Trends in Diet Modification: Practice Catching up to Research

Trends in Diet Modification: Practice Catching up to Research Naomi Gurevich, Danielle Osmelak, Marissa Van De Weg, Shaun O'Keeffe Purdue University Fort Wayne PRESENTED AT: INTRODUCTION Recent studies from our group and from others indicate a growing concern in dysphagia management regarding texture modified diets (TMDs): ✱Insufficient evidence of benefit or safety •McCurtin et al. (2024) •Hansen et al. (2022) •Makhnevich et al. (2022) •O'Keeffe et al. (2023) •Shimizu et al. (2021) ✱Overprescription & calls to change this practice •Groher & McKaig (1995) •Logemann et al (2008) •Hansen et al. (2022) •Makhnevich et al. (2022) •O’Keeffe et al. (2025) •Royal College of Speech and Language Therapists (2024) ✱There is recent evidence of a positive trend (regarding thickened liquids at least) •McCurtin et al. (2024) found a growing awareness of concerns about their use by speechlanguage pathologists in countries including Australia, the USA and Britain, and fewer reported using them regularly than in previous surveys •McCurtin et al. (2025) report a 15% decline over 5 yrs in prescriptions of thickeners by family doctors in Britain ✱Need for training (& lit on the widespread practice of no training) •McCurtin et al. (2025) •Gurevich & Osmelak (2024) •Okon et al. (2024) •Gurevich et al. (2021) •Hirzel et al. (2020) •O'Keeffe (2018) Next, recent qualitative data regarding current experience of SLPs in healthcare. RECENT QUALITATIVE DATA The growing awareness of TMD issues and positive emerging trends calls for an exploration of lived experience of SLPs in healthcare. A qualitative approach can contribute to informing healthcare services and policies (Sofaer, 1999). ✱Mixed methods •Semi-structured interviews by zoom •Optional Follow-up questionnaires by email ✱Participants •Ten SLP clinicians working in healthcare settings in the U.S. •Most had 6-10 years clinical experience ✱Data saturation reached Next, a look at the thematic analysis of these data and how these all fit in the greater aim of affecting changes in clinical practice. THEMES & TRENDS Data corroborate previous studies and identify actionable directions for improving patient care. ✱ Four main themes: 1. TMDs being initiated by other professionals 2. Overuse of TMDs 3. The need for education and change 4. The importance of interprofessional practice (IPP) Positive trends → good starting points ✱ Increased clinician awareness of issues with TMD practices and the move towards more effective and safer uses • This echoes growing awareness among SLTs reported in McCurtin et al. (2025) ✱ Attention to IPP and cross-disciplinary collaboration. Key challenges reported by participants: ✱ Difficulty with access to dysphagia specialists • Especially in rural settings ✱ Need for education and clearer guidelines Next, the EBP of de-implementation. EBP OF DE-IMPLEMENTATION We strive to let research guide clinical practice, prioritizing EBP. Research can also guide deimplementation. Let's talk frameworks. ✱The ACE-STAR Model of Knowledge Transformation (Stevens, 2004; see figure) ✱What if the goal is to discontinue outdated or harmful practices? ✱Phases of de-adoption of low-value clinical practices (Niven et al., 2015): •Identify low-value clinical practices •Facilitate the de-adoption process •Evaluate de-adoption outcomes •Sustain de-adoption ✱The ACE-STAR model applied to de-implementation: •Evidence that a practice is ineffective or harmful •Evidence summary •Translation into recommendations •Integration into practice - finding new effective practices and phasing out the old •Tracking resulting patient outcomes Next, where do we go from here? MIND THE GAP Practice catching up to research: Where are we in the path to de-implement? •Evidence that the practice of overprescribing TMDs is ineffective or harmful •Evidence disseminated and summarized in systematic reviews •Synthesized into recommendations •Integration into practice (started; need professional support) •Tracking outcomes (started tracking of practice, but what about patient outcomes?) Next, the main takeaway. A CALL TO ACTION ✱We need competency-based requirement for modifying diets and clear guidelines. ✱We need higher training in dysphagia, more trained personnel, and better cross-professional collaboration. ✱We need the involvement of professional organizations to effectively phase out harmful practices. --- Thank you --- AUTHOR INFORMATION & DISCLOSURES Naomi Gurevich (presenting author) Purdue University Fort Wayne, United States Naomi Gurevich, PhD, CCC-SLP, is an Associate Professor in the Department of Communication Science and Disorders at Purdue University Fort Wayne. Her research interests combine her background in theoretical phonology with acquired language disorders. Her primary research area is the phonology of intelligibility, and she is the director of the Clinical Linguistics and Acquired Disorders (CLAD) lab. Disclosure(s): Yes, Employer, Affiliations (memberships, board/committees, etc.) • Salaried Associate Professor in Communication Science and Disorders at Purdue University Fort Wayne I serve as an Editorial Board Member for ASHA Perspectives for SIG 19 I serve as a reviewer for additional peer-reviewed journals Danielle Osmelak (presenting author) Governors State University, United States Danielle Osmelak EdD, MS, CCC-SLP/L, FNAP is an Associate Professor in the Department of Communication Disorders at Governors State University. Dr. Osmelak’s research interests include interprofessional dysphagia management and ethical clinical decision-making. Dr. Osmelak is the President-Elect of the Illinois Speech-Language-Hearing Association. Disclosure(s): No, I do not have associations, activities, personal and professional perspectives, or financial relationships relevant to the content of the session. Marissa Van De Weg (presenting author) Purdue University Fort Wayne, United States Marissa Van De Weg is a student at Purdue University Fort Wayne working towards a Bachelor of Science in Communication Sciences and Disorders. After earning an undergraduate degree, she plans to attend graduate school for Speech Language Pathology. Disclosure(s): No, I do not have associations, activities, personal and professional perspectives, or financial relationships relevant to the content of the session. Shaun O'Keeffe (presenting author) University of Galway, Ireland Shaun O'Keeffe is a physician, geriatrician and honorary personal Professor in Medicine, University of Galway, Ireland. He is the National Clinical Lead for consent and mental capacity law in Ireland. Research interests include dysphagia and ethical issues in the care of older people. Disclosure(s): No, I do not have associations, activities, personal and professional perspectives, or financial relationships relevant to the content of the session. TRANSCRIPT My name is Shaun O’Keeffe and I’m a physician in Galway Ireland. Welcome to our poster titled “Trends in Diet Modification: Practice Catching up to Research". Texture modified diets, that is softening solid foods and thickening liquids to potentially compensate for reduced swallowing function, has become central to the current management of dysphagia. However, as we will discuss, the effectiveness of this intervention has been questioned increasingly in recent years, with concerns that TMDs are overused. That highlights the importance of good decision making about this intervention. Our main message for you is that decisions about texture modified diets requires skill and judgement and that means adequate training is essential. Note that we are not calling for diet modification decisions to be restricted to speech language pathologists, but any discipline involved in such decisions must have sufficient dysphagia training. The background to this is that recent studies and reviews have found insufficient evidence that TMDs are effective or safe enough to be so widely used. In particular, there is no evidence of a reduction in death or in pneumonia (and some reports suggest an increased risk of pneumonia) while they can impair nutrition, hydration and quality of life of people with dysphagia. For example, in a 2022 update to their high quality 2016 systematic review, Hansen and colleagues continued to recommend against thickening liquids in adults with oropharyngeal dysphagia. Concerns about overprescription of pureed foods date back at least to Groher & McKaig in 1995 while Logemann and colleagues noted overuse of thicken liquids in 2008. Calls a change in practice have become even louder in recent years. This has led, for example, to the Royal College of Speech and Language Therapists in a 2024 position paper advising against use of thickened liquids as a blanket approach or go-to treatment and recommending that their use requires careful consideration, comprehensive assessment and informed consent. There is good news that suggests SLPs are paying attention to the literature on this topic, at least for use of thickened fluids. Recent work by McCurtin and colleagues found that speech-language pathologists around the world have a growing awareness of concerns about thickened fluids and are becoming slower to use them. And prescriptions of thickeners by family doctors in Britain for has been in decline in recent year. A more negative finding is evidence in recent years from multiple countries confirming just how widespread the practice is of prescribing diet modifications by those with no dysphagia training. For example, Gurevich & Osmelak found that of 503 SLPs working in healthcare, 89% had experience with personnel untrained in dysphagia initiating texture modified diets. Gurevich and colleagues, in 2021, identify a “phantom permission” in U.S. healthcare that appears to allow nursing staff to downgrade diets without consult of dysphagia-trained professionals. I noted earlier that the Royal College of Speech and Language Therapists recommended careful clinical consideration and assessment and informed consent; how is any of this possible from someone with no dysphagia training? It isn’t! And that’s why there is a call for diet modification decisions to be restricted to those with dysphagia training. Dr Gurevich is now going to discuss recent qualitative data regarding current experience of SLPs in healthcare. Hello, my name is Naomi Gurevich, and I will narrate the rest of the poster. Given the growing awareness of issues with texture modified diets in healthcare, and some emerging positive trends, it is worth exploring the lived experiences of clinicians working in healthcare settings. A qualitative approach was useful for this purpose. Such an approach provides insights into the changing, and evolving, practices and can therefore contribute to informing healthcare services and policies The qualitative data was collected using mixed methods: There were semi structured interviews conducted by zoom where we asked 4 big picture questions And follow-up, optional, 7 questions by email (to which 9 of our 10 participants responded).