Dietetics - Extra support with a nourishing diet and healthy activity

This leaflet is intended to provide additional support to help meet your nutritional needs during a period when you may be finding it more difficult to eat enough food or may be experiencing unintentional weight loss.

If you have a problem with your oesophagus (food pipe) or stomach, it can be difficult to eat enough food. This can be for a variety of reasons, some of the factors include:

• Low appetite
• Difficulty swallowing normal textured foods
• Food becoming stuck and coming back up
• Heartburn or acid reflux
• Feeling full easily

Protein

Protein is used to grow and repair tissues, including muscle, in your body.

Protein is found in food groups such as meat (and meat alternatives like tofu, tempeh, Quorn), dairy (and dairy alternatives), fish, eggs, beans and pulses. When you are unwell, the body needs more protein than usual. Your dietitian will be able to advise you on a daily protein target. As a general guide, try to include a source of protein at every meal, snack time or after exercise.

Some easy to prepare protein examples and the grams of protein they provide per serving include:

Energy

During times of illness, the body uses more energy than usual to recover from infection or disease. This means that you need to eat more to provide your body with that energy.

Fats - butter, spreads, vegetable oil and fat on meat.

Protein - meat, diary, eggs, fish, beans, nuts and pulses.

Carbohydrates - bread, pasta, rice, noodles, potatoes.

For a lot of people, their portions can naturally become smaller when they are not feeling well. It can be useful to choose high energy foods that give you lots of energy in a small volume.

Examples include:

• Scrambled eggs with added cheese and cream, on toast with good amounts of spread
• Porridge made with whole milk and an added spoonful of honey or peanut butter
• Fish in white sauce and mashed potato made with whole milk and cream
• Fortified milk - Combine a pint of whole milk with 4 tablespoons of skimmed milk powder. Use this milk in drinks and meals

Having a high fat diet for a long time can increase your risk of developing issues such as heart disease, but in the short term if you are losing a lot of weight, then these foods can help slow down weight loss and should not be avoided. Choosing healthier fats such as olive/rapeseed oils and spreads rather than butter or coconut oils are better for heart health.

Multi Vitamins

Fruits and vegetables provide a range of vitamins that are essential to health. If you have a low appetite or difficulty swallowing, you may find that your intake of fruits and vegetables, especially stringy or hard vegetables, becomes naturally smaller.

If this is the case, you may benefit from a multivitamin to ensure that your body has all the vitamins and minerals needed for growth and repair. Speak to your dietitian if you feel you would benefit from this.

It is important to tell your team about any supplements you are already taking as these can interact with some medications or treatments.

Foods that are easy to chew and swallow

If you find it difficult or painful to swallow or find that some foods get stuck and must be regurgitated, it can significantly reduce the amount of food you manage to eat. Therefore, it can be helpful to choose easier to chew alternatives or blended foods.

Foods that are easier to chew or blended are classified into categories, in line with the International Dysphagia Diet Standardisation Initiative (IDDSI). Further information about the differences in diet textures can be found at https://iddsi.org/

The textures we refer to on the following pages that some people find easier to manage are:

IDDSI level 6 – soft and bite sized (soft and bite sized foods should be cut into 1.5 cm pieces)
IDDSI level 4 – pureed
IDDSI level 3 – liquidised
 
If you have been given separate advice from a Speech and Language therapist, then please let your dietitian know so they can liaise with the team. Dietitians don’t provide advice regarding thickened fluids, if you have been told to thicken your fluids by a Speech and Language therapist then you should continue to do so.

Ready Meal Companies

Some ready meals can be purchased already pureed or as a liquid. Some companies that make and deliver these meals include:

Wiltshire farm foods - www.wiltshirefarmfoods.com
Tel 0808 239 7930

Oakhouse foods - www.oakhousefoods.co.uk
Tel 0333 370 6700

Meal Ideas - Breakfast ideas

Soft and bite sized (IDDSI level 6)

• Weetabix soaked in whole milk
• Porridge/Ready brek with whole milk
• Stewed fruit with yogurt, cream or evaporated milk
• Bite sized pieces of banana with thick and creamy yogurt, eg. Greek yogurt or high protein varieties

Pureed (IDDSI level 4)

• Pureed creamy scrambles eggs with extra cheese
• Pureed/smooth porridge, ready brek or oatmeal
• Thick high protein yogurts (smooth no bits)

Liquidised (IDDSI level 3)

• Liquidised versions of the soft/pureed suggestions
• Smooth fruit smoothies made up with full fat yogurt/milk
• Smooth yogurts with honey, jam, marmalade or peanut butter (smooth no bits)

Main meals ideas

Soft and bite sized (IDDSI level 6)

• Tender cooked meat/vegetable stews
• Curries with tender cooked meat, meat alternatives or pulses
• Soft fish (steamed, poached or baked) in sauce
• Cottage, shepherd’s or fisherman’s pie
• Omelettes with soft fillings , e.g. cheese, well cooked vegetables or potatoes
• Well-cooked soft pasta with bolognese/carbonara sauce
• Corned beef hash or tinned fish with spaghetti or mashed potato
• Skinless sausage (cut onto bite sized pieces) with mashed potatoes and gravy

Pureed - (IDDSI level 4)

• Blended dhal or curry with blended rice
• Thick soups - 'cream of' versions (with no bits) and add cream or grated cheese
• Blended vegetables with additional creams and cheeses (carrots, turnips, cauliflower, broccoli, parsnip, swede)
• Pureed minced meat or chicken with blended potatoes/ vegetables
• Pureed pasta/rice with sauce e.g. blended lentil and vegetable curry

Liquidised diet (IDDSI level 3)

• Thin soups with additional creams/cheese
• Milkshakes made up with whole milk, double cream or ice- cream

Puddings and snacks

Soft and bite sized (IDDSI level 6)

• Biscuits (try dipping in hot drink if easier)
• Ripe fruit salad without skins with full fat yogurt
• Fromage frais
• Mousses/creme caramel
• Sponge pudding with cream/custard
• Baked egg custard (no pastry)

Pureed (IDDSI level 4)

• Thick yoghurts/custard (no bits)
• Milk puddings e.g rice pudding, milk jellies, semolina, custard, use full cream varieties where possible and add fruit compote, honey, jam, cream/sugar
• Hummus or cream cheese
• Cake blended with custard/cream
• Pureed fruit (mango, apple without the skin, tinned peaches, or pears) and cream

Liquidised (IDDSI level 3)

• Thin yoghurts
• Ice-cream
• Milk puddings e.g rice pudding, milk jellies, semolina, custard - use full cream varieties where possible and add fruit compote, honey, jam, cream/sugar
• Angel delight/instant whips
• Nourishing fluids - glasses of milk, hot chocolate, smooth fruit juices or smoothies

Nutritional Supplements

High energy, protein, vitamins and minerals

If you are finding it difficult to eat enough food, your dietitian may advise you to trial nutritional supplement drinks.

These products are specially developed to provide high energy, protein, vitamins and minerals essential for bodily function. Your dietitian will be able discuss which are most appropriate for you to meet your needs. If you think you would benefit from these please discuss with your dietitian.

Tube feeding - extra support

For some people, if they lose a lot of weight or find it difficult to eat and drink, extra support is needed to make sure that they can get enough nutrition. A small feeding tube can be inserted up the nose and into the stomach, or directly into the abdomen to deliver liquid feed. You can have this feeding at home, although you may need a short inpatient stay to be trained on how to use the tube and to build up the feed to full volume. If you need this, your team will discuss the practicalities of this with you in depth.

Exercise

Regular exercise is essential to prevent muscle loss. There is a lot of evidence that people with good muscle mass recover better and quicker from illness.

Exercise can make you feel hungrier. Aim to have food or drink containing protein around 30 minutes post exercise, such as a glass of milk or a yogurt as this also helps to build and repair muscle. In addition, to make sure your body has enough energy to complete the activity, it is recommended to have eaten a meal around 1-2 hours before the exercise.
 
Further information is available at: www.nhs.uk//live-well/ exercise

Recommendations

• Moderate level exercise each week (out of breath but able to hold a conversation) – 150 minutes
• Vigorous activity (very out of breath) – 75 minutes or a combination of both

Moderate exercise:

• Brisk walking
• Water aerobics
• Mowing the lawn
• Vacuuming
• Walking up stairs
• Hiking
• Dancing
• Vigorous exercise
• Jogging/running
• Sports such as football, hockey, rugby, swimming
• Heavy gardening
• Pushing a wheelchair
• Lifting weights

If you don’t meet these levels already, any increase in activity levels can lead to better recovery.

Monitoring nutritional concerns

Here are some common nutritional concerns that people can develop when they are unwell. If any of these become an issue for you or increase in severity, please contact your team as a priority.

Tiredness

It can take a lot of energy to prepare and eat regular snacks and meals, especially if you’re not feeling very hungry.

Keep a stock of ready meals and easy to eat snacks (custards, yogurts, crisps).

Regular physical activity can lead to better quality sleep and less tiredness, any consistent increase in activity levels can be beneficial.

Lack of hunger

Low appetite can be caused by lots of factors including tiredness, medication, pain, and the feeling of fullness:

• Eat smaller portions but more often
• Eat something small every couple of hours
• Nourishing drinks like glasses of milk or milkshakes can be less filling than a meal
• Choose smaller portions - high energy protein choices as listed in this diet sheet

Heartburn/acid reflux

A burning sensation in your chest after eating or at night can be very uncomfortable. If you experience this:

• Avoid spicy or very high fat foods
• Raise the top of your bed by adding pillows
• Avoid eating within 2 hours of going to bed
• There are also medications that can help with this so please let your team know if you are experiencing these symptoms

Dehydration

Drinking enough fluid can be difficult if you having difficulty swallowing or frequently bring back up the drinks you take. Signs you may be dehydrated include dark coloured and strong- smelling urine, headaches, dizziness and dry mouth/lips. Aim to drink at least 6-8 cups per day. If you find you are struggling to drink enough fluid, please contact your team.

Weight loss

Weight loss can be a sign that you’re not eating enough to meet your needs. This can be caused by many factors and your dietitian will be able to advise you if you could benefit from additional support including nutritional supplements, so let them know if you are experiencing weight loss.

Swallowing difficulties

If you find it difficult to swallow foods or often bring food back up, it may be necessary to choose softer foods, or using a blender to make them thinner if needed, to take in enough volume of foods. Usually, people struggle most with chunky, difficult to chew foods such as tough meats or vegetables. If you find you can’t tolerate your normal textured diet, please contact your dietetic team for more information and support.