My name is Liu Jinwei, and I am a stationed traditional Chinese medicine (TCM) physician. Today, I am pleased to give a seminar with Jiang Mingai on the topic of managing swallowing difficulties from a TCM perspective. As the saying goes, "eating is a blessing." Being able to swallow delicious food is actually a very important aspect of life. However, many elderly people experience difficulties in swallowing due to the degeneration of the neuromuscular system or illness, which affects their intake of sufficient nutrition. In foreign countries, many people die each year due to swallowing issues. Among various illnesses, 20% to 40% of elderly stroke patients experience varying degrees of swallowing difficulties. Therefore, swallowing difficulties should not be overlooked in our society.
The purpose of today’s talk is to help everyone understand the causes and symptoms of swallowing difficulties, as well as how to understand and treat this condition from a TCM perspective.
What is swallowing difficulty? The definition is that the patient encounters difficulties during the swallowing process and cannot safely and effectively transport food from the mouth to the stomach to obtain sufficient nutrition and hydration. Common diseases that lead to swallowing difficulties include degenerative brain diseases, such as stroke, Parkinson's disease, or cognitive impairment. Additionally, if a person has cancer near the oral cavity or tongue that requires surgical removal, the process may damage the tongue and surrounding nerves, affecting swallowing. Cancer treatments, such as radiotherapy or nasopharyngeal cancer, can also lead to nerve damage, affecting saliva secretion and tongue control. Furthermore, chemotherapy can cause oral ulcers, making it difficult to bite, chew, or eat.
It is crucial to manage swallowing difficulties well. Many people often mention swallowing difficulties; we must analyze the specific conditions affecting different types of swallowing issues. The first type is mechanical swallowing difficulties. This occurs due to blockages in the esophagus or gastrointestinal tract, often caused by esophageal cancer, leading to increasingly larger food particles becoming lodged and narrowing the pathway, impacting diet. Eventually, this can affect even liquid intake, hence it is called mechanical difficulty.
The second type is motility swallowing difficulties, which arise from neurological issues, such as stroke, leading to poor nerve control that affects the swallowing of liquid food. Interestingly, while solid food has an impact, liquids may be less affected due to not being a swallowing problem but rather a blockage issue. Motility issues arise from muscle control problems, making liquids potentially dangerous as they may silently flow into the trachea.
Some individuals may experience swallowing difficulties due to stress, irregular eating habits, excessive gastric acid, or acid reflux, which can cause problems in the esophagus. There is also a type called neuromuscular dysfunction, where nervous tension causes relaxation of the esophageal sphincter. This can lead to gastric reflux; when gastric energy rises, it can create a sensation of nausea, causing a loss of appetite. This condition in TCM is referred to as "mosaic qi," where patients often feel as if something is stuck when swallowing, similar to symptoms experienced by those with esophageal cancer. However, the difference is that with esophageal cancer, it can be seen through imaging, while this neuromuscular dysfunction is like a blockage of liquid, where the passage is clear but still feels obstructed.
Other causes include ill-fitting dentures, large or hard food pieces, or very slippery or sticky foods that make swallowing difficult. Of course, positioning while eating matters; if one doesn’t lower their head or lies down, food may be affected. Additionally, talking or being distracted during meals or eating too quickly without chewing can also cause swallowing difficulties.
What are the symptoms of swallowing difficulties? How can you tell if there is a problem? For example, you may notice an elderly friend who struggles to swallow food, needing to make several attempts. Or they may feel as if food is stuck. Additionally, if a person with a neurological condition is fed liquids, it may lead to choking; you often see that elderly individuals find solids easier to manage, whereas drinking water may lead to choking. This is why thickening agents are often added.
If individuals experience these neurological issues, they may frequently have low-grade fevers due to irritation of the lung mucosa, resulting in mild inflammation or swelling. This can lead to pneumonia if swallowing difficulties persist. A person with chronic swallowing difficulties will likely consume less food, leading to weight loss and dehydration.
From a TCM perspective, how do we view swallowing difficulties? TCM generally believes that swallowing difficulties often result from consuming rich and heavy foods, which are usually very tasty. Secondly, people who are overly anxious or irritable can also have issues. Finally, excessive fatigue can contribute; working 24 hours non-stop is certainly problematic over time. We often refer to conditions like liver qi stagnation or spleen deficiency. Following these pathological changes, phlegm and qi stagnation can occur.
In terms of diagnosis, generally, there may not be significant symptoms initially. The person may just feel some discomfort when eating, which is often overlooked. As the condition progresses, they may find it difficult to swallow solids, liquids, or even vomit. Due to poor absorption, patients may experience weight loss and have narrow stools, often described as "sheep dung" (small, hard stools).
In TCM, we use various methods to diagnose swallowing difficulties. Generally, mechanical blockage refers to increasing obstruction, and we observe several symptoms, including phlegm and qi issues. To assess TCM conditions, we observe phlegm, heaviness, and discomfort.
In traditional Chinese medicine (TCM), this is how we view it: If there is phlegm-dampness, we feel there is some phlegm, very stuffy and heavy, uncomfortable. Generally, we use Yun Ling (Poria) with plain water or spleen-strengthening herbs. If there is blood stasis, we usually think “if there is no free flow, there is pain,” so there will be stabbing pain. Therefore, we generally use blood-activating herbs like peach kernel (Tao Ren) and safflower (Hong Hua) to invigorate blood and resolve stasis. If blood stasis transforms into fire, it will burn and feel very hot, and the throat will also hurt because the fire is burning, leading to a sensation of liver dryness. In this situation, there is also constipation because of insufficient fluids. We usually use nourishing things, such as Shashen congee with meat, or Maimendong fish soup, or drink some pear juice or lotus root juice to nourish it.
The last type is qi deficiency with raised eyebrows, which is the final stage: pale face, swelling all over the body. These are relatively later stages. We will use more ginseng and astragalus (Huang Qi) to tonify qi, hoping to help the patient.
Everyone should understand: the swallowing difficulty I mentioned earlier—if it is mechanical, there is no problem. But if it is caused by neurological disease, you know that in TCM, taking medicine must involve drinking decoctions or pills; there is no such thing as injecting Chinese medicine. In Hong Kong, there isn’t any; in mainland China, there is, but not in Hong Kong. So for some cases, especially neurological ones where the patient already has difficulty swallowing (as I said earlier, even drinking water can cause choking), giving them Chinese herbal medicine actually poses a great risk. Therefore, for swallowing difficulties caused by neurological system issues, acupuncture may be one of the treatment options to consider. You can use acupuncture to stimulate the muscles around both shoulders, the muscles responsible for opening and closing the mouth, and nerve transmission, which can have a chance to improve the patient’s ability to gather food.
For example, when we treat with acupuncture, for the muscles that open the mouth: first, there are the lateral pterygoid muscles; when they contract, the mandible bone moves forward. Combined with the suprahyoid muscles, it produces the downward movement to open the mouth. The lateral pterygoid muscle, according to anatomy or TCM meridian studies, is exactly at the Xiaguan (ST7) acupoint. So we can acupuncture Xiaguan to stimulate the lateral pterygoid muscle. As for the suprahyoid muscle group, we can stimulate the posterior belly muscles using the Fengchi (GB20) acupoint. If it is the muscles in front of the hyoid bone, we can acupuncture Lianquan (CV23), which needs to go about 1.5 to 2 inches deep to stimulate the muscles.
I just talked about opening the mouth; for food, there must be both opening and closing. This is the closing muscle group. We have the masseter muscle and the temporalis muscle. When these two groups contract together, they lift the mandible upward, allowing the mouth to close forcefully and bite off food. In clinical treatment, since we want to enhance masseter contraction, we can stimulate the Jiache (ST6) acupoint because the muscle is larger, along with Xiaguan (ST7) and Shangguan (GB3). As for the temporalis muscle, which acupoints can we needle? It is the Xiaxie acupoint, just in the lower facial area—such as Daying (ST5) and Quanliao (SI18). These points can target different muscles.
If we find that elderly people have muscle issues, and when drinking soup or liquids, water often leaks from the corners of the mouth, it is usually because the orbicularis oris muscle is not strong enough. We can stimulate Dicang (ST4) to target it, which can reduce leakage if the mouth also leaks. Dicang is just at the corner of the mouth, slightly over half a cun. That is the point. Besides acupuncture, for the orbicularis oris, patients can also press Dicang themselves to help.
Everyone knows I am wearing a mask. The novel coronavirus is widespread worldwide, even in Hong Kong. In terms of eating, for now, we know there is no vaccine yet. Actually, most patients rely on their own immune system to fight and win against the virus to recover. We often say prevention is better than cure. As in the Huangdi Neijing, it says “when vital qi is strong, evil cannot invade,” meaning when our vital qi is strong enough, viruses cannot attack the body, and we won’t get sick. For preventing this pandemic, since there is no vaccine, the best method for prevention is definitely to strengthen our own constitution. In TCM, this is called “wei qi,” similar to resistance in Western medicine. We can coordinate with health-preserving foods to harmonize the yin-yang balance in our body, which can greatly reduce the chance of infection.
There are four seasons in a year: spring, summer, autumn, winter. I will share with everyone four-season health preservation. Four-season health preservation means adapting to the natural environment and adjusting our daily life and diet according to the changes in the four seasons’ climate to strengthen the constitution, prevent catching colds, and thereby achieve longevity. You know the coronavirus is so powerful; as long as we strengthen our constitution, unite in the fight against the epidemic, we can kick the coronavirus out.
We introduce a method that doesn’t cost much: how to maintain four-season health preservation with food. First, spring: in spring, you know everything grows, the weather easily becomes warmer, so in spring, it may cause the body’s resistance to adapt and decline, leading to colds. In TCM, we focus on two things: first, protecting the liver, because spring corresponds to wood, and the liver governs wood. So, we use more liver-soothing and liver-protecting foods, such as chrysanthemum with goji berries, carrots—these are good for the liver. Also, spleen-strengthening foods—everyone knows, like Chinese yam (Huai Shan) is the best, some lotus seeds, Job’s tears—these strengthen the spleen. If in soups, we generally use—in spring, it is relatively damp-heavy, so we use spleen-strengthening and stagnation-resolving soup, mainly with Chinese yam, Job’s tears—these are called spleen-strengthening herbs. Often, we like to use hawthorn and malt; actually, hawthorn and malt are sour, and many elderly people like sour things. So, using hawthorn to boil water, add a little rock sugar—actually, many elderly people like it.
Summer: everyone knows it is definitely very hot. Because of heat and humidity, it often depletes our fluids, making us feel stuffy, hot, and sweaty. If severe, it can cause dehydration or even heatstroke. We choose foods mainly that are sweet-cool and fluid-generating, and can relieve summer heat, such as ingredients like bitter melon—these can be soaked soft, steamed, and eaten. Watermelon is very cooling every day. Mung bean soup can also clear heat. However, everyone should note: if elderly people have swallowing problems, mung bean soup really needs to have the skins removed and then ground into a paste-like form. If eating with skins, there is a risk of choking, but if it’s sand-like, half-dissolved with water, it is actually quite tasty.
Next is autumn: in autumn, everyone sees it is definitely dry. Our lungs prefer moisture and dislike dryness, so dryness and heat especially in autumn easily invade people. So many people in autumn, when skin is dry, often have dry cough symptoms. In autumn, we now focus on nourishing yin and moistening the lungs. We usually choose some moisturizing foods, such as snow pear, sugarcane—these; for example, snow fungus can also. If it gets to late autumn and is colder, you can eat some sweet-warm foods, such as sesame paste ground into a paste, then add some honey.
For example, take some papaya or banana, try the method I just mentioned, then swallow. But after the process, we emphasize safety is very important: ask the patient to exhale forcefully. The benefit of exhaling vigorously is that even if some food gets stuck in the throat, when you blow it out, at least anything in the trachea can be expelled to the mouth, which reduces the risk of what’s commonly called aspiration leading to pneumonia or choking.
Also, as I mentioned earlier, for drinking, to increase stimulation—besides color, aroma, and taste—use slightly cold water or thicker textures; these provide more sensory stimulation. Thicker things create greater resistance, which also strengthens control ability. So this works too. Everyone can try these exercises at home with the elderly, repeat the practice, and see if it helps.
That’s all I want to share with you today. Thank you, everyone.
 Subtitles provided by the Amara.org community
Through this, we can learn about different types of swallowing difficulties in the elderly—for example, mechanical versus neurological—and gain more knowledge about selecting ingredients, processing and cooking methods, food materials, size, and texture. This makes caring for the elderly more effective and safer.
From a TCM perspective, what resources or knowledge are needed for food therapy? How does it relate to the development of care meals?
This is a great question. For our generation of elderly—people my age or older—our dietary culture is predominantly Chinese. So many high-nutritional-value TCM ingredients, like the ones I mentioned earlier (Chinese yam, lotus seeds—we even use lotus paste in mooncakes, Job’s tears, etc.), can be incorporated. As I said, there are four seasons in a year, and with seasonal health preservation, we eat different ingredients in different seasons. By integrating TCM principles, we can provide foods suitable for the elderly in each season. The elderly will eat more happily and feel more at ease. So, I think this is very important.
Today’s sharing by Dr. Liu ends here. Thank you, everyone.