nutilis recipes prepared to manage dysphagia

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Nutilis recipesPrepared to manage dysphagia

Making the difference

Dysphagia

Dysphagia is defined as difficulty ordiscomfort in swallowing.

It affects people of all ages particularly theelderly. It can occur in varying degrees,ranging from mild discomfort! difficulty, tocomplete inability to swallow.

The ability to swallow safely is a physiological function

that is vital to the maintenance of life. Eating and drinking

nourish the human body and are often considered to be

the most important aspects of social life.

Hence problems with swallowing have a severe impact

on a person's physical and mental wellbeing.

Causes of dysphagia:

• Neurological problems e.g. CVA(stroke), Parkinson's disease, motorneurone disease, Alzheimer'sdisease, multiple sclerosis, dementia

• Head and neck tumours

• Huntington's disease

• Cerebral palsy

• Benign stricture

The prevalence of dysphagia hasbeen demonstrated to be as high as74% of nursing home patients,'15% of all hospital in-patients," andup to 65% of stroke patients."

Symptoms of dysphagia include:

• Loss of appetite and/or weight loss

• Food sticking in the throat

• Choking on food, liquid or saliva

• Pain while swallowing

• Discomfort in the throat or chest

• Dribbling during eating and drinking

Food or fluids passing into the pharynx inan uncoordinated manner can enter theairway - this is termed 'aspiration'.Aspiration can lead to the development ofchest infections. As a result, many patientshave a reduced food intake whichinevitably leads to poor nutritional status.

Malnutrition is associated with manyserious health risks such as reducedwound healing, increased susceptibility toinfection and reduced mental and physicalwellbeing. Increasing concern regardingthe high prevalence of malnutrition inhospitalised elderly patients means thatnutritional therapy should be a vital partof care.

If patients are having difficulty with eatingand/or drinking or there is doubt abouttheir ability to swallow safely, a Speechand Language Therapist should becontacted. They will assess theswallowing reflex and advise on the mostsuitable texture of both food and drink foreach individual.

Nutritional therapy has three main goals:

• To provide suitable foods and fluids tominimise the risk of aspiration andchoking

• To optimise nutritional status andprevent malnutrition

• To improve a patient's ability to takeadequate fluid to prevent dehydration

In order to minimise the risk of aspirationand choking, dysphagia treatment usuallyinvolves texture modification of food anddrink. Fluids may need to be thickenedand solid foods pureed or softened.

Many people assume that water and other liquids are easier for dysphagia sufferers toswallow. In fact they present a unique challenge because they can flow freely throughthe mouth and into the airways. Where the swallow is normal, a cough reflex protectsthe airway, but this reflex is often impaired or absent for many dysphagic patients.Therefore thickening liquids is particularly important to help prevent aspiration of fluids

and ensure that dysphagic patients are adequately hydrated. This can easily beachieved using an appropriate thickening agent such as Nutilis.

swallowing

A normalswallow hasfour stages.

When a personsuffers fromdysphagia, thefollowing difficultiesmay occur:

Red areas represent food or drink

1. Initial

2. Oral

3. Pharyngeal

4. Oesophageal

Food remains in thesides of the mouth

Uquid is brought upthrough the nose

Food and fluids mayenter the airway

Food gets stuck inthe throat

On average we swallow 580 times a day inorder to eat, drink and drain saliva. Theswallowing process actually starts at thelips and ends with food and fluids arrivingin the stomach. A normal swallow consistsof four stages.

1. Initial stageFood and fluid is taken into the mouth. Asa response to the sight, smell and taste offood we produce saliva. The lips and jawclose to seal the mouth.

2. Oral stage

The tongue positions the food betweenthe teeth where it is chewed and mixedwith saliva and then formed into a ball(bolus). The tongue then propels the foodbolus to the back of the mouth intothe pharynx.

3. Pharyngeal stageThe bolus passes via the pharynx into theoesophagus (a muscular tube that extendsto the stomach). The epiglottis closes thelarynx to prevent any food or liquidpassing into the airway.

4. Oesophageal stageThe bolus passes down the oesophagusinto the stomach.

Impairment can occur at any stage of theswallowing process and may involve justone, or a combination of stages.

Management ofdysphagia

Developments in swallowing therapy overthe last decade have seen the introductionof postural modifications and therapeuticmanoeuvres that can be used to limit therisk of aspiration. These methods relyupon the co-operation of the patient eachtime he or she swallows. Many patientsare cognitively impaired, leavingmodification of the texture of both fluidand food as the only satisfactory therapy.

Thickening with Nutilis helps patients withdysphagia swallow fluids and pureedfoods safely and comfortably. Nutilisquickly achieves the consistency desiredfor each individual patient.This puts a greater range of food anddrink back on the menu, helping to ensurepatients get a varied diet which improvestheir nutritional status.

In the upper row: Typicalmenu.Undemeath: Same menu using Nutilis forthickening drinks and food which preservescolour and taste.

Nutilis advantages:

• Mixes easily with a range of fluids andpureed food

• Performs particularly well insupplements like Fortisip, Fortifresh,Fortimel and Fortijuce

• Quickly achieves desired consistency forindividual patients with no separation

• Thickening does not continue onstanding

• Taste of food and drink does not alterdue to thickening

• Thickened food retains attractiveappearance

• Thickened food can be heated, cooledor frozen, without any change inconsistency

• Nutilis is suitable for gluten free, lactosefree and vegetarian diets

Soaking Solutions

Bread and other foods made withgrain, such as biscuits and cakes, area particular problem for patients withdysphagia.The granular structure of these foods

means that they are extremely hard toswallow. Using Nutilis soakingsolutions you can achieve a smoothtexture with these foods. You will findsome recipe examples using thesoaking solutions on pages 11 & 12in this booklet. Always check with aSpeech and Language Therapist toensure that soaking solutions are

appropriate for your patient.

Useful recipes

All recipes list approximate calories, protein values, and portions basedon raw ingredients. These recipes are not compatible with other foodthickeners, the quantities recommended are based on using Nutilis foodthickener only. All food should be blended while hot. If you are not usingfood moulds, recipes can be served, scooped or piped. Please note thatthe National Descriptors for Texture Modification in Adults state that allpureed food should be sieved before thickerinq.'

500 g cooked, boneless, skinless cod25 g butter400 ml white sauce madewith full fat milk40 g grated cheddar cheese24 g Nutilis (approx. 8 scoops)

• Cook the fish. Drain excess water. Makesure there are no bones in the fish!

• Place the fish, butter, cheese, and whitesauce into a blender and blend untilsmooth.

• Add Nutilis, whisk into a smooth pasteand allow to stand for 60 sees.

• Place into mould and then blast freezefor 2 hrs or until food reaches -18°C.

• Turn out into bag and store in deepfreezer.

• When the food is needed, place onto aplate and leave to defrost in the fridge.

• Re-heat to the required temperature.

167 kcal and 14.6 9 protein per portion.

500 g cooked, skinned, diced chicken300 ml chicken gravy25 g butter50 g milk powderwith vegetable fat27g Nutilis (approx. 9 scoops)

• Place the chicken, butter, milk powderand gravy into a blender and blend untilsmooth.

• Add Nutilis, whisk into a smooth pasteand allow to stand for 60 secs.

• Place into mould and then blast freezefor 2 hrs or until food reaches -18·C.




This recipe can be adapted using differentsauces, i.e. chasseur, a la king or curry.


Filling: 300 9 meat bolognaise sauce35 9 milk powder with vegetable fat10 9 butter175 ml tomato juice24 9 Nutilis (approx. S scoops)Pasta: 100 9 over cooked pasta400 ml cheese sauce madewith full fat milk24 9 Nutilis (approx. S scoops)

• Place bolognaise, butter, milk powderand tomato juice into a blender and blenduntil smooth.


• Place the pasta and cheese sauce into ablender and blend until smooth.

• Add the Nutilis, whisk Into a smoothpaste and allow to stand for 60 secs.

• Then put pasta into one piping bag andbolognaise into another.

• Pipe bolognaise in a strip about 7 cmwide and 7 cm long (not too thick).

• Pipe the pasta on the piped bolognaise.

• Repeat the process once more.

• Place into blast freezer for 2 hrs or untilfood reaches -1S·C.Turn out into bag andstore in deep freezer.




100 9 cooked ham110 ml pineapple juice or syrup50 9 pineapple chunks25 9 milk powder with vegetable fat9 9 Nutilis (approx. 3 scoops)

• Place the diced ham into a blender andcover it with the pineapple juice, pineapplechunks and milk powder. Blend untilsmooth.


• Place into mould and blast freeze for2 hrs or until food reaches -1S·C.

• Turn out into bag and store indeep freezer.

• When the food is needed, placeonto a plate and leave todefrost in thefridge.

• Re-heat to therequiredtemperature.

248 kcal and15.5 9 protein perportion.

Useful recipes

All recipes list approximate calories, protein values, and portions basedon raw ingredients. These recipes are not compatible with other foodthickeners, the quantities recommended are based on using Nutilis foodthickener only. All food should be blended while hot. If you are not usingfood moulds, recipes can be served, scooped or piped. Please note thatthe National Descriptors for Texture Modification in Adults state that allpureed food should be sieved before thlckeninq.'

500 g cooked, boneless, skinless cod25 g butter400 ml white sauce madewith full fat milk40 g grated cheddar cheese24 g Nutilis (approx. 8 scoops)

• Cook the fish. Drain excess water. Makesure there are no bones in the fish!

• Place the fish, butter, cheese, and whitesauce into a blender and blend untilsmooth.


• Place into mould and then blast freezefor 2 hrs or until food reaches -18·C.




167 kcal and 14.6 g protein per portion.

500 g cooked, skinned, diced chicken300 ml chicken gravy25 g butter50 g milk powderwith vegetable fat27g Nutilis (approx. 9 scoops)

• Place the chicken, butter, milk powderand gravy into a blender and blend untilsmooth.

• Add Nutilis, whisk into a smooth pasteand allow to stand for 60 sees.

• Place into mould and then blast freezefor 2 hrs or until food reaches -18'C.




This recipe can be adapted using differentsauces, i.e. chasseur, a la king or curry.


,

Filling: 300 g meat bolognaise sauce35 g milk powder with vegetable fat10 g butter175 ml tomato juice24 g Nutilis (approx. 8 scoops)Pasta: 100 g over cooked pasta400 ml cheese sauce madewith full fat milk24 g Nutilis (approx. 8 scoops)

• Place pasta and cheese sauce into ablender and blend until smooth. AddNutilis, whisk into a smooth paste andallow to stand for 60 sees.• Spread mixture (about 20 cm long and12 cm wide) onto cling film.• Place bolognaise, butter, milk powderand tomato juice into a blender and blenduntil smooth. Add Nutilis, whisk into asmooth paste and allow to stand for60 secs.• Place pureed bolognaise sauce intopiping bag and pipe down the middle ofthe cling film. Alternatively, spoonbolognaise mixture.• Take the corners of the cling film andgently fold the pasta over the middle ofthe bolognaise sauce to cover.• Gently roll the pasta and the bolognaisetogether.• Place onto freezing tray and then blastfreeze for 2 hrs or until food reaches-18'C. Turn out into bag and store in deepfreezer.• When the food is needed, place onto aplate and leave to defrost in the fridge.Slice once defrosted.• Re-heat to the required temperature.475 kcal and 19.6 9 protein per portion.

6 boiled eggs450 ml full fat milk33 g Nutilis (approx. 11 scoops)

• Shell the boiled eggs and put the yolk inthe blender.

• Add 150 ml full fat milk, blend untilsmooth and thicken with 4 scoops ofNutilis. Allow to stand for 60 sees.

• Take the egg whites, add 300 ml of fullfat milk and blend until smooth. Thickenwith 7 scoops of Nutilis. Allow to stand for60 sees.

• Put the yolk in the eye of the egg in themould. Put a spoonful of the white overthe mould and smooth over.

• Place into blast freezer for 2 hrs or untilfood reaches -18·C.





500 g minted peas220 ml full fat milk15 g butter18 g Nutilis (approx. 6 scoops)

• Cook peas in full fat milk.

• Place the peas and butter into a blender.Blend into a smooth paste.

• If the peas still have husks, put theblended paste through a sieve.

• Add Nutilis, whisk to a smooth paste andallow to stand for 60 secs.

• Place into pea moulds and then blastfreeze for 2 hrs or until food reaches-18·C.

• Turn food out of mould and place infreezer bags.

• When the food is required place onto aplate and leave to defrost in the fridge.


88 kcal and 5. 1 9 protein per portion.

500 g carrots220 ml water50g milk powder with vegetable fat150 ml full fat milk20 g butter21 g Nutilis (approx. 7 scoops)

• Cook the carrots in water until soft.

• Place the butter, milk powder, milk andthe drained carrots into a blender andblend until smooth.

• Add Nutilis, whisk to a smooth paste andstand for 60 sees.

• Place into the carrot moulds and thenblast freeze for 2 hrs or until food reaches-18·C.

• Turn food out of the moulds and place infreezer bags.

• When food is required place onto a plateand leave to defrost in the fridge.



500 g cauliflower15 g butter80 g grated cheddar cheese200 ml white sauce made with full fat milk24 g Nutilis (approx. 8 scoops)

• Cook the cauliflower. Drain excess water.

• Place the cauliflower, butter, cheese, andwhite sauce into blender and blend untilsmooth.


• Place into the cauliflower moulds andthen blast freeze for 2 hrs or until foodreaches -18·C.


• When the food is needed, place the foodonto a plate and leave to defrost in thefridge.



A checklist for making pureedmeals attractive

All the pureed food must be smooth

with no lumps in the mixture.

Please note that the NationalDescriptors for Texture Modificationin Adults state that all pureed food

should be sieved before thickening. 4

Nutritional value of the meal can beincreased by adding milk powder andbutter.

Mix Nutilis into pureed food and allowto stand for 60 seconds.

Always blend freshly cooked food.

Always cover food in the refrigerator.

Always defrost moulded meals beforere-heating.

Never heat the meals more than once

after defrosting.

Always follow Hazard Analysis CriticalControl Point (HACCP) Regulations.

When in doubt, consult Speech andLanguage Therapist or Dietitian.

Mandatory re-heating temperaturemay vary from country to country.

Use a combination of moulds, pipingbags and scoops to prepare more

visually attractive meals.

Desserts

Fortifresh Raspberry Mousse(approx. 12 portions)

750 ml whipping cream2 cartons Raspberry Fortifresh20 g strawberry milkshakepowder30 g Nutilis (approx. 10 scoops)

• Place the cream, Raspberry Fortifresh,milkshake powder and Nutilis into a bowl.

• Whisk until stiff and then pipe or spooninto small tubs.


Fortisip Chocolate Mousse(approx. 12 portions)

750 ml whipping cream2 cartons Chocolate Fortisip60 g sieved drinking chocolate33 9 Nutilis (approx. 11 scoops)

• Place cream, Chocolate Fortisip, drinkingchocolate and Nutilis into a bowl.

• You may add whisky or brandy with theFortisip for more flavour but make sure thepatient is allowed to have alcohol.

• Whisk until stiff and then pipe or spooninto small tubs.


Pear Belle Helene(approx. 8 portions)

400 9 of drained tinned pears100 ml drained pear juice or syrup21 9 Nutilis (approx. 7 scoops)

• Place drained pears and 100ml of thedrained pear juice or syrup into a blender,and blend until smooth.

• Add Nutilis. Whisk into a smooth pasteand stand for 60 secs.

• Place into pear moulds and then blastfreeze for 2 hrs or until food reaches-1 S·C.

• Turn out into a bag and store in deepfreezer.


• Cover with a small ladle of thickenedfruit sauce (make with Fortijuce andseedless jam).

• Pipe one rosette of cream onto the side.


TipToprepare strawberries, pears,pineapple, grapefruits and peaches -use canned fruits only and drain first,but remember to save the juice orsyrup!

Drinks

Banana Smoothie Milk Shake(4-5 portions)

500 ml full fat milk2 cartons Banana Fortisip MultiFibre1 large banana100 g full fat vanilla ice cream

o Place all ingredients into a blender andblend until smooth.

o Serve in a glass.

o By adding scoops of Nutilis you canthicken the drink (follow recommendationson Nutilis tin).


Fortijuce Summer Sunrise(8-10 portions)

3 cartons Forest Fruits Fortijuce1 bottle (750 ml) sparkling wine,lemonade or flavoured fizzywaterCrushed ice

o Pour wine and Fortijuce into a jug withthe crushed ice.

• By adding scoops of Nutilis you canthicken the drink (follow recommendationson Nutilis tin).

118 kcal and 2. 7 9 protein per portion(made using lemonade).

Soaking Solutions

Biscuits

• Make up soaking solution using fruitjuice or milk. Use immediately, do notallow to thicken.

• Preferably use plain biscuits, avoidingdried fruit, nuts or chocolate chips.

• Place the biscuits in the soaking solutionfor 30 to 45 secs.

• Drain off excess liquid.

o Cover and refrigerate for 2 hrs.

Cream CrackersI

o Make up soaking solution. Useimmediately, do not allow to thicken.

o Place the crackers in the soakingsolution for 30 secs.

o Drain off excess liquid.

o Beat 30 9 cream cheese with a spoon,add 2 teaspoons of milk and mix together.

o Add half a scoop of Nutilis and mix intosmooth paste.

o Pipe softened cream cheese ontocracker.

• Cover and refrigerate for 2 hrs.

Sandwich Fillings

• Ham can be blended with pineapple,corned beef with tomato, egg withmayonnaise.

• Always try to use mayonnaise or saladcream. This will add more energy to thefood.

• Blend the food until smooth.

• Add Nutilis for smooth and soft texture.

• Make up soaking solution using milk orvegetable stock. Use immediately, do notallow to thicken.

• Use plain brown or white bread (nobread with seeds or nuts).

• Remove bread crust.

• Place the bread in the soaking solutionfor 60 secs. Drain off excess liquid.

• Spread fillings on top (for fillings, seeabove) and place next piece of soakedbread on top.

• Cover and refrigerate for 2 hrs.

Ginger Cake, Swiss Roll,Madeira Cake etc

• When using cakes, make sure they donot contain fruit or nuts.

• Cut cake into 1cm slices.

• Make up soaking solution, try to usesome type of fruit juice.

• You may add alcohol but make sure thepatient is allowed.

• Place the cake in the soaking solutionfor 30 to 45 secs. Drain off excess liquid.

• Cover and refrigerate for 1'/2 hrs.

General tips for soakingsolutions200 ml liquid

3 g Nutilis (one scoop)

Place liquid into bowl, add Nutilis andwhisk thoroughly. Use immediatelyand do not allow soaking solution tothicken before adding food.

12

Always follow the recipe, add the required amount of Nutilis and allow to stand for60 seconds.

Spread pureed food into mould trays and remove the excess with a knife.

Cover each tray individually with cling film.

Chill hot food in the blast freezer or brast chiller.

Label each tray separately, stating:(a) Content of the mould.(b) Date of preparation.(c) Best before date (no more than 3months).(d) Made by (name of person).

Place in the freezer until frozen.

Remove food from the moulds by turning upsidedown and gently pressing out the shape.

Place frozen food into clean freezer bags.Do not overfill.

Seal the freezer bags and label each separately,stating:(a) Contents of the bag.(b) Date of preparation.(c) Best before date (no more than 3months).(d) Made by (name of person).

Re-seal bags after each use to avoid freezer burns.

In the event of freezer burns discard food.

Check regularly for damage to bags and discard expired items.

Do not re-use bags.

Make sure that good stock rotation takes place.

Place frozen shape on a plate, cover and defrost in fridge for 2 to 3 hrs.

Re-heat in combi oven, steamer or microwave (650W for approx. 1-1.5 min).

In the UK, ensure food temperature is above 75°C before serving (guidelines val}' indifferent countries).

To clean the moulds place them In hot water with detergent for 10-15 minutes. Washthem in a dishwasher and store in sealed plastic bags.

1. O'Laughlin G and Shanley C (1998) Swallowing problems in the nursing home:A novel training response. Dysphagia; 13: 172·183.

2. Jones B (1999) Radiological evaluation of the dysphagic patient. Nutr CUn Pract; 14: 510·512.

3. Park C and O'Neili P (1994) Management of neurological dysphagia. Clin Rehabll: 8: 166-174.

4. Joint Working Party of the British Dlete1ics Association & Royal College of Speech andLanguage Therapists (2002) National Descriptors for Texture Modification In Adults.

Made in cooperation withNeil Paliiser-Bosomworth (Consultant Chef)

Nutricia Clinical Care, Nutricia Ltd, White Horse Business Park,Trowbridge, Wiltshire BA14 OXQ. Tel: 01225 711688.

www.nutricia-clinical-care.co.uk

Nutricia Ireland Ltd, 1B Sandyford Business Centre,Burton Hall Road, Dublin 18, Ireland

Tel: (01) 206 1983.www.ncc.nutricia.ie

NUTRICIA..,.: .. .,.,. care

Making the difference

http://www.nutricia-clinical-care.co.uk

http://www.ncc.nutricia.ie

nutilis recipes prepared to manage dysphagia

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