Swallow and Nutrition Support soft & bite-sized Level 6 Diet

Sometimes a puréed diet may not be enough to meet your nutritional requirements, especially if you have a small appetite. If your portions are smaller than normal, it is important that you eat foods that are nutritionally dense. Try some of the ‘top tips’ 
below:

• eat your most filling meal of the day when your appetite is at its best
• serve smaller, more manageable portions
• have snacks or nourishing drinks between your meals
• eat foods that you enjoy
• fresh air or activity before your meal may help stimulate your appetite
• use whole milk if possible
• if possible add cheese, butter, or sour cream to puréed potatoes 
• cover vegetables such as purée cauliflower and broccoli with a cheese sauce
• add evaporated milk or cream to puddings such as Angel Delight and custards 
• be generous with butter, margarine or oil in cooking puréed meals
• add jam, syrup, sugar or honey to drinks, puddings or breakfast cereals

Snack ideas

• thick and smooth fortified soup and fortified milk (see recipes below)
• cheesy mashed potato
• smooth guacamole and puréed carrots
• milky puddings or custard made with full-fat milk or fortified milk
• full-fat yoghurt with puréed fruit
• a bowl of porridge made with full-fat milk or fortified milk and honey.

Nourishing drinks

If you are unable to manage a full meal you can increase your intake with nourishing drinks. Try the following suggestions:

• make a smoothie with puréed fruit, honey, ice cream and fortified milk
• replace water with fortified milk to make a creamy coffee
• add cream to hot chocolate
• try Complan or Meritene drinks, available from chemists and supermarkets.

Fortified milk 

Ingredients

1 pint or 600ml of full fat milk
4 tablespoons of skimmed milk powder 

Method

Mix the milk powder to a paste with a little of the milk, then stir in the rest of the milk. 
This fortified milk can be used in drinks, breakfast cereal or wherever you would normally use milk

Fortified soup

• add fortified milk, instead of water to condensed soup or cup-a-soup before
  liquidising OR 
• add milk powder, cream, soft cheese, and/or olive oil to homemade or puréed
  canned soups.

Remember; drinks may need to be thickened according to your speech and language therapist’s advice.

A guide to starchy carbohydrates for a soft and bite-sized diet, and those to avoid

Acceptable for soft and bite-sized diet	Avoid
Breakfast cereals softened with milk Porridge, oatmeal, Ready Brek, semolina Boiled, mashed potatoes, jacket potato filling, potato waffle, boiled or oven-baked sweet potato Quiches with soft pastry only Very well cooked pasta, chopped noodles, spaghetti, small or chopped pasta eg. macaroni cheese, spaghetti Bolognese, ravioli Creamed rice Well cooked rice	Muesli Crusty, grainy bread Toasted bread Biscuits Flaky pastry, eg. puff, filo Crumbles on fruit Brown or special fried rice Sandwiches Jacket potato skins Naan bread Chapatti

Meat and meat alternatives

Meat must be soft, tender meat, in pieces no bigger than 15x15mm. Serve in a thick, smooth, non-pouring sauce or gravy. If meat cannot be finely mashed it should be minced. Fish must be soft enough to break up into small pieces with a fork.

A guide to meat and meat alternatives for a soft and bite-sized diet, and those to avoid

Acceptable for soft and bite-sized diet

Avoid

Well cooked, tender meat or poultry that can be broken up with a fork Tender stews, curry and casseroles Cottage pie, lasagne, meat loaf Sliced delicatessen meats, corned beef, pâté, sausage meat with no skin Boneless fish fillets, steamed or grilled, and served with white sauce Canned tuna or salmon, with mayonnaise or tomato sauce, no bones Quiche with no hard pastry Well-cooked legumes, eg. lentils and kidney beans, fork-mashable tofu, Quorn, soya pieces with no breadcrumbs, soy-mix Baked beans Soft poached or scrambled eggs Omelettes Mashed hard-boiled eggs Smooth nut butters.

Tough, stringy or dry meat or poultry Bread-crumbed meat and fish Grilled meat Sausages, salami, frankfurters and other solid meat snacks Nuts and seeds Fish with bones Sausage rolls Fried eggs Coarse nut butters.

 

A guide to fruit and vegetables for a soft and bite-sized diet, and those to avoid

Acceptable for soft and bite-sized diet

Avoid

Smooth vegetable-based soups Stewed or canned fruit which can be mashed down with a fork, eg. pear, peach, plum Certain soft, fresh fruit which can be mashed down with a fork, eg. pawpaw, banana, strawberries  Soft salad, eg. potato salad Well-cooked fresh, frozen or canned vegetables, cut up with pips and skin removed; courgette, mushy peas, parsnips, swede Ratatouille Tinned tomatoes and stuffed vegetables Vegetables added to stews

Dried fruit Unpeeled fruit Hard fruits, eg. fresh apple, pineapple, oranges, berries, coconut Stringy or tough vegetables, eg. celery, sweetcorn, peas, beans, tomatoes Skin and seeds Raw vegetables and salad Undercooked or crunchy vegetables Soups with hard pieces

A guide to milk and milk products for a soft and bite-sized diet, and those to avoid

Acceptable for soft and bite-sized diet	Avoid
Plain or fruit yoghurt Yoghurt desserts, eg. fruit fool, fruit compote, fromage frais Soft, smooth milk puddings, eg. rice pudding, tapioca, mousse, instant pudding Soft cheeses  Cheesecake without crust Instant whip puddings, blancmange and crème caramel	Ice-cream with hard chunks, eg. nuts Grilled cheese or hard cheese Yoghurt with nuts or muesli

A guide to puddings and snacks for a soft and bite-sized diet, and those to avoid

Acceptable for soft and bite-sized diet	Avoid
Thick smooth yoghurt with soft, tender pieces of fruit no bigger than 15mm Stewed apple in thick custard Light sponge cake fully softened with thick, smooth custard or cream Egg custard with no pastry Shop-bought mousse desserts eg. Cadbury's Caramel, Rolo, Milky Bar, Aero chocolate Chocolate spread.	Dry biscuits Toffee and sweets Crisps Flaky pastry Dry or hard crumble Nuts

The following foods may be more difficult to eat and should be avoided:

• Stringy, fibrous textures eg. pineapple, runner beans, celery, lettuce
• Vegetables and fruit with skins eg. beans including broad beans, baked beans, soya beans and black eyed beans, peas, sweetcorn and grapes
• Crunchy foods eg. toast, flaky pastry, dry biscuits, crisps
• Crumbly items eg. bread crusts, pie crusts, crumble, dry biscuits
• Hard foods eg. boiled and chewy sweets and toffees, nuts and seeds
• Husks eg. sweetcorn, granary bread

If you are on texture modified fluids (thickened drinks) a speech and language therapist may advise you to avoid ice-cream and jelly. This is because they change consistency in your mouth and become too runny. Please speak to your therapist if you are unsure.

Before eating and drinking please ensure that the person who is eating:

• can remain consistently awake and alert during eating and drinking
• is able to sit as upright as possible
• has a clean and clear mouth.

During eating and drinking please ensure that the person who is eating:

• has the correct texture of diet and fluids recommended by the speech and 
  language therapist
• if you are feeding, explain what you are doing and what the person will be eating and drinking
• ensure the mouthfuls provided are not too large 
• concentrate on each swallow
• monitor for any coughing, ‘gurgly’ voice, increased respiratory rate or fatigue. If  you notice any of these symptoms, stop and contact the community speech and language therapist for advice. 

You may also need to:

• remind the person eating to swallow more than once each time to clear any 
  residue 
• allow extra time between mouthfuls for extra swallows

At the end of eating and drinking:

• ensure the person’s mouth is clear and clean
• keep the person sitting up for 30 minutes, to minimise the risk of reflux
• medication may also need to be modified in line with eating and drinking guidelines. Please speak to your pharmacist for advice.

If you are on texture modified fluids (thickened drinks) a speech and language therapist may advise you to avoid ice-cream and jelly. This is because ice-cream and jelly change consistency in your mouth, and become too runny. Please speak to your therapist if you are unsure. 

If you would like more information on how to prepare a puréed diet please visit the IDDSI website www.IDDSI.org. You can also find information on how to use the fork test and spoon tilt test to check that your food is the correct consistency.

Who should I contact if I have a problem or question?

If you have concerns regarding swallow safety or aspiration, contact your GP who can put you in touch with your local Community Speech and Language Therapy Team.

Dietetic Department, Hillingdon Hospital: 01895 279416

What should I do in case of an emergency?

Contact your GP or call 111 if non-urgent. Attend A&E or call 999 if an emergency.