Issue 124 dysphagia puree diet week category c challenge

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CONDITIONS & DISORDERS

DYSPHAGIA: PUREE DIET WEEK CATEGORY C CHALLENGE Lucy Blackstone, Rourke Thomas, Janette Banks, Sophie Johnston Band 5 Dietitians, Salford Royal NHS Foundation Trust The Team see a wide range of patients from elderly care to trauma across both the hospital and the community setting. They are all enthusiastic about seeing things from a different perspective and enjoy a challenge; what better way to learn about a puree diet than to fully immerse themselves in the experience, all in the name of charity.

As dietitians working across a variety of areas within the hospital, we all experience a vast number of patients on a modified consistency diet and, aside from tasting sessions, none of us had ever eaten a full puree meal, let alone followed a pureed diet. So, for one week in October, we decided to follow a puree diet to raise money for the Motor Neuron Disease association.

We also wanted to develop our knowledge and understanding of the difficulties faced by this patient group. Four dietitians committed to the challenge, including two vegetarians and one working Mum, and we all made it through to the end. The following questions cover what we feel to be the most important lessons learnt. WHAT WAS THE MOST DIFFICULT PART OF THE PUREE CHALLENGE?

S: The weekends and seeing friends in

the evenings was the most difficult time for me. Eating is such a social activity and it felt quite isolating to be the one in the corner eating a pureed ready meal whilst others were enjoying my favourite pizza takeaway. This really affected my mood and I found myself opting out of social activities if I knew food would be involved. I can see how this could result in social isolation over a longer period. Snacking was also difficult, as it had to be pre-planned; there was no grabbing a slice of cake from the weekly baking rota in the office!

L: I agree, as someone who doesn’t like The Authors would like to thank Wiltshire Farm Foods and Simply Puree for donating ready meals for the pureed diet challenge.

yoghurt, I found it particularly hard to find anything I liked, and the lack of savoury snack options was difficult. Similarly to Sophie, I also struggled with social situations, I took a ready meal to a friend’s birthday party and when some of the guests couldn’t even look at my meal, it made me feel a bit embarrassed. Eventually, I just avoided social situations where food was involved.

R: For me, it was the constant craving for

a little more bite! Just because a healthcare professional has advised that you follow a texture-modified diet doesn’t mean it’s going to be easy. For many patients, breaking the routine of their usual meal plans, not being able to just grab a quick snack on the way out of the house or being able to eat without thinking “Can I have this? Is this the right consistency?” could be a real burden psychologically. It’s not like becoming vegetarian, vegan or even going gluten-free, it’s not a case of restriction, it’s total reconstruction of your diet. It’s like changing all rules on something that’s second nature.

J: Fitting the diet into family life - cooking

one meal for the family and blending mine down - had time implications for a busy working mum. Blending my daughter’s apple crumble cooked at school led to cries of ‘you’re ruining it’. Blending a family one-pot meal, like fish pie, led to one big bowl of grey amorphous mush. I found the lack of crunch and variety of texture difficult for someone who doesn't like soggy cereal. This food soon became boring and so I tended to rely on yoghurts and smoothies for breakfast. IF YOU COULD GIVE PATIENTS ON A PUREE DIET ONE TIP WHAT WOULD IT BE?

S: I enjoyed mealtimes much more

when others were eating pureed foods too, which was easy for us, as the four of us were doing it together and I had continuous support. I would www.NHDmag.com May 2017 - Issue 124

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. . . puddings are very often energy dense and the great thing is that many already exist at smoother consistencies (think custard pots, yoghurts, mousses etc) . . . suggest trying to link in with other people with swallowing issues, for example, by accessing dysphagia support groups on social media sites. I would also recommend asking friends or family to eat a puree meal with you, even if it's only once a week. I found this helped me to enjoy my meal more when my boyfriend had it with me.

L: We had a lot of ready meals kindly donated

to us to try out for our challenge and this helped us to see the different options that dysphagia patients have. I personally struggled with these and didn’t realise how much importance I place on the appearance of foods. I found that when cooking meals from scratch, I was able to enjoy them more because I had seen what had gone into it. Pureeing different components of the meal separately also helped, as otherwise it all became quite boring. It’s quite easy to be tempted to puree meals in bulk and eat them for a few days in a row, but this again can lead to taste fatigue.

R: Puddings and milkshakes always have your back! Particularly in the beginning when you’re experimenting with meals, trying different flavours and just simply adjusting to life on a texture-modified diet. Milkshakes are a great way to add in some extra energy to your diet, and different combinations of ingredients (fruits, milkshake powders/syrups, honey, peanut

butter/chocolate spreads) can produce very different flavours, ensuring you only compromise on texture, not taste. Again, puddings are very often energy dense and the great thing is that many already exist at smoother consistencies (think custard pots, yoghurts, mousses etc), meaning you’ll always be able to squeeze in some extra calories even on days when your experiments haven’t quite gone to plan.

J: Don't settle for boring food; puréed food

doesn't have to be bland. Be experimental add herbs for a twist, or spices for a kick. Basil and garlic go well with tomato, garam masala or curry powder to a lentil dish. Try blending different family foods to see what works better. Blend foods separately - perhaps in bulk and freeze, portioned out for ease. Use foods with a naturally puréed texture (soups, custards, smooth yoghurts etc). Sweets and puddings seemed more acceptable in purée form than savouries, so have puddings daily, as these will also help to keep calories up. Use ready meals for increased variety. WHAT WAS THE BEST MEAL YOU ATE (READY MEAL OR HOMEMADE) DURING THE CHALLENGE?

S: My favourite meals were those with stronger flavours, mainly curries and chilli. It’s amazing how much texture can affect the tastes you experience. I like quite spicy foods normally, but www.NHDmag.com May 2017 - Issue 124

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CONDITIONS & DISORDERS

I enjoyed meals that had a lot of taste to them, similar to the experience of the other dietitians. I enjoyed curries and chilli in particular I found myself adding extra herbs and spices to some of the readymade foods for an extra kick. All of the ready meal puddings were amazing; I particularly enjoyed the jam sponge and custard and would happily still eat that now I’m back on a normal diet!

L: I enjoyed meals that had a lot of taste to them,

similar to the experience of the other dietitians. I enjoyed curries and chilli in particular; I also like mashed potato anyway so was happy to eat this at almost every meal. I didn’t really enjoy the puddings because I don’t have much of a sweet tooth, so I found them quite sickly, so instead, I had stewed apple and raspberries that I had sieved and these were really nice.

R: I attempted to make Fajitas on Day 5, as I had a

real craving for them. While I couldn’t quite figure out how to blend a wrap, I did manage to blend and sieve peppers, onions and vegetarian chicken style pieces in fajita spices with chopped tomatoes. I then made guacamole on the side and had a dollop of sour cream on top. It definitely helps to cook as you usually would and blend, as Lucy says, you see the real ingredients in front of you whilst prepping your meals and this helps you to still visualise the meal as normal post blending.

J: I had blended some of my own foods together

for ease rather than separating them out, but found every mouthful tasted the same. My first ready meal, after being on pureed food for two days, was delicious. It was a chicken casserole - the vegetables tasted amazing and the mashed potatoes were creamy. I also really liked the puddings - they were more palatable and more closely resembled ‘normal’ foods. DID YOU MAINTAIN YOUR NUTRITIONAL STATUS THROUGHOUT THE CHALLENGE?

S: No! I lost almost 4% of my body weight in one week and although I didn't do any 30

www.NHDmag.com May 2017 - Issue 124

anthropometry, I felt I lost muscle mass and strength as I was struggling with my normal weights at the gym. At my baseline I would always finish what was on my plate, however, on the pureed diet I struggled to finish most meals and never once went back for seconds. I was often left feeling physically full from the extra fluid, but not satiated. This has made me reflect on patient’s needs for food fortification advice and nutritional supplements, as it highlighted how difficult it can be to meet nutritional needs on a texture modified diet.

L: No, I didn’t weigh myself before or after,

but I wish I had! I felt like my clothes were looser and I was weaker. I went on a night out with friends and had no stamina. The meals left me feeling bloated and full, but then hungry again a short while later. It has certainly put into perspective the difficulties faced when on a puree diet and the importance of food fortification. I am now much more likely to consider supplementation earlier on for patients on a puree diet.

R: No, I lost approximately 3% of my body

weight during the week. I also felt more tired, very bloated and constantly hungry. I noticed a definite drop in my fruit consumption. Smoothies/fruit juices are a good way to ensure micronutrient requirements are met in addition to your diet – though of course make sure any pips or pulp are sieved out and that fluids are at the correct consistency for individual patients.

J: I maintained my weight, likely due to a

combination of daily puddings and fortified milkshakes. The fact that fruit stopped being an easy snack and required preparation meant I ate less of it and I'm sure that if this challenge had gone on longer, this would have become an issue and may have impacted upon both my micronutrient status and my fibre intake.


CONCLUSION

Since completing the puree challenge and raising a massive £1,000 for the MND association, we have all seen puree meals in a different light; we now have more empathy for patients on this diet and feel our advice is more practical having experienced it ourselves. We understand the difficulties maintaining nutritional status due to experiencing early satiety. Food fortification advice becomes a standard requirement and oral nutritional supplements are considered much sooner in assessments.

Having been regularly asked the question, “Have YOU tried this?”, patients are always surprised when the answer is, “yes”. We feel that their confidence in us has improved as a result. Experiencing social isolation is something that none of us envisaged and we would definitely consider pointing patients in the direction of dysphagia support groups on discharge. We feel the challenge has had a huge impact on our practice and look forward to our next experiment!

Table 1: A food diary of an average puree meal day

Breakfast

Mixed berries and apple (to be added to yoghurt and blended porridge)

Lunch

Ready meal tuna sandwich/homemade bean bake with peas and mash

Homemade lemon sponge

Evening meal

Ready meal omelette, sautéed potatoes and beans/homemade broccoli bake (before and after)

Ready meal jam sponge www.NHDmag.com May 2017 - Issue 124

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Looks good, tastes good, does good

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