NDR-UK Easier Swallowing IDDSI Update Peer Review Pack

Transcription

1 NDR-UK Easier Swallowing IDDSI Update Peer Review Pack Contents Page Specification extracts 1 Level 3 (draft) 7 Level 4 (draft) 22 Level 5 (draft) 37 Level 6 (draft) 54

2 1 STEP 2 TARGET GROUP (TG) Aim: Describe target group (TG) and and their characteristics. Action Specification Writers Brief Notes and Inclusions 1. TG s clinical problem People with eating, drinking and swallowing difficulties. This can include and must consider the importance/impact of posture, dental health and temporary issues following surgery. The condition should be reviewed regularly and depending on cause, can both improve and 2. Different disease states or causes of the TG s clinical problem 3. TG s demographic details and appropriate action to address potential issues The different disease states or causes of the TG clinical problem include: Acquired and/or progressive neurological disorders e.g. stroke, dementia, Parkinson s disease, Multiple Sclerosis, Motor Neurone Disease, Huntington s disease. Adults with learning and/or physical disabilities e.g. Cerebral Palsy. Mental health issues e.g. Dementia, catatonia, bipolar personality disorder, schizophrenia Maxiofacial surgery. Anoxic brain injury. Traumatic-head injury. Other patients with difficulties i.e. chewing and dentition, oesophageal strictures, sore mouth. deteriorate. Much of the information in the diet sheet will be common to all EDS problems, therefore develop generic information for common themes and adapt key points as appropriate for specific sections i.e. food and fluid levels (7-0). Page 1 of 6

3 2 a) Gender All b) Age 16+ Paediatric version is not part of this project s remit. c) Other (for example social, residential, level of independence) All 4. Communication or physical issues that may impact of using, understanding and/or following guidance provided: a) Communication Factors i Ability to follow English verbal and written instruction ii Ability to communicate to enable feedback iii Sight b) Physical Factors and cognitive factors i Eating, drinking and swallowing ii Head control, feeding position and limb function Varying ability i EDS is impaired so TG is following a texture modified diet. ii - Head control may be affected - Seating position must be considered and guidance provided on optimal position for the individual - Alertness may be affected with guidance provided to aid safe and adequate nutrition for the individual - Where appropriate, suggestions on /signposting to, relevant eating/drinking equipment will be provided e.g. adapted cutlery, plates, cups etc. Note that many people with EDS difficulties who are prescribed a texture modified diet are able to live very independently (e.g. oncology patients) Where learning/neurological/cognitive issues impact on learning/understanding, it is assumed that carers will be the target audience (TA) and use the resource to support the TG. Imagery will be an essential communication tool for all learning, literacy and English language abilities. Note that TG and/or carers may have low health literacy. Guidance and goals within the resources must be realistic for TG s cognitive and physical ability. This will consider their level of alertness and offer guidance on how modify the eating environment to limited distractions and promote interest and focus on eating and drinking. Page 2 of 6

4 3 5. Support needed/available to implement the dietary advice: a) Multidisciplinary liaison MDT Dietitian (DT), Physiotherapist (Physio), Speech and Language Therapist (SLT), Occupational therapist (OT), social worker b) Funding identify sources of stateassistance (benefits, prescriptions etc) c) Follow-up i Contact name and number ii Guidance to other contacts 6. Who is the Target Audience (TA)? a) TG b) TG s family or carers c) Staff in TG s care settings (please specify) d) Other 7. TA s knowledge and experience of: a) the clinical condition b) management of the condition c) cooking d) food preparation for this diet Leave a notes box for name/contact info and notes All Vary (no experience to very experienced) Vary (no experience to very experienced) Vary (no experience to very experienced) Vary (no experience to very experienced) Make reference to the MDT involved, including: i Advice from Speech and Language Therapist (SLT) on appropriate food and fluid consistency and techniques for eating and drinking. ii Dietary information from DTs to ensure balanced nutrition and hydration through appropriate food and fluid choices. iii Advice from SLT, Physiotherapist and Occupational therapist (OT) on body posture and positioning for eating and drinking. iv Guidance to identify routes to support and care packages from Social Workers. Check with OT for any charity funding Where learning/neurological/cognitive issues impact on learning/understanding, it is assumed that carers will be the target audience (TA) and use the resource to support the TG. Assume TG have no previous knowledge or experience. Therefore all information regarding the clinical condition and its management must be at a basic level. Page 3 of 6

5 4 STEP 3 Content* Aim: Describe the resource s care aims and learning outcomes to shape the key messages and how they will be communicated Action Specification Care Aim(s) and Learning Outcomes 1. Overall care aim(s) To reduce risk of harm, and improve safety and understanding, and quality of life. Reduce risk and raise awareness of aspiration, choking, dehydration and under nutrition. The importance of nutrition and hydration. 2. Learning outcomes/key messages The TG will understand their EDS difficulties for TG s disease state, its including the risk of aspiration and choking and management and nutrient adequacy malnutrition The TG will understand the food and fluid consistency has been recommended for them The TG will have the knowledge to prepare their food/fluid consistency. The TG will have the knowledge to apply dietary and fluid advice safely to ensure nourishment and hydration. 3. Dietary risks/consideration/guidance to be included. a) Possible nutrient deficiencies or nutritional problems for TG. b) What are the TG s nutrition recommendations? Specify what the dietary guidance is based on a) TG at risk of poor hydration and fibre intake, and micronutrient deficiency. b) TG is at risk of undernourishment therefore key messages will advise and provide guidance on to safely ensure nourishment food fortification Writers Brief Notes and Inclusions Be aware that the initial diagnosis/assessment and review will be by an SLT. Not all areas have direct access to all AHPs involved in dysphagia management. Adhere to IDDSI colour-code through design phase to ensure clarity and consistency with the framework. IDDSI provides labels of IDDSI levels to support implementation. Consider use of these to personalise resources and ensure consistency with general information and package labelling on ready meals, thickeners and related product information. b) The Eatwell Guide is not appropriate for this group due to risk of nutrient deficiency and weight loss. Guidance on food groups Page 4 of 6

6 5 and how this should be explained, for example: i. DRVs ii. Eatwell Guide c) Dietary considerations, for example: i. foods or ingredients to be avoided ii. portion size and frequency of meals/snacks iii. fluid intake iv. alcohol tips will be provided if/when necessary. Standard public health dietary messages will not be applied. c) i. include a list of high risk foods (see previous resources) ii. Aim for optimal nutritional intake through 3meals and 2 snacks/6 mini meals daily by promotion of Little and often messages where needed and provide an appropriate list of snack foods for use when there is malnutrition risk iii. Highlighting the importance of fluid intake and the role of foods with high fluid content to combat dehydration and support increased nutritional intake e.g. gravy, sauces, soups, yoghurt and custard. Tips on appropriate thickeners for fizzy drinks (QoL) iv. Tips on appropriate thickeners (QoL) will be provided via descriptions of suitable food choices from each group and presentation of plated meals/prepared snacks. c) iii. Include practical advice and tips on achieving both macro and micronutrient sufficiency e.g. protein in soup, fortified milk drinks Page 5 of 6

7 6 4. Practical advice to support TA achieve the learning outcomes and follow the recommendations: a) Food choices and supplements b) Recipe suggestions c) Purchasing and preparing food (raw ingredients, ready meals, freezing and reheating, texture modification) d) Eating (planning meals/menus, environment, aids, eating out/away from home etc.) e) Physical activity f) Medication g) Other a) High risk and recommended snacks. Do not include information on nutritional supplements. b) Consider inclusion only for most modified diets c) Include a general section or stand-alone booklet on how to present food to make it appetising d) Guidance on planning, preparation, eating out and away from home. e) NA f) Ensure that medication can be safely consumed. Contact your GP and pharmacist about how to safely take these. If you have difficulty taking medication, speak to your SLT about an appropriate for. g) If using a starch based thickener beware of wiping the spoon to avoid thinning by saliva. a) Note UK-wide efforts to limit prescribable ONS with many areas moving towards no ONS prescribing. b) Consider recipe lists in other ranges e.g. Nourishing Drinks (ref: 9034) and fortified food recipe book currently in development d) Consider convenience foods, packed lunches and how to eat whilst away from home and preparation areas/aids. f) Note that Liquid forms of medications are available, but access is limited. Page 6 of 6

8 7 Easier Swallowing Guidance for a level diet Difficulties with eating, drinking and swallowing are called dysphagia. This condition affects lots of people due to many different causes. A Speech and Language Therapist has assessed and diagnosed your eating, drinking and swallowing difficulties. Your Speech and Language Therapist has recommended that you should follow a diet with level foods. This booklet aims to help you understand why eating, drinking and swallowing can be difficult and how to safely adapt food to level so it is safe, tasty and nourishing for you. Why is it difficult? Eating, drinking and swallowing require a complex sequence of actions. Nerves and muscles must work to control how food and fluids safely pass from your mouth to your stomach. Problems can occur if you have a condition that affects your lips, tongue, throat, voice box or breathing. <Labelled picture of side of the head INCLUDE LABELS TO SHOW LIPS, TEETH, TONGUE, SOFT PALLET, EPIGLOTTIS, VOICE BOX/LARYNX/WINDPIPE (ENTRY TO THE AIRWAY AND PASSAGE IF FOOD GOES DOWN THE WRONG WAY), FOOD PIPE (GULLET - CHANNEL FOR FOOD AND DRINK TO THE DIGESTIVE SYSTEM FOR HYDRATION AND NOURISHMENT)> What can go wrong? When nerves and muscles become weak and don t work properly, eating, drinking and swallowing becomes less efficient and unsafe, risking serious complications. - Aspiration occurs when food or drink goes down the wrong way and enters your lungs. You may not be aware that this is happening, but it can cause chest infections and pneumonia. - Choking happens when food goes down the wrong way and blocks your windpipe and you struggle to breathe. Choking can be fatal. - Malnutrition is sometimes called undernutrition, and is when the body is lacking the necessary energy and nutrients to function properly. - Dehydration is the term used for when somebody does not have enough fluid in the body. Our body consists of around 70% water, so having enough fluid each day is vital for your good health. The advice in this booklet aims to help you reduce the risk of developing these complications. Page 1 of 15

9 8 How do I know if I have an eating, drinking or swallowing problem? There are many symptoms that indicate an eating, drinking or swallowing problem. Being aware of these will help you identify any change in your condition. Drooling Food sticking in your mouth, even after swallowing Difficulty chewing and avoiding certain food Swallowing feels like hard work Food gets stuck in your throat Coughing or choking when swallowing Your voice sounds wet or gurgly after swallowing Repeated chest infections or pneumonia You take a long time to eat your meal or feel reluctant to eat You notice significant, unplanned weight loss Who can help? A Speech and Language Therapist will assess and diagnose your eating, drinking and swallowing difficulties. Your Speech and Language Therapist will advise you, your GP and other health professionals or carers about the consistency of food and fluid you should have, plus any appropriate medicines. A GP will assess and advise on your general medical needs, address any complications and prescribe any medicines you need. Ask about other specialists who can help: Dietitians recommend how to get the nutrition and hydration needed they offer guidance on food choices, food preparation and adding extra nourishment to your diet. Physiotherapists provide advice on the best posture and positioning when you are eating and drinking. Occupational Therapists assess and recommend any aids or adaptations to make eating and drinking easier and more effective. Page 2 of 15

10 9 How does modifying my food and drink help? If you are having swallowing problems, you may have to change the texture of your food and drinks. Your Speech and Language Therapist has assessed that all your drinks should be: Tick as Appropriate It is really important to drink enough fluids. Drinking at least 10 cups (1.5-2 litres or 3-4 pints) every day will ensure you keep well hydrated and healthy. Drinks can be hot or cold, for example tea, coffee, milk or fruit juices. You may be advised to fortify your drinks to increase their nutritional content. Using a thickener in drinks will help to slow the fluid as it moves through your mouth, past your airway and into your gullet. This will give you more time to swallow safely. You will find instructions on how to achieve the required/recommended level of thickness for your drink on the side of the can of thickener. Page 3 of 15

11 10 How to get the nourishment you need If your appetite is poor or you have lost weight you may need to eat little and often. Aim to have 3 small meals and 2-3 snacks each day. It is important to eat as varied a diet as possible. Our bodies need a range of different foods every day. Protein foods, such as meat, fish, poultry, eggs, beans, lentils, tofu and Quorn. Try to eat 2-3 portions daily. Starchy foods, such as potatoes, pasta, bread and breakfast cereals provide energy. Try to eat some of these foods with every meal and snack. Dairy foods and alternatives, such as milk, cheese, yoghurt, fromage frais. Dairy products provide calcium and protein always use fortified, full-fat dairy alternatives. Try to have 2-3 portions daily. Use fortified milk in drinks and to make puddings and aim for 1 pint of this daily. Use the recipe below. Fruit and vegetables five portions daily are recommended so try to include fruit or fruit juice and vegetables at each meal and snack. Making fortified milk 4 tablespoons skimmed milk powder 1 pint full fat milk Whisk ingredients together and either use as a drink or in drinks and cooking. Aim to complete a pint of fortified milk daily. If you have lost weight or your appetite is poor, it is important to fortify/enrich your food and drinks to increase their nutritional content. It might also be necessary to take a multivitamin supplement, which may have to be thickened. Discuss your needs with your Dietitian or Speech and Language Therapist. Page 4 of 15

12 11 You can fortify your food by adding high protein and energy foods to your meals, snacks and drinks. Aim to add at least 100ml of fortified milk or 1 tablespoon of spreads, creams, cheese, oil or powders per serving. For example: Food Type Cereals Sauces Mashed potato Vegetables Soups Puddings Ideas to add Fortified milk or full-fat yoghurt, cream, honey, seedless jam, syrup, pureed fruit. Always drain off excess fluid after soaking. Grated cheese, cream cheese, silken tofu, milk powder, coconut milk powder, full-fat yoghurt, cream, butter, margarine, evaporated milk Grated cheese, cream cheese, milk powder, smooth nut/seed butters or pastes, cream, crème fraiche, margarine, butter, olive oil Full-fat salad cream, full-fat mayonnaise, smooth nut/seed butters or pastes, grated cheese, sauces, olive oil, margarine, butter, full-fat yoghurt Grated cheese, mascarpone or other full-fat soft/cream cheese, cream, full-fat crème fraiche, evaporated milk, fortified milk, milk powder, silken tofu, soft bread crumbs, red split lentils, yellow split peas (you may need to puree and/or sieve the ideas in bold) Full-fat yoghurt, cream, evaporated or condensed milk, fullfat crème fraiche, coconut milk powder, custard, chocolate sauce, seedless jam, honey Use fortified milk to make milk puddings. Avoid reduced sugar/fat or diet desserts. Page 5 of 15

13 12 Food level should be liquidised. Liquidised food: - Can be drunk from a cup - Can be taken with a normal or wide bore straw with some effort - Cannot be piped or moulded - Can be eaten with a spoon - No chewing is required - Should be a smooth texture with no bits, lumps, fibres, skin, husk or gristle - Easily pours from a spoon when titled <insert images> It is not possible to hold a sample of this food texture using your fingers. Examples of foods with this texture include: - Tinned tomato soup - Thin sauces and gravies Choosing and preparing food for level All food must be cooked until it is soft and then pureed/liquidised to a smooth consistency. Some foods may need to be sieved and thickened. Adding liquid to the food makes it easier to liquidise. Do not add water it will dilute the nutritional value of the meal. Always use nourishing liquids or sauces to make liquidising easier. Suitable liquids include fortified or full-fat milk, thin cheese sauce, gravy, cream or crème fraiche. A nourishing balance Eating little and often is the best way to get the nutrition you need. Aim for 3 small meals and 3 snacks per day. Try to have something to eat every 2-3 hours during waking hours. Avoid diet or slimming foods such as reduced-fat, low-fat, sugar-free or low-calorie varieties. Page 6 of 15

14 13 High risk foods When you have difficulty chewing or swallowing, some foods should be avoided as they pose a high risk of causing choking and aspiration. Stringy, fibrous texture e.g. pineapple, runner beans, celery, lettuce, onions, pickled vegetables, sausages, stringy melted cheese such as mozzarella or gruyere. Vegetable and fruit skins and pith e.g. beans (broad, baked, soya), black-eyed peas, orange/mandarin segments, grapes, tomatoes, peppers, potato skins. Mixed consistency foods e.g. cereals that don t blend with milk (e.g. muesli), mince with thin gravy, and soup with lumps and soaked bread. Crunchy foods e.g. toast, flaky pastry, dry biscuits, and crisps. Crumbly foods e.g. bread crusts, pie crusts, crumble, and dry biscuits. Hard foods e.g. boiled and chewy sweets and toffees, nuts and seeds. Husks e.g. sweetcorn and granary bread Page 7 of 15

15 14 Lists of examples are not exhaustive. Starchy carbohydrates include with every meal Meals all must include a source of protein such as meat, fish, eggs, pulses, cheese or vegetarian alternatives Suitable foods to liquidise. Always prepare the food to meet the level 3 description. Always use nourishing liquids or sauces to make liquidising easier. Porridge made with milk may need to be sieved. Ready Brek or instant porridge without bits made with milk. Weetabix soaked in plenty of warm milk and sieved. Well-cooked pasta. Do not add hard or crispy topping such as baked/toasted breadcrumbs, crispy cheese, hard baked pasta edges. Potatoes, sweet potatoes without skins, add milk, butter, margarine, cream etc. Tender meat such as stew, casserole or curry served with potatoes. Mince and potatoes, corned beef hash or stovies. Shepherd s, cottage or fish pie with soft mashed potato topping. Scottish black pudding and baked beans. Fish in sauce with potatoes. Tuna in mayonnaise with mashed potato. Lentils cooked in sauce/gravy/stock e.g. dhal or lentil casserole Root vegetable curry with silken tofu Eggs, scrambled, baked, hard boiled or poached in sauce or mayonnaise Foods to avoid Crispy, coarse and/or mixed texture cereals such as All Bran, Shredded Wheat, muesli, bran flakes, corn flakes or Rice Krispies. Porridge with bits such as Apple Ready Brek or multigrain varieties Bread, toast, pancakes, bagels, pizza and other baked goods Rice Tough meat, fat or gristle. Cold or processed meat such as chopped pork, luncheon meat, sausage, burgers, haggis Meat, fish and poultry with bones e.g. chicken thighs, sardines Fried/breaded/battered fish and chicken products etc. Pastry any pies, pastries, pasties or sausage rolls. Pizza Scotch eggs Fried eggs Notes Ensure all bones are removed from fish. Page 8 of 15

16 15 Lists of examples are not exhaustive. Soup Always ensure that this is thickened to the appropriate liquid level Vegetables Fruit Suitable foods to liquidise. Always prepare the food to meet the level 3 description. Always use nourishing liquids or sauces to make liquidising easier. Smooth soups liquidised to a smooth, consistent texture and contains meat, fish, lentils, split peas, silken tofu or has fortified milk, cheese, cream or soft breadcrumbs added for extra nourishment may need to be sieved Tomatoes - tinned and sieved or fresh skinned and deseeded. Well-cooked soft vegetables no stalks, for example cauliflower and broccoli tops, carrot, turnip, parsnip, butternut squash Baked beans and mushy peas may need sieving Stewed apples or pears with skins removed Tinned mandarins Soft fresh fruit or tinned fruit pears, peaches, nectarines, banana Kiwi fruit, strawberries, raspberry sieved to remove seeds Melon, excess fluid drained and may require thickener. Fruit puree Fruit smoothie may need to be sieved Foods to avoid Soups with mixed texture and/or have not been liquidised such as Scotch broth or chicken and rice Raw or under-cooked (al dente) vegetables Salads and salad vegetables lettuce, cucumber, raw carrot, onions, peppers, celery, coleslaw. Mushrooms, peppers, courgettes Peas, sweetcorn, runner beans Kidney, borlotti, broad or black-eyed beans or chick peas. Hard and/or mixed texture fresh fruit such as pineapple, apple, orange and other citrus fruits Dried fruit Notes Page 9 of 15

17 16 Lists of examples are not exhaustive. Dairy and alternatives Desserts and sweet snacks Savoury snacks Suitable foods to liquidise. Always prepare the food to meet the level 3 description. Always use nourishing liquids or sauces to make liquidising easier. Cream and soft cheese with no rind, for example mascarpone, ricotta, soft goats cheese, full-fat Philadelphia. Cheddar, red Leicester, parmesan, pecorino cheese grate and add to sauce, mashed potato or soup - make sure it is fully melted and blended to ensure it is not stringy. Natural yoghurt, fromage frais, crème fraiche and cream can all be added to savoury dishes. Silken tofu can be used in sauces, soups and desserts as a substitute for cream always blend it well to ensure it is smooth and fully incorporated. Smooth yoghurt, fromage frais Thick custard/semolina thinned with fortified/full-fat milk or cream. Rice pudding with seedless jam Mousse or whips Smooth syrup style sauces such as chocolate or fruit flavour Fruit smoothie - may need to be sieved Avocado pureed with yoghurt, mayonnaise Fortified soup Foods to avoid Hard, solid cheese Cheese with rind Chewy cheese such as halloumi or paneer Yoghurt with bits e.g. fruit, nuts, toffee, chocolate Cheesecake Pies and sweet pastries Crumbles Meringue Biscuits, cookies, doughnuts. Sweets mints, boiled, novelty chocolate. Crisps, nuts, pretzels, Bombay mix. Notes Page 10 of 15

18 17 Sample Meal Plans Breakfast Day 1 Day 2 Pureed fruit Thickened fruit juice Porridge made with milk or Rice pudding with seedless jam cream, pureed and sieved Mid-morning See snack ideas See snack ideas Lunch Cauliflower cheese liquidised with milk or cream and mashed potatoes Pureed banana and custard Mid afternoon See snack ideas See snack ideas Evening meal Corned beef hash with broccoli tops Chocolate mousse with fruit syrup Bedtime Fortified hot milky drink e.g. hot chocolate Horlicks, Ovaltine etc. Lentil soup with added soft breadcrumbs and grated cheese Pureed fruit and smooth yoghurt Chicken casserole with carrots Custard and fruit puree Fruit smoothie Page 11 of 15

19 18 How to prepare the food Depending on the food used and the texture required, different equipment is useful to achieve the texture you need. Whatever tools or preparation method you use, always check that the consistency is correct for the texture you need. - Liquidiser/food processor Best for puréeing foods containing different textures such as stews and casseroles. Fortifying ingredients can easily be added e.g. fortified milk, grated cheese or soft breadcrumbs to create a smooth, uniform texture. - Sieve Can be used to create a fine puree or hold back bits for example in porridge or fruit purée. - Small balloon (wire) whisk Useful for adding in dry powders like milk powder, corn flour, or thickeners. Also cream and yoghurt can easily be whisked into purées and sauces. Some foods may need to be re-heated after altering texture. Re-heating can be done easily in the microwave or in a bowl over a pan of simmering water. This should only be done once, and any remaining food must be discarded. Pureeing/Liquidising - Ensure the blades are covered with food. - Never overfill the container - Do not use boiling liquids - Take care if food is hot - Hold lid firmly (use a cloth to do this if the food is hot) - Purée/liquidise main course and vegetables separately. Ensure that all pureeing/liquidising equipment is cleaned thoroughly after use as they tend to trap food and can be hard to clean once food is dried on. How to make foods and meals as appetising as possible - Do not liquidise the meal altogether, as it is difficult to know what you are eating, it may not look appealing and you may miss out on different flavours. - Make use of the natural colour of food to ensure variety e.g. puréed fish and sauce, puréed carrots, mashed potato, chocolate dessert. - Serve thin purees in individual bowls so that food does not spread on the plate and become cold quickly. - Use milk, or milk-based sauces when puréeing/liquidising foods. - Do not use water to thin pureed food, as you will dilute the nourishment. - Fortify meals as advised by your healthcare team. Freeze extra meals - Allow to cool, cover, label and freeze quickly. Page 12 of 15

20 19 - Allow to thaw completely before re-heating. - Re-heat foods until piping hot and allow to cool to individual preference. - Only re-heat once and discard any leftover food. Page 13 of 15

21 20 Tips for managing some problems you might experience? Mouth Care: It is very important to look after your mouth and keep it as clean as possible. Food might remain in your mouth after eating and can be a source of infection. To avoid this: - Clean your teeth regularly, ideally after each meal - Check there is no residue in your mouth after eating - Clean your dentures every night - Use a denture fixative so your dentures fit well. Constipation: Constipation can be due to poor food and fluid intake, lack of fibre, reduced mobility and a side effect of some medication. To help ease this: - Aim to drink at least 10 cups of fluid per day (approximately litres or 3-4 pints). Always make sure that it is the right consistency for you. - Eat plenty of fruit and vegetables prepared for your level 3 diet. - Include high-fibre cereal such as porridge or Weetabix prepared for your level 3 diet. - Get active even gentle walking and chair based exercises can make a big difference. Ask your GP or other health professional for suggestions about where to get support locally. Do not add natural bran to your food. Chest infections: Because these can be very serious, it is important to follow the diet texture recommended to you by your Speech and Language Therapist. Sore Mouth: This might be due to your medical condition or medication. Tips to help: - Ensure you drink plenty but avoid very hot drinks. - Keep food moist by adding extra sauce or gravy - Clean your teeth regularly; a baby toothbrush can be more comfortable than an adult one. - See Mouth Care tips earlier in this booklet. Tiredness: If tiredness or low energy affects you, consider the following: - Eat smaller meals more frequently aim for 5-6 small meals spaced evenly throughout the day. - Add extra nutrition to your food so you don t have to eat big meals see page X - Try to eat most when you re awake and alert. - A lot of people feel more tired in the evenings so consider having your main meal at lunchtime. - If you can t manage a full meal, have a nutritious drink such as hot chocolate, Ovaltine or milkshake made with fortified milk. Page 14 of 15

22 21 Useful contacts and notes Page 15 of 15

23 22 Easier Swallowing Guidance for a level diet Difficulties with eating, drinking and swallowing are called dysphagia. This condition affects lots of people due to many different causes. A Speech and Language Therapist has assessed and diagnosed your eating, drinking and swallowing difficulties. Your Speech and Language Therapist recommends that you should follow a diet with level foods. This booklet aims to help you understand why eating, drinking and swallowing can be difficult and how to safely adapt food to level so it is safe, tasty and nourishing for you. Why is it difficult? Eating, drinking and swallowing require a complex sequence of actions. Nerves and muscles must work to control how food and fluids safely pass from your mouth to your stomach. Problems can occur if you have a condition that affects your lips, tongue, throat, voice box or breathing. <Labelled picture of side of the head INCLUDE LABELS TO SHOW LIPS, TEETH, TONGUE, SOFT PALLET, EPIGLOTTIS, VOICE BOX/LARYNX/WINDPIPE (ENTRY TO THE AIRWAY AND PASSAGE IF FOOD GOES DOWN THE WRONG WAY), FOOD PIPE (GULLET - CHANNEL FOR FOOD AND DRINK TO THE DIGESTIVE SYSTEM FOR HYDRATION AND NOURISHMENT)> What can go wrong? When nerves and muscles become weak and don t work properly, eating, drinking and swallowing becomes less efficient and unsafe, risking serious complications. - Aspiration occurs when food or drink goes down the wrong way and enters your lungs. You may not be aware that this is happening, but it can cause chest infections and pneumonia. - Choking happens when food goes down the wrong way and blocks your windpipe and you struggle to breathe. Choking can be fatal. - Malnutrition is sometimes called undernutrition, and is when the body is lacking the necessary energy and nutrients to function properly. - Dehydration is the term used for when somebody does not have enough fluid in the body. Our body consists of around 70% water, so having enough fluid each day is vital for your good health. The advice in this booklet aims to help you reduce the risk of developing these complications. Page 1 of 15

24 23 How do I know if I have an eating, drinking or swallowing problem? There are many symptoms that indicate an eating, drinking or swallowing problem. Being aware of these will help you identify any change in your condition. Drooling Food sticking in your mouth, even after swallowing Difficulty chewing and avoiding certain food Swallowing feels like hard work Food gets stuck in your throat Coughing or choking when swallowing Your voice sounds wet or gurgly after swallowing Repeated chest infections or pneumonia You take a long time to eat your meal or feel reluctant to eat You notice significant, unplanned weight loss Who can help? A Speech and Language Therapist will assess and diagnose your eating, drinking and swallowing difficulties. Your Speech and Language Therapist will advise you, your GP and other health professionals or carers about the consistency of food and fluid you should have, plus any appropriate medicines. A GP will assess and advise on your general medical needs, address any complications and prescribe any medicines you need. Ask about other specialists who can help: Dietitians recommend how to get the nutrition and hydration needed they offer guidance on food choices, food preparation and adding extra nourishment to your diet. Physiotherapists provide advice on the best posture and positioning when you are eating and drinking. Occupational Therapists assess and recommend any aids or adaptations to make eating and drinking easier and more effective. Page 2 of 15

25 24 How does modifying my food and drink help? If you are having swallowing problems, you may need to change the texture of your food and drinks. Your Speech and Language Therapist has assessed that all your drinks should be: Tick as Appropriate It is really important to drink enough fluids. Drinking at least 10 cups (1.5-2 litres or 3-4 pints) every day will ensure you keep well hydrated and healthy. Drinks can be hot or cold, for example tea, coffee, milk or fruit juices. You may be advised to fortify your drinks to increase their nutritional content. Using a thickener in drinks will help to slow the fluid as it moves through your mouth, past your airway and into your gullet. This will give you more time to swallow safely. You will find instructions on how to achieve the required/recommended level of thickness for your drink on the side of the can of thickener. Page 3 of 15

26 25 How to get the nourishment you need If your appetite is poor or you have lost weight you may need to eat little and often. Aim to have 3 small meals and 2-3 snacks each day. It is important to eat as varied a diet as possible. Our bodies need a range of different foods every day. Protein foods, such as meat, fish, poultry, eggs, beans, lentils, tofu and Quorn. Try to eat 2-3 portions daily. Starchy foods, such as potatoes, pasta, bread and breakfast cereals provide energy. Try to eat some of these foods with every meal and snack. Dairy foods and alternatives, such as milk, cheese, yoghurt, fromage frais. Dairy products provide calcium and protein always use fortified, full-fat dairy alternatives. Try to have 2-3 portions daily. Use fortified milk in drinks and to make puddings and aim for 1 pint of this daily. Use the recipe below. Fruit and vegetables five portions daily are recommended so try to include fruit or fruit juice and vegetables at each meal and snack. Making fortified milk 4 tablespoons skimmed milk powder 1 pint full fat milk Whisk ingredients together and either use as a drink or in drinks and cooking. Aim to complete a pint of fortified milk daily. If you have lost weight or your appetite is poor, it is important to fortify/enrich your food and drinks to increase their nutritional content. It might also be necessary to take a multivitamin supplement, which may have to be thickened. Discuss your needs with your Dietitian or Speech and Language Therapist. Page 4 of 15

27 26 You can fortify your food by adding high protein and energy foods to your meals, snacks and drinks. Aim to add at least 100ml of fortified milk or 1 tablespoon of spreads, creams, cheese, oil or powders per serving. For example: Food Type Cereals Sauces Mashed potato Vegetables Soups Puddings Ideas to add Fortified milk or full-fat yoghurt, cream, honey, seedless jam, syrup, pureed fruit. Always drain off excess fluid after soaking. Grated cheese, cream cheese, silken tofu, milk powder, coconut milk powder, full-fat yoghurt, cream, butter, margarine, evaporated milk Grated cheese, cream cheese, milk powder, smooth nut/seed butters or pastes, cream, crème fraiche, margarine, butter, olive oil Full-fat salad cream, full-fat mayonnaise, smooth nut/seed butters or pastes, grated cheese, sauces, olive oil, margarine, butter, full-fat yoghurt Grated cheese, mascarpone or other full-fat soft/cream cheese, evaporated milk, fortified milk, milk powder, silken tofu, cream, full-fat crème fraiche, soft bread crumbs, red split lentils, yellow split peas (you may need to puree and/or sieve the ones in bold) Full-fat yoghurt, cream, evaporated or condensed milk, fullfat crème fraiche, fortified milk, coconut milk powder, custard, chocolate sauce, seedless jam, honey Use fortified milk to make milk puddings. Avoid reduced sugar/fat or diet desserts. Page 5 of 15

28 27 Food level is pureed and extremely thick. Pureed food: - Is usually eaten with a spoon, although it is possible to eat it with a fork - Cannot be drunk from a cup - Cannot be sucked through a straw - Does not require chewing - Can be piped, layered or moulded - Cannot be poured - Falls off a spoon in a single spoonful when dropped - Holds its shape on a plate - Does not contain lumps - Is not sticky - Liquid must not separate from solid - Similar texture to shop bought baby foods* - Slides off a tilted spoon easily, with little food left on the spoon <insert images> It is just possible to hold a sample of this texture using fingers this texture will slide smoothly between your fingers. Examples of suitable pureed foods include pureed meat or thick cereal. Prepared pureed food may be a convenient addition to meals and snacks. *Baby food does not have enough nutrition for adults. Choosing and preparing food for level All food must be cooked until it is soft and then pureed/liquidised to a smooth consistency. Food may need to be sieved, and on occasion thickener may need to be added to achieve correct consistency. You may need to add additional sauce or gravy to achieve the required consistency after liquidising. A nourishing balance Eating little and often is the best way to get the nutrition you need. Aim for 3 small meals and 3 snacks per day. Try to have something to eat every 2-3 hours during waking hours. Avoid diet or slimming foods such as reduced-fat, low-fat, sugar-free or low-calorie varieties. Page 6 of 15

29 28 High risk foods When you have difficulty chewing or swallowing, some foods should be avoided as they pose a high risk of causing choking and aspiration. Stringy, fibrous texture e.g. pineapple, runner beans, celery, lettuce, onions, pickled vegetables, sausages, string melted cheese such as mozzarella or gruyere. Vegetable and fruit skins and pith e.g. beans (broad, baked, soya), black-eyed peas, orange/mandarin segments, grapes, tomatoes, peppers, potato skins. Mixed consistency foods e.g. cereals that don t blend with milk (e.g. muesli), mince with thin gravy, and soup with lumps and soaked bread. Crunchy foods e.g. toast, flaky pastry, dry biscuits, and crisps. Crumbly foods e.g. bread crusts, pie crusts, crumble, and dry biscuits. Hard foods e.g. boiled and chewy sweets and toffees, nuts and seeds. Husks e.g. sweetcorn and granary bread Page 7 of 15

30 29 Lists of examples are not exhaustive. Starchy carbohydrate include with every meal Suitable foods to be pureed. Always prepare the food to meet the description of level 4 food. Additional sauce or gravy may be needed. Porridge made with milk may need to be sieved. Ready Brek or instant porridge without bits made with milk. Weetabix soaked in plenty of warm full-fat, fortified milk and any excess drained. Liquidised toast with butter and jam remove the crusts from bread with no seeds or grains; lightly toast the bread and break it up into a liquidiser, add melted butter and warmed jam, and puree to required consistency. Well-cooked pasta. Do not add hard or crispy topping such as baked/toasted breadcrumbs, crispy cheese, hard baked pasta edges. Foods to Avoid Crispy, coarse and/or mixed texture cereals such as All Bran, Shredded Wheat, muesli, bran flakes, corn flakes or Rice Krispies. Porridge with bits such as Apple Ready Brek or multigrain varieties Seeded bread. Ordinary toast Pancakes, bagels, pizza and other baked goods Rice Notes Meals all must include a source of protein such as meat, fish, eggs, pulses, cheese or vegetarian alternatives Potatoes, sweet potatoes without skins add milk, butter, margarine, cream etc. Tender meat, fish, Quorn or tofu stew, casserole or curry served with potatoes. Mince and potatoes, corned beef hash or stovies. Shepherd s, cottage or fish pie with soft mashed potato topping. Tough meat, fat and gristle Cold or processed meat such as chopped pork, luncheon meat, sausage, burger, haggis Meat, fish and poultry with bones e.g. chicken thighs, sardines Ensure all bones are removed from fish Page 8 of 15

31 30 Lists of examples are not exhaustive. Soup Always ensure that this is thickened to the appropriate liquid level Vegetables Suitable foods to be pureed. Always prepare the food to meet the description of level 4 food. Additional sauce or gravy may be needed. Scottish black pudding (skin removed) and baked beans Fish in sauce Tuna in mayonnaise with mashed potato. Eggs - scrambled, baked, hard boiled or poached in sauce or mayonnaise. Lentils cooked in sauce/gravy/stock e.g. dhal or lentil casserole Root vegetable curry with silken tofu Soft breadcrumbs can be added before liquidising Smooth soups liquidised to a smooth, consistent texture and contains meat, fish, lentils, split peas, silken tofu or has cheese, cream or soft breadcrumbs added for extra nourishment. Tomatoes either tinned and sieved or fresh skinned and deseeded. Well-cooked soft vegetables no stalks, for example cauliflower and broccoli tops, carrot, turnip, parsnip, butternut squash Baked beans and mushy peas may need sieving Foods to Avoid Fried/breaded/battered fish or poultry products e.g. fish cakes, chicken Kiev, breaded turkey escallops, Scotch egg. Pastry any pies, pastries, pasties or sausage rolls. Pizza Fried egg Soups with mixed texture and/or have not been liquidised such as Scotch broth or chicken and rice Raw or under-cooked (al dente) vegetables Salads and salad vegetables lettuce, cucumber, raw carrot, onions, peppers, celery, coleslaw. Mushrooms, peppers, courgettes Peas, sweetcorn, runner beans Kidney, borlotti, broad or black-eyed beans or chick peas. Notes Page 9 of 15

32 31 Lists of examples are not exhaustive. Fruit Dairy and alternatives Suitable foods to be pureed. Always prepare the food to meet the description of level 4 food. Additional sauce or gravy may be needed. Soft fresh fruit such as banana Kiwi fruit, strawberries, raspberry sieved to remove seeds Melon, excess fluid drained and may require thickener. Stewed apples or pears with skins removed Soft tinned fruit pears, peaches, nectarines, mandarins Fruit puree Fruit snack tubes or pouches such as GoGo Squeeze, Heinz Fruit Pouches or shops own brand may be suitable Fruit smoothie may need to be sieved Cream and soft cheese with no rind, for example mascarpone, ricotta, soft goats cheese, full-fat Philadelphia. Cheddar cheese grate and add to sauce, mashed potato or soup - make sure it is fully melted and blended to ensure it is not stringy. Natural yoghurt, fromage frais, crème fraiche and cream can all be added to savoury dishes. Silken tofu can be used in sauces, soups and desserts as a substitute for cream always blend it well to ensure it is smooth and fully incorporated. Foods to Avoid Hard and/or mixed texture fresh fruit such as pineapple, apple, orange and other citrus fruits Dried fruit Hard, solid cheese Cheese with rind Notes Page 10 of 15

33 32 Lists of examples are not exhaustive. Desserts and sweet snacks Savoury Snacks Suitable foods to be pureed. Always prepare the food to meet the description of level 4 food. Additional sauce or gravy may be needed. Smooth yoghurt, fromage frais Thick custard/semolina. Trifle with soft fruit may need to be sieved Plain sponge with thick custard Rice pudding with seedless jam Mousse or whips Smooth syrup style sauces such as chocolate or fruit flavour Fruit smoothie may need to be sieved Avocado pureed with yoghurt, mayonnaise Fortified smooth soups Smooth nut butter, soft cream cheese, smooth pȃté, hummus and meat/fish/bean paste. These can be eaten on their own or with bread or crackers which have been soaked in soaking solution. Foods to Avoid Yoghurt with bits e.g. fruit, nuts, toffee, chocolate Cheesecake Pies and sweet pastries Crumbles Meringue Biscuits, cookies, doughnuts. Sweets mints, boiled, novelty chocolate. Crisps, nuts, pretzels, Bombay mix. Notes Page 11 of 15

34 33 Sample Meal Plans Breakfast Day 1 Day 2 Pureed fruit Fruit juice Porridge made with milk pureed and Wheat biscuit breakfast cereal sieved pureed with milk Pureed toast with melted butter and Pureed toast with melted butter warm seedless jam (see method on and warm seedless jam - pureed suitable food list) (see suitable food list) Midmorning Lunch Midafternoon Evening meal Bedtime See snack ideas Tuna in mayonnaise and mashed potato Pureed banana and custard See snack ideas Shepherd s pie, broccoli tops Rice pudding and seedless jam Hot milky drink egg hot chocolate Horlicks Ovaltine etc. See snack ideas Lentil soup with added bread and grated cheese Pureed fruit and smooth yoghurt See snack ideas Chicken casserole with potatoes, carrots Plain sponge and thick custard Fruit smoothie Page 12 of 15

35 34 How to prepare the food Depending on the food used and the texture required, different equipment is useful to achieve the texture you need. Whatever tools or preparation method you use, always check that the consistency is correct for the texture you need. - Liquidiser/food processor Best for puréeing foods containing different textures such as stews and casseroles. Fortifying ingredients can easily be added e.g. fortified milk, grated cheese or breadcrumbs to create a smooth, uniform texture. - Sieve Can be used to create a fine puree or hold back bits for example in porridge or fruit purée. Small balloon (wire) whisk Useful for adding in dry powders like milk powder, corn flour, or thickeners. Also cream and yoghurt can easily be whisked into purées and sauces. Some foods may need to be re-heated after altering texture. Re-heating can be done easily in the microwave or in a bowl over a pan of simmering water. This should only be done once, and any remaining food must be discarded. Pureeing/Liquidising - Ensure the blades are covered with food. - Never overfill the container - Do not use boiling liquids - Take care if food is hot - Hold lid firmly (use a cloth to do this if the food is hot) - Purée/liquidise main course and vegetables separately. Ensure that all pureeing/liquidising equipment is cleaned thoroughly after use as they tend to trap food and can be hard to clean once food is dried on. How to make foods and meals as appetising as possible - Do not liquidise the meal altogether, as it is difficult to know what you are eating, it may not look appealing and you may miss out on different flavours. - Make use of the natural colour of food to ensure variety e.g. puréed fish and sauce, puréed carrots, mashed potato, chocolate dessert. Freeze extra meals - Allow to cool, cover, label and freeze quickly. - Allow to thaw completely before re-heating. - Re-heat foods until piping hot and allow to cool to individual preference. - Only re-heat once and discard any leftover food Page 13 of 15

36 35 Tips for managing some problems you might experience? Mouth Care: It is very important to look after your mouth and keep it as clean as possible. Food might remain in your mouth after eating and can be a source of infection. To avoid this: - Clean your teeth regularly, ideally after each meal - Check there is no residue in your mouth after eating - Clean your dentures every night - Use a denture fixative so your dentures fit well. This will also help with chewing. Constipation: Constipation can be due to poor food and fluid intake, lack of fibre, reduced mobility and a side effect of some medication. To help ease this: - Aim to drink at least 10 cups of fluid per day (approximately litres or 3-4 pints). Always make sure that it is the right consistency for you. - Eat plenty of fruit and vegetables prepared for your level 4 diet. - Include high-fibre cereal such as porridge or Weetabix into your routine prepared for your level 4 diet. - Get active even gentle walking and chair based exercises can make a big difference. Ask your GP or other health care professional for suggestions about where to get support locally. Do not add natural bran to your food. Chest infections: Because these can be very serious, it is important to follow the diet texture recommended to you by your Speech and Language Therapist. Sore Mouth: This might be due to your medical condition or medication. Tips to help: - Ensure you drink plenty but avoid very hot drinks. - Clean your teeth regularly; a baby toothbrush can be more comfortable than an adult one. - See Mouth Care tips earlier in this booklet. Tiredness: If tiredness or low energy affects you, consider the following: - Eat smaller meals more frequently aim for 5-6 small meals spaced evenly throughout the day. - Add extra nutrition to your food so you don t have to eat big meals see page X - Try to eat most when you re awake and alert. - A lot of people feel more tired in the evenings so consider having your main meal at lunchtime. - If you can t manage a full meal, have a nutritious drink such as hot chocolate, Ovaltine or milkshake made with fortified milk. Page 14 of 15

37 36 Useful contacts and notes Page 15 of 15

38 37 Easier Swallowing Guidance for a level diet Difficulties with eating, drinking and swallowing are called dysphagia. This condition affects lots of people due to many different causes. A Speech and Language Therapist has assessed and diagnosed your eating, drinking and swallowing difficulties. Your Speech and Language Therapist recommends that you should follow a diet with level foods. This booklet aims to help you understand why eating, drinking and swallowing can be difficult and how to safely adapt food to level Why is it difficult? so it is safe, tasty and nourishing for you. Eating, drinking and swallowing require a complex sequence of actions. Nerves and muscles must work to control how food and fluids safely pass from your mouth to your stomach. Problems can occur if you have a condition that affects your lips, tongue, throat, voice box or breathing. <Labelled picture of side of the head INCLUDE LABELS TO SHOW LIPS, TEETH, TONGUE, SOFT PALLET, EPIGLOTTIS, VOICE BOX/LARYNX/WINDPIPE (ENTRY TO THE AIRWAY AND PASSAGE IF FOOD GOES DOWN THE WRONG WAY), FOOD PIPE (GULLET - CHANNEL FOR FOOD AND DRINK TO THE DIGESTIVE SYSTEM FOR HYDRATION AND NOURISHMENT)> What can go wrong? When nerves and muscles become weak and don t work properly, eating, drinking and swallowing becomes less efficient and unsafe, risking serious complications. - Aspiration occurs when food or drink goes down the wrong way and enters your lungs. You may not be aware that this is happening, but it can cause chest infections and pneumonia. - Choking happens when food goes down the wrong way and blocks your windpipe and you struggle to breathe. Choking can be fatal. - Malnutrition is sometimes called undernutrition, and is when the body is lacking the necessary energy and nutrients to function properly. - Dehydration is the term used for when somebody does not have enough fluid in the body. Our body consists of around 70% water, so having enough fluid each day is vital for your good health. The advice in this booklet aims to help you reduce the risk of developing these complications. Page 1 of 17