**2.5 Dual-emission X-ray absorptiometry (DEXA)**

The dual-emission X-ray absorptiometry (DEXA) is an invasive method that has become a popular measure for the assessment of body composition in developed countries (Madsen; Jensen; Sorensen, 1997; Tothill et al., 1996; Snead; Birge; Kohrt, 1993). This method allows the structural assessment of body composition, dividing the body mass by three basic components: mineral- and fat-free soft tissue, bone mineral content and fat (Laskey, 1996).

Some studies show the use of such technique in ALS patients (Tadan et al., 1998; Nau et al., 1995; Kanda et al., 1994), however Desport et al. (2003) emphasizes the equipment is

Nutritional Care in Amyotrophic Lateral Sclerosis:

**3.1 Influence of viscosity** 

Furkim, 2000).

(Silva et al, 2010).

*Source: ADA, 2002.* 

2004).

**4. Nutritional therapy** 

and consequently should be treated.

the nutritional care of subjects with dysphagia.

An Alternative for the Maximization of the Nutritional State 601

In order to minimize respiratory and nutritional complications in the treatment of dysphagia, interdisciplinary assessment is extremely important, and the modification of the

Food viscosity is one of the most important variables of swallowing. Thin liquids make difficult swallowing by patients with reduced laryngeal control, since they are quickly swallowed and do not maintain their shape inside the oral cavity, which can prematurely leak into the pharynx and, thus, penetrate the airways still open. To avoid such effect, the optimal viscosity must be determined so the swallowing may occur safety (Macedo &

Viscosity influences many aspects of the assessment and management of dysphagia. It can be defined as the fluid resistance to the flow and is measured in Centipoise (ctps or cPs)

There are different types of viscosity that can be easily achieved using commercial thickeners. These types can be classified in centipoise (cP) values (Table 1) as thin (1-50 cP),

**Classification Viscosity (cP)** 

**Thin** 1-50

**Nectar** 51-350

**Honey** 351-1750

Table 2. Classification of viscosity, in centipoise (cP) values, according to the ADA (2002), for

Patients with symptoms of dysphagia limiting their intake of foods and liquids, hospitalized or at home, should be considered those at high risk of experiencing nutritional deficiencies

Appropriate nutrition and hydration in patients with dysphagia are based on a complex balance between preparation, intake and absorption of foods and drinks (Steele & Lieshout,

When diagnosing the cause and severity of dysphagia, healthcare professionals can determine the texture of foods and the thickness of fluids for a safer swallowing by dysphagic patients, since the consistency of the diet should be individualized according to the type and extent of dysfunction. In case the recipe is not followed, the subject may face

Table 1 shows an example of a modified diet with restriction of "thin liquids" (1-50 cP) and

serious consequences for health (Silva et al, 2010; Macedo & Furquim, 2000).

solids for subjects with dysphagia and swallowing impairment.

**Pudding** > 1750

texture of foods is an alternative for the maintenance of the oral route.

nectar (51-350 cP), honey (351-1750 cP) and pudding (> 1750 cP).

very expensive, and the fact that the patient remains in a horizontal position with his/her arms extended along the body for more than 10 minutes can be a problem for subjects with ALS.

In a study conducted by Rio and Cawadias (2007), it was discussed the main techniques adopted by nutritionists of some centers for the treatment of ALS in Europe and Canada for nutritional assessment of ALS subjects. The researchers found only 22% of nutritionists had more than 4 years of experience in ALS. Amongst the most used nutritional assessment methods were weight, % WL, BMI and arm circumference, used by 100%, 96%, 83%, and 9% of the professionals, respectively. The bioelectrical impedance, validated by Desport et al. in 2003, as well as DEXA, were not reported by the professionals from the centers investigated by Rio and Cawadias.

Analyzing the measures adopted by the relevant literature, in ALS, as well as in other diseases, the use of parameters such as weight, % WL and BMI, as well as skinfolds, BIA, DEXA and indirect calorimetry can also be observed (Rio; Cawadias 2007; Desport et al., 2003; Desport et al., 2001; Silani; Kasarkis, Yanagisawa, 1998).
