Safe Swallowing, Easy Eating

Safe Swallowing, Easy Eating Information booklet for Patients and Carers Patient Name

Patient Name: Date: You have been advised to take the following: Food Texture B Texture C Texture D Texture E Normal Thin Purée Thick Purée Moist Mashed / Pre-Mashed Soft/Fork Mashable Fluids Normal Stage 1 Stage 2 Stage 3 Additional Information Dietitian: Telephone: Speech & Language Therapist: Telephone:

Contents Page number Introduction What is dysphagia? 4 How is it managed? 4 What happens? 5 Signs that your swallow might not be working well 5 Who can help? 6 Safe swallowing guidelines 7 Treatment options 8 Dysphagia Food Texture Descriptors 9 What is Texture B/ Thin Purée? 10 What is Texture C/ Thick Purée? 11 What is Texture D/ Moist Mashed / Pre-Mashed? 12 What is Texture E / Soft/Fork Mashable? 13 High Risk Foods 14 Fluid Thickening 15 Guidelines on thickening liquids 16 How do I use Nutilis Powder? 17 How do I use Nutilis Clear? 19 Meeting your nutritional needs 21 Fluids 21 Boosting calories in a soft diet 22 Making foods of your choice soft & smooth 23 Tips for preparing 23 Tips for serving and presenting food 24 Useful equipment 25 Tips for managing dry mouth 26 Tips for managing taste changes 27 Constipation 27 Medications 28 Who pays for these products? 29 Appendix 1: Weight Chart 30

Page 4 Introduction This booklet is intended to help people who have been told by their Speech and Language Therapist or Doctor that they have a swallowing problem (dysphagia). What is dysphagia? It happens when the muscles of chewing and swallowing (lips, jaw, tongue, palate, throat muscles) become weakened. This can happen to people with a number of conditions, for example: Stroke Alzheimer's Disease Multiple Sclerosis Cerebral Palsy Head Injury Parkinson s Disease Motor Neurone Disease Surgery to head & neck Learning disabilities How is it managed? This condition is managed by the Speech & Language Therapist (SLT) and Dietitian. The Doctors and Nurses are also involved.

Page 5 What happens? Weakness of the mouth and throat muscles may result in food or drinks going down the wrong way. This means that the food or drinks will go into the lungs instead of the stomach. This can cause chest infections and pneumonia. (1) Normal Swallow (2) Dysphagia Nose Mouth Food/Drink To Lungs To Stomach To Lungs To Stomach Signs that your swallow may not be working well: Coughing and choking when you are swallowing food or drink. Food or drink going down the wrong way. Coughing fits, during or after mealtimes. Your voice may sound wet and gurgly after eating/drinking. Food left in the mouth after a meal. Eating slower than usual, or leaving food on the plate. Losing weight. Feeling chesty or unwell.

Page 6 Who can help? Your Speech & Language Therapist will: Assess the strength of the muscles in the mouth & throat and your ability to perform a safe swallow. Recommend foods and drinks which are easier to swallow. Show you exercises and positions to make swallowing easier and safer, if relevant. Your Dietitian will: Monitor your weight. Recommend the correct food choices to ensure you meet your nutritional needs. Give you advice on fortifying your food. If necessary, your Dietitian will recommend appropriate nutritional supplements e.g. Nutilis Complete Stage 1, Nutilis Complete Stage 2, Nutilis Fruit Stage 3, Fortisip Compact, Forticreme Complete, Fortijuice or an alternative nutritional supplement brand. It is important that your bowels move regularly. If constipation is a problem, try the following: Make sure you are taking enough fluid daily - aim for at least 8 cups of fluid per day. Your bowel cannot work properly if you are dehydrated.

Page 7 Safe Swallowing Guidelines Main points Fig 1 1 Sit upright with arms and shoulders forward, don't rest your arms/ elbows on the table (figure 1). 2 Remain in the above position for at least 30 minutes after every meal/drink. 3 Avoid eating or drinking in a lying down position as it is very difficult and/or unsafe to swallow in this way. 4 Never talk while eating or drinking. 5 Take small amounts at a time, especially of liquids a teaspoon is best. 6 Swallow twice on every mouthful. 7 If you can hear a gurgly sound to your voice after swallowing, cough and swallow again. 8 Avoid foods of a mixed consistency e.g. minestrone soup, fruit and vegetables with skins such as peas, stringy food such as celery. Please refer to page 14 for high risk foods to avoid. 9 Avoid beakers with upright mouth pieces as they cause you to tilt your head backwards, making it easier for drinks to go down the wrong way. 10 Never use a straw for taking drinks. Note for family/carers: Do not offer food or fluids to a person with swallowing problems unless he/she is fully alert.

Page 8 Treatment Options One way to manage swallowing difficulties is to thicken food and drinks to a consistency considered safe and appropriate by a Speech & Language Therapist. Thickened food and drinks are easier to control in the mouth and can be more safely swallowed. Drinks You may need your drinks thickened to a safe consistency for swallowing* (e.g. Stage 1, Stage 2, Stage 3). Thickened drinks move slowly in the mouth and throat. This gives you more time to swallow them safely and easily. Food You may need soft or puréed food which is easier to chew and swallow. Certain foods are difficult to swallow. You may have to avoid foods like brown bread, nuts, crumbly biscuits etc (Please refer to page 14 for high risk foods to avoid.). Exercise You may need to do exercises to strengthen the muscles used in biting, chewing and swallowing food. Your Speech and Language Therapist will advise you on these if relevant. Nutilis * Nutilis Powder and Nutilis Clear are thickening powders that are added to foods and fluids to thicken them up. Please see page 16 for more information.

Page 9 Dysphagia Food Texture Descriptors What are these descriptors? These descriptors detail the types and textures of foods needed by individuals who have dysphagia (swallowing difficulties) and who are at risk of choking or aspiration (food or liquid going into their airway). The food textures are: B = Thin Purée Dysphagia Diet C = Thick Purée Dysphagia Diet D = Moist Mashed / Pre-Mashed Dysphagia Diet E = Soft/Fork Mashable Dysphagia Diet Your speech and language therapist will tell you which texture diet you should follow.

Page 10 What is a Texture B/ Thin Purée Diet? Unmodified Regular Foods Texture B Thin Purée Texture C Thick Purée Texture D Moist Mashed / Pre-Mashed Texture E Soft/Fork Mashable NAME Description Characteristics Food exclusions TEXTURE B- THIN PURÉE Food has been puréed or has purée texture and does not require chewing. It is a thin purée. It is smooth throughout with no bits (no lumps, fibres, bits of shell/skins, bits of husk, particles of gristle/bone etc). It may need to be sieved to achieve this. It may have a fine textured quality as long as the bolus remains cohesive in the mouth. It is moist. Any fluid in or on the food is as thick as the purée itself. There are no loose fluids that have separated off. The texture is not sticky in the mouth. No garnish. Does not hold its shape on a plate or when scooped. Cannot be eaten with a fork because it slowly drops through the prongs. The prongs of a fork do not make a clear pattern on the surface. Cannot be piped, layered or moulded. Can be poured. Spreads out if spilled. A light, disposable plastic teaspoon must be able to stand upright. If it does not do this, the texture is too thin. No hard pieces crust or skin that have formed during cooking/heating, standing.

Page 11 What is a Texture C/ Thick Purée Diet? Unmodified Regular Foods Texture B Thin Purée Texture C Thick Purée Texture D Moist Mashed / Pre-Mashed Texture E Soft/Fork Mashable NAME Description Characteristics Food exclusions Sample Foods TEXTURE C- THICK PURÉE Food has been puréed or has purée texture and does not require chewing. It is a thick purée. It is smooth throughout with no bits (no lumps, fibres, bits of shell/skin, bits of husk, particles of gristle/bone etc.) It may need to be sieved to achieve this. It may have a fine textured quality as long as the bolus remains cohesive in the mouth. It is moist. Any fluid in or on the food is as thick as the purée itself. There are no loose fluids that have separated off. The texture is not sticky in the mouth. It is not rubbery. No garnish. Holds its shape on a plate or when scooped. Can be eaten with a fork because it does not drop through the prongs. The prongs of a fork make a clear pattern on the surface. It can be piped, layered or moulded. Cannot be poured. Does not spread out if spilled. No hard pieces, crust or skin that have formed during cooking / heating / standing. Fluid / gravy / sauce / custard in or on the food has not thinned out or separated off. Breakfast:Thick smooth porridge made from powder (purée porridge) with no loose fluids. Wheat-biscuit breakfast cereal fully softened with milk fully absorbed. Dessert: Purée rice pudding, mousse with no bits.

Page 12 What is a Texture D/ Moist Mashed / Pre-Mashed Diet? Unmodified Regular Foods Texture B Thin Purée Texture C Thick Purée Texture D Moist Mashed / Pre-Mashed Texture E Soft/Fork Mashable NAME Description Characteristics Food exclusions Sample Foods TEXTURE D- MOIST MASHED / PRE-MASHED Food is soft, tender and moist. Needs very little chewing. It has been mashed up with a fork. It usually requires a very thick, smooth (non-pouring) sauce, gravy or custard. No mixed (thick-thin) textures. No loose fluid. No hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits. No pips, seeds, pith/inside skin. No skins or outer shells e.g. on peas, grapes. No husks, skin, bone or bristle. No round or long-shaped foods e.g. sausages, grapes, sweets. No hard chunks e.g. pieces of apple. No sticky foods e.g. cheese chunks, marshmallows. No floppy foods e.g. lettuce, cucumber, uncooked baby spinach leaves. No juicy food where juice separates off e.g. water melon. It holds its shape on a plate or when scooped, cannot be poured and does not spread out if spilled. Thinner single texture foods maybe suitable if a person is on thinner fluids SLT to advise on an individual basis. No hard pieces, crust or skin that have formed during cooking/ heating/standing. Check that fluid/gravy/sauce/custard in or on the food has not thinned out or separated off. Meat: Must be finely minced-pieces approximately 2mms. No hard bits of mince. Serve in a very thick, smooth (non-pouring) sauce or gravy. If it cannot be finely minced, it should be puréed (to texture C) Fish: Serve finely mashed and in a very thick, smooth (non-pouring) sauce or gravy. Fruit: Serve mashed. Drain away any juice that has separated. Casserole/stew/curry: Must be very thick. Can contain meat, fish or vegetable if prepared as above. Bread: No bread unless assessed as suitable by a SLT on an individual basis. Cereal: The texture of very thick smooth porridge with no lumps or the texture of fully softened wheat-biscuit breakfast cereal with milk fully absorbed. Desserts: The texture of very thick, smooth yoghurt (no bits) or stewed apple in a very thick custard. Or the texture of soft sponge cake with smooth filling, fully softened by mashing and mixing in very thick, smooth (non-pouring) custard.

Page 13 What is a Texture E/ Soft/Fork Mashable Diet? Unmodified Regular Foods Texture B Thin Purée Texture C Thick Purée Texture D Moist Mashed / Pre-Mashed Texture E Soft/Fork Mashable NAME Description Characteristics Food exclusions Sample Foods TEXTURE E- SOFT/FORK MASHABLE Food is soft, tender and moist but needs some chewing. It can be mashed with a fork. It sometimes requires a thick, smooth sauce, gravy or custard. Any fluid, gravy, sauce or custard in or on the food is thick. No mixed (thick-thin) textures. No thin loose fluid. No hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy or crumbly bits. No pips, seeds, pith/inside skin. No skins or outer shells e.g. on peas, grapes. No husks, skin, bone or bristle. No round or long-shaped foods e.g. sausages, grapes, sweets. No hard chunks e.g. pieces of apple. No sticky foods e.g. cheese chunks, marshmallows. No floppy foods e.g. lettuce, cucumber, uncooked baby spinach leaves. No juicy food where juice separates off in the mouth e.g. water melon. Any fluid, gravy, sauce or custard in or on food must be thick a light disposable plastic teaspoon would stand upright. Those on Texture E must therefore be able to cope with thinner fluids stage 2. Thinner single texture foods maybe suitable if a person is on thinner fluids SLT to advise on an individual basis. No hard pieces crust or skins that have formed during cooking/heating/standing. Check that Fluid/gravy/sauce/custard in or on the food has not thinned out or separated off. Meat: Pieces of soft tender meat must be served no bigger than 15mms. Or serve meat finely minced. No hard bits of mince. Serve in a thick smooth sauce or gravy. Fish: Soft enough to break up into small pieces with a fork. Serve in thick smooth sauce or gravy. Fruit: Juicy fruit should be mashed drain away any juice that has separated. Casserole/stew/curry: Must be thick. Can contain meat, fish or vegetables if prepared as above. Bread: No bread unless assessed as suitable by SLT on an individual basis. Cereal: he texture of thick smooth porridge with no hard lumps. Fully softened wheat-biscuit breakfast cereal with milk fully absorbed. Desserts: Thick smooth yogurt (fork mashable or soft tender pieces of fruit no bigger than 15mms are acceptable). Stewed apple in thick custard. Soft sponge cake with smooth filling, fully softened with thick smooth custard.

Page 14 High Risk Foods Some foods can be particularly difficult to swallow safely. Some will need extra care, others should be avoided altogether. Your Speech and Language Therapist or Dietitian will advise you. Below is a list of types of food that may be difficult to eat: Stringy, fibrous texture e.g. pineapple, celery, runner beans, lettuce. Vegetable and fruit skins e.g. broad beans, baked beans, soya beans, peas, grapes. Mixed consistency foods e.g. soup with lumps, stewed fruit, mince with thin gravy, cereals which do not blend with milk (muesli). Crunchy foods e.g. toast, flaky pastry, crisps. Crumbly items e.g. pie crusts, crumble, dry biscuits. Hard foods e.g. boiled and chewy sweets and toffees, nuts and seeds. Husks e.g. sweetcorn and granary bread. NOTE: No ice cream, ice lollies or jelly unless advised by a speech and language therapist on an individual basis.

Page 15 Fluid Thickening As you are experiencing swallowing difficulties your speech and language therapist has advised thickened fluids to ensure your swallow is as safe as possible. A thickened fluid is one to which a commercial thickener has been added. By thickening your fluids, drinking will become easier and safer. If you are in hospital, thickeners will be provided. At home, they will be prescribed by your GP. Thickeners can be used in both hot and cold drinks. The different stages of thickening Stage 1 This consistency can be drunk through a straw or from a cup (if advised or preferred). It leaves a thin coat on the back of a spoon. Stage 2 This consistency is too thick to drink through a straw, but can be drunk from a cup. It leaves a thick coat on the back of a spoon. Stage 3 This consistency cannot be drunk through a straw, or from a cup. It needs to be taken with a spoon.

Page 16 Guidelines on Thickening liquids The thickener you are using is: Nutilis Powder Nutilis Clear You have been advised to thicken all your fluids to the following consistency: Stage 1 Stage 2 Stage 3 It is extremely important that ALL fluids or liquid foods are thickened according to the guidelines below. This includes soup, tea, nutritional supplements and liquid medications. Mixing Guide for Nutilis Powder The table below outlines the suggested amount of level scoops of Nutilis Powder required for different liquids. Please note: the quantity of Nutilis Powder required may vary slightly depending on the temperature or thickness of the liquid to be thickened. NUTILIS POWDER SCOOP CHART Stage 1 Stage 2 Stage 3 Syrup Custard Pudding 200ml Regular fluids 2 3 4 200ml Hot drinks 3 4 5 200ml Milk 3 4 5 Pre-thickened Nutilis Complete Nutilis Complete Nutilis Fruit Supplement Stage 1 Stage 2 Stage 3 200ml Fortisip 3 5 6* 200ml Fortijuce 5 8 Nutilis Fruit Stage 3 125ml Fortisip Compact 1 2 3* *Forticreme Complete and Nutilis Fruit Stage 3 can both be used as a Stage 3 nutritional supplement. Nutilis Powder scoop is 4g. Alternatively, your Speech and Language Therapist can cross out the table above and complete this table for your specific needs: Per 200ml fluids Stage 1 Syrup Stage 2 Custard Stage 3 Pudding Regular Fluids Hot drinks Milk Supplements:

Page 17 How do I use Nutilis Powder? Note! Additional Tips... 1 Always use a beaker/shaker for mixing and the scoop provided for measuring the right amount of thickener. 2 Add Nutilis Powder to 200ml of fluids in the shaker/ beaker. Screw the lid on tightly. 3 Shake vigorously for approximately 10-20 seconds until all the powder is dissolved. 4. Remove the lid. 5 Allow to stand for a few minutes until the desired consistency is reached. Do not add more thickener during this time. 6 Pour and serve. 7 If the drink is too thick after 3-5 minutes, add some liquid to thin it down to the right consistency. An average sized cup or glass = 200ml. An average sized plastic or polystyrene cup = 150ml. The guidelines set out above apply to Nutilis Powder. If thickening alcoholic drinks, please ensure that they are thickened to the recommended consistency or speak to your Speech and Language Therapist. Replace lid securely after each use. Use thickener to thicken all liquids, including soup and alcohol. REMEMBER to take your thickener with you if you are going on holiday or eating out. Mixing hot drinks: (temperature > 60 C) Please allow hot drinks to cool for 8 minutes prior to thickening. The use of the shaker is not recommended for hot drinks. However, if using the shaker for hot drinks, please make sure the lid is securely tightened, shake lightly and remove the lid immediately after shaking. If desired or needed, drinks may be heated in the microwave after the addition of Nutilis Powder. If reheating thickened hot drinks please ensure they are reheated immediately. Mixing cold drinks: (temperature < 7 C): Allow the cold drink to stand for a few minutes prior to thickening. Let the prepared liquid stand for a few minutes to achieve the desired thickness. Mixing carbonated drinks: Please use caution when thickening carbonated drinks, and stir to reduce fizz before mixing with a fork. The use of a shaker is not recommended for carbonated drinks. If a shaker is used, make sure the lid is securely tightened, shake lightly and remove the lid immediately after shaking.

Page 18 Mixing Guide for Nutilis Clear The table below outlines the suggested amount of level scoops of Nutilis Clear required for different liquids. Please note: the quantity of Nutilis Clear required may vary slightly depending on the temperature or thickness of the liquid to be thickened. NUTILIS CLEAR SCOOP CHART Stage 1 Stage 2 Stage 3 Syrup Custard Pudding 200ml Drinks (water, coffee, 1 2 3 tea, juice, milk, etc) Pre-thickened Nutilis Complete Nutilis Complete Nutilis Fruit Supplement Stage 1 Stage 2 Stage 3 Nutilis Clear scoop is 3g. Alternatively, your Speech and Language Therapist can cross out the table above and complete this table for your specific needs: Per 200ml fluids Stage 1 Syrup Stage 2 Custard Stage 3 Pudding Regular Fluids Hot drinks Milk Supplements:

Page 19 How do I use Nutilis Clear? Nutilis Clear can be mixed using a fork, whisk or shaker. The powder may be added to the glass or shaker before adding the liquid, or you can add the powder after the liquid has been added to the glass or shaker. The recommended method is: Using a fork: 1. Put the required amount of Nutilis Clear into a cup, glass, bowl or shaker 2. Add the drink or liquid to the powder 3. Stir vigorously with a fork for 15-30 seconds 4. Leave to stand for a minute 5. Stir gently for 5 seconds and serve Using Nutilis Clear correctly will mean that the food and drinks that you thicken will maintain their flavour, appearance and consistency Additional Tips... General tips for usage: Use only the scoop provided in the tin. Add all the powder at once. Start stirring or shaking as soon as possible. Stir or shake quickly. Stop stirring or shaking as soon as the powder has dissolved, to prevent air bubbles forming in the drink. Mixing hot drinks: (temperature > 60 C) Allow the drink to cool slightly before adding Nutilis Clear. If thickening tea or coffee, always add the milk and sugar to the drink before adding the powder. It is not recommended to use the shaker when preparing hot drinks, for safety reasons. Mixing carbonated drinks: For best results, stir carbonated drinks until the drink has gone flat, prior to adding the powder. Mixing water: The clarity of thickened water may differ, depending on regional variations in water hardness.

Page 20 REMEMBER: If recommended, Nutritional Supplements must be your first choice of drink. Which drinks taste best when thickened? Based on a survey carried out, the following advice is offered; Juices When thickened, juices taste the same. The thickener does not alter the taste. Juices are easy to thicken. Dilutable squashes These taste very nice if made less dilute than usual. Try 1/5 squash, ⁴ ₅ water. Both the sugar free and full sugar versions looked and tasted good. Tea, Coffee Tea and coffee tend to need a little more thickener than other drinks. Please note: Thickener should only be added after the drink has cooled slightly and any milk or sugar have already been added. Fizzy drinks Mixing carbonated drinks including sugar free and diet drinks: Please use caution when thickening carbonated drinks, and stir to reduce fizz before shaking. Water Water does not look or taste good when thickened. Milk Milk has quite a strong flavour once thickened. Try adding flavouring e.g. chocolate/banana to make a tasty milkshake. Try flavoured milks. Taste ratings of drinks Excellent! OK! Least Palatable

Page 21 Meeting your nutritional needs It can be difficult to meet your body s needs for food and fluids when you have a swallowing problem. It may take longer for you to finish a meal and sometimes soft meals are less nutritious than normal meals. If you have been sick, it is particularly important to make sure you eat and drink enough every day. This will help prevent any weight loss and help regain any weight you have lost already. Here is some advice to make this a little easier: Eat little and often. Aim for at least two nutritious snacks in between your meals. Try adding extra calories and protein to your food to make it as nourishing as possible. (See Boosting Calories in a Dysphagia Diet page 20). You may be recommended to take special nutritional supplements by your Dietitian or Doctor. These may come in the form of a ready-to-drink liquid or as a powder that is made into a drink. Pre-thickened nutritional supplements include Nutilis Complete Stage 1, Nutilis Complete Stage 2 and Nutilis Fruit Stage 3. Fluids It is important that you take enough thickened fluids every day. Aim for 8 cups every day. If you are having difficulty managing eight cups per day, your Speech and Language Therapist or Dietitian may suggest trying prethickened drinks. Tip! To give variety and prevent boredom, try different temperatures of fluids in both sweet and savoury flavours.

Page 22 Boosting calories in a dysphagia diet People who need a dysphagia diet sometimes find it hard to eat all the food that they need. Here are some tasty tips to help prevent you losing weight. Please check with your SLT/Dietitian, which of these foods are suitable for your diet. Mash vegetables with milk, cream or cream cheese. Try adding some grated cheese and egg. Porridge is a very nutritious breakfast make with milk rather than water and add honey or sugar and Make up instant soups or gravies with milk instead of water. Add cheese and cream to an omelette. Dip cooked soft vegetables in dips such as cream cheese, hummus or sour cream. Make instant coffee, hot chocolate or Horlicks (Add Nutilis Powder as required) with milk and enrich with a spoonful of cream. Make milkshakes with Scandishake, add ice-cream, yoghurt and fresh fruit (Make sure there are no bits/lumps as per your recommended diet texture). Dip your favourite biscuits into tea and coffee. Make sure you use full fat milk and not skimmed or low fat milk. You could fortify milk by adding a few tablespoons of dried milk powder to a pint. Use this for drinking and cooking. Note: If you notice you are losing weight, you should contact your Dietitian or Doctor who will make recommendations to you to prevent this (see the contact details at the start of this booklet). Always take your supplement drinks as prescribed!

Page 23 Making foods of your choice soft & smooth Some of your favourite foods can be made soft and smooth using a soaking solution. Soaking Solution 200ml liquid (e.g. milk, fruit juice, stock). 1 scoop of Nutilis Powder. Method 1 Place liquid into a bowl, add Nutilis Powder or an alternative thickener and whisk thoroughly. 2 Use immediately and do not allow soaking solution to thicken before adding food. 3 Dip food in soaking solution to thicken for one minute and place on a plate. 4 Cover and refrigerate for 30 mins before serving. Serving Suggestions Plain biscuits can be made soft and smooth using a fruit juice soaking solution. Sponge cake can be made soft and smooth using a sherry soaking solution. Bread can be made soft and smooth using a vegetable stock to make the soaking solution. Tips for preparing food Everyday foods can be made soft by finely chopping, mashing or mincing. Soft foods can be prepared without liquidising, but must be soft enough to be mashed with a fork. A potato masher can be used to remove lumps e.g. potato, fruit, vegetables. A fork can be used to mash soft foods e.g. banana. A blender can be used to mince meat and chicken into smaller sized pieces suitable for a soft diet. Vary flavours by adding soy sauce, Worcester sauce, tomato ketchup, curry powder, herbs and spices to savoury dishes or jam to sweet dishes.

Page 24 Tips for serving and presenting food Present each food separately. Avoid mashing everything together. If gravy or sauces are required blend, well into food. Avoid using low calories or low fat liquids to soften food e.g. use milk or cream instead of water. Drain off any excess liquid before serving. Serve foods at hot or cold temperatures rather than at room temperature. For a copy of the Nutilis Powder Recipe Book please contact your Speech & Language Therapist or call Nutricia Medical on Freephone 0800 783 4379.

Page 25 Useful Equipment The following pieces of equipment may help to prepare the recommended consistency and reduce the amount of time needed to prepare meals. Many of the items will already be in your kitchen. Sieve/Strainer is very useful for removing lumps from sauces, gravies, soups or puréed foods. Graters are useful for shredding vegetables before cooking. Whisk & hand-held blenders are useful to mix dry ingredients into sauces and gravies. They are also useful for adding thickener to drinks, soups or whipping cream and puréeing small amounts of soft foods. They are not useful for puréeing hard foods such as cooked meat as they tend to leave lumps. Food Processors that chop, grate, mince, shred, slice and whisk are ideal time-saving devices for preparing food. Food can then be cooked and/or blended to a smooth and thick texture. Benchtop blenders are a necessity when preparing most smooth and thick meals. They are also helpful in producing tasty thickened drinks. Food Moulds can be used to improve the presentation of modified meals. Smoothie makers blend and foam fruit into healthy smoothies. Plastic beakers (with lids) are very useful for thickening liquids. They are available from any shop that sells kitchenware. Nutilis Beakers/Shakers are also available from Nutricia Medical. Please call 0800 783 4379.

Page 26 Tips for managing dry mouth Always take fluids or non-alcoholic drinks with meals (thickened to correct consistency). Avoid anything that may worsen dryness, such as drinking alcohol and caffinated drinks, smoking cigarettes and breathing through the mouth. Sip on juices and other fluids (supplement drinks) throughout the day. Keep fluids by your bedside. Replace saliva with salivary substitutes e.g. Glandosane, BioXtra Moisturising Gel. Stimulate the production of saliva by Chewing sugar-free gum, rubbing a cotton bud dipped in lemon juice under the tongue, sucking sugar-free citrus flavoured sweets/lollipops (Speak with your Speech & Language Therapist before trying these). Avoid spicy, dry or hard crunchy foods such as biscuits. Minimise your intake of salty foods as they may cause pain in a dry mouth. Eat soft creamy foods such as casseroles and soups. Moisten foods with gravies, sauces, extra oil, margarine, butter, salad dressings, mayonnaise or yoghurt. Chew pineapple as it has enzymes that help clean the mouth. Check with your Speech and Language Therapist that this texture is appropriate. Protect against dental caries/decay by brushing teeth and gums regularly. Avoid sticky foods such as toffee. Keep your mouth very clean (twice daily toothbrushing). Use fluoride toothpaste. Use a fluoride, alcohol free mouthwash. Have regular dental check ups. If the air in your home feels dry, try using a humidifier or place a pot/bowl of water near the heat source to help moisten the air. (The humidifier and pot of water should be cleaned on a regular basis). Remember...It is important to take your supplement drinks as prescribed.

Page 27 Tips for managing taste changes Use an alcohol free mouthwash regularly. Drink plenty of liquids. Thicken as advised. Sharp-tasting fruit drinks/juices may help to take away unpleasant tastes. Using strong flavoured sauces can help curry sauce, chilli sauce or sweet and sour sauce. Note, strong flavours or spicy foods are not recommended if you have dry mouth (see page 24). Enhance the flavour of foods by using more seasonings and herbs e.g. oregano, basil, thyme, tarragon, garlic or worcester sauce. All drinks should be thickened as per speech and language therapist recommendations. Constipation It is important that your bowels move regularly. If constipation is a problem, try the following: Make sure you are taking enough fluid daily aim for at least 8 cups of fluid per day. Your bowel cannot work properly if you are dehydrated. Take cereal fibre sources e.g. Weetabix, porridge etc. Take extra fruit e.g. banana, stewed apple or rhubarb with thickener. Include fruit juice e.g. prune or orange, thickened to the correct consistency. Regular exercise to the best of your ability.

Page 28 Medications Tablets may be switched to a syrup form where appropriate. Some medications may be crushed and given in food (e.g. yoghurt) but these should be checked with your pharmacist.

Page 29 Who pays for the food thickener and nutritional supplements? Nutilis Powder and Nutilis Clear are available on prescription from your Doctor. Most nutritional supplements are available on prescription from your Doctor - ask your Dietitian, Pharmacist or Doctor for further information.

Page 30 Appendix 1 Weight Chart Please record your weight on a weekly basis. Weigh yourself in the morning, in your bed clothes & before eating. DATE WEIGHT WEIGHT CHANGE If you are losing weight please contact your Dietitian or Doctor.

Notes

For more information Freephone 0800 783 4379 We wish to acknowledge the input from all members of the Speech and Language Therapy Department at St.Vincents University Hospital.