Recommendations: 

In early stages of ALS, patients with fatigue on eating should eat several small meals a day.  High-calorie foods are beneficial and added fiber can help with constipation. The swallow reflex can be helped by emphasizing taste or temperature of the food (Borgas et al., 2018). 

Consumers of pureed foods experience “burn out” and find that such foods lack sensory appeal, variety, and the “crunch” that is a crucial part of experiencing foods (Keller & Duizer, 2014). It has been shown that improving the flavor of foods can improve caloric intake and body weight in nursing-home patients (Mathey et al., 2001). Addressing these issues in the ALS population could have similar benefits. 


How can Savorease snack supplements support eating enjoyment and nutrition: 

  • The meltable crackers and puree dips fit the ketogenic diet 
  • They require no chewing and break down quickly with moderate tongue pressure giving the satisfaction of eating solid foods but rapid transition to a soft texture (transitional food)
  • They are full flavored with citrus flavors in the dips that can help with the swallow reflex
  • Eating Savorease finger foods can help support nutrition and provide the escape from soft, wet foods and offer an alternative to liquid supplements when they crave the crunch
  • Small, ready made, easy-melt snacks help with chewing fatigue and convenience especially during long appointments. 

Consult your dietitian or speech and language pathologist and inquire on whether this innovative solution could support nutrition with dysphagia. 


Bibiliography 


Burgos R, Bretón I, Cereda E, et al. ESPEN guideline clinical nutrition in neurology. Clinical Nutrition. 2018;37(1):354-396. doi:10.1016/j.clnu.2017.09.003

Dorst J, Kühnlein P, Hendrich C, Kassubek J, Sperfeld AD, Ludolph AC. Patients with elevated triglyceride and cholesterol serum levels have a prolonged survival in amyotrophic lateral sclerosis. J Neurol. 2011;258(4):613-617. doi:10.1007/s00415-010-5805-z

Fergani A, Oudart H, Gonzalez De Aguilar J-L, et al. Increased peripheral lipid clearance in an animal model of amyotrophic lateral sclerosis. J Lipid Res. 2007;48(7):1571-1580. doi:10.1194/jlr.M700017-JLR200

Kasarskis EJ, Berryman S, Vanderleest JG, Schneider AR, McClain CJ. Nutritional status of patients with amyotrophic lateral sclerosis: relation to the proximity of death. The American Journal of Clinical Nutrition. 1996;63(1):130-137. doi:10.1093/ajcn/63.1.130

Keller HH, Duizer LM. What do consumers think of pureed food? Making the most of the indistinguishable food. J Nutr Gerontol Geriatr. 2014;33(3):139-159. doi:10.1080/21551197.2014.927302

Kellogg J, Bottman L, Arra EJ, Selkirk SM, Kozlowski F. Nutrition management methods effective in increasing weight, survival time and functional status in ALS patients: a systematic review. Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration. 2018;19(1-2):7-11. doi:10.1080/21678421.2017.1360355

Kim B, Jin Y, Kim SH, Park Y. Association between macronutrient intake and amyotrophic lateral sclerosis prognosis. Nutritional Neuroscience. 2020;23(1):8-15. doi:10.1080/1028415X.2018.1466459

Mathey MF, Vanneste VG, de Graaf C, de Groot LC, van Staveren WA. Health effect of improved meal ambiance in a Dutch nursing home: a 1-year intervention study. Prev Med. 2001;32(5):416-423. doi:10.1006/pmed.2001.0816

Mazzini L, Corrà T, Zaccala M, Mora G, Del Piano M, Galante M. Percutaneous endoscopic gastrostomy and enteral nutrition in amyotrophic lateral sclerosis. J Neurol. 1995;242(10):695-698. doi:10.1007/bf00866922

Miller RG, Jackson CE, Kasarskis EJ, et al. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2009;73(15):1218-1226. doi:10.1212/WNL.0b013e3181bc0141

Paganoni S, Wills A-M. High-Fat and Ketogenic Diets in Amyotrophic Lateral Sclerosis. J Child Neurol. 2013;28(8):989-992. doi:10.1177/0883073813488669

Shune SE, Moon JB, Goodman SS. The Effects of Age and Preoral Sensorimotor Cues on Anticipatory Mouth Movement During Swallowing. J Speech Lang Hear Res. 2016;59(2):195-205. doi:10.1044/2015_JSLHR-S-15-0138

Zhao Z, Lange DJ, Voustianiouk A, et al. [No title found]. BMC Neurosci. 2006;7(1):29. doi:10.1186/1471-2202-7-29

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