Fortifying meals is a good way in which the nutritional content can be increased but the volume of food taken remains basically the same. An easy way to do this is through the addition of toppers to increase the energy and protein of the foods given.
Care must be taken to ensure that the texture of the foods provided remains appropriate for the patient if anything additional is added.
Quiz: Can you identify the appropriate additional/alternative to add to Connie’s meals to increase her nutritional intake? (drag and drop your choices into the box)
Connie is recommended a level 5 (minced and moist) diet which is being fortified to give her extra calories and protein. This is a technique used to add extra nourishment. Most texture modified diets within a hospital setting are fortified and provide more nutrition than normal hospital meals. It is important that Connie continues to receive a varied diet with foods she enjoys from all food groups including starchy foods such as potatoes, pasta, smooth cereals, protein foods such as meat, fish, poultry, eggs, beans, lentils, dairy foods and alternatives such as milk, cheese, yoghurt and fruits and vegetables.
Sometimes meals in hospitals are purchased externally and are pre-prepared as level 5, sometimes meals are modified within local catering departments. Patients on texture modified diets should still be given an option or choice of meal.
The following images show examples of meals which would be suitable for Connie, these include minced chicken and vegetable casserole and minced cod in parsley sauce. The cod has been moulded to represent whole cod and may be more appealing to Connie to eat.
Name: Connie Smith Ward: Stroke Unit, Gourmet General Hospital Nutritional Risk: High
Nutritional/Dietetic Diagnosis: Inadequate intake related to dysphagia, reduced appetite as evidenced by BMI < 18kg/m2 and 7.9% unintentional weight loss.
Aim/outcomes: Help Connie to meet her nutritional requirements to maintain her weight and support recovery from stroke
Plan: SLT recommendations – level 5 food (minced and moist) and level 0, thin fluids
Offer level 5 snacks between meals, e.g. custard, full fat yoghurt
Offer full cream milk
1 x compact milk based supplement per day
Daily food and fluid chart Weekly weight and MUST score
Connie has been identified as being at risk of malnutrition due to her MUST score of 5 and swallowing issues. It is important to be able to monitor how well she manages her diet and drinks. There are many reasons why she may not manage to meet her needs whilst in hospital after having a stroke. In the exercise below you can find some of these reasons:
Select the video clips below for an example of a poor mealtime experience and a good mealtime experience.
Safety awareness
Is it essential to make sure the patient is getting the right meal and consistency, following your local policies and guidelines.
Further information
For further information as to how to develop your skills and knowledge in order to contribute more effectively to the identification and management of people with swallowing disorder. Please link to:
“Thickener may be useful in the preparation of texture modified solids, however the evidence for the medical effectiveness of thickening drinks for patients with swallowing problems remains variable.
Thickener in drinks should not be used routinely for people with dysphagia but it may be recommended by Speech and Language Therapists after thorough assessment of all aspects of patient care.”
(NHS Highland Speech and Language Therapy consensus statement regarding Thickener. NHS Highland Speech and Language Therapy Adult Specialist Network (2017)).
There are various commercial thickening powders on the market. The most widely used ones in the UK are:
Thick and Easy (Fresenius Kabi)
Nutilis (Nutricia)
Resource Thicken up (Nestle)
(Please note: these pictures & details are due to be updated to reflect the most widely used thickening products)
For some patients, the SLT recommendations might be to thicken a patient’s drinks to a level 1,2,3 or 4 consistency as per IDDSI 2019 (See previous page).
All of these products have guidance on the label about how much thickener is required to produce drinks of the consistency recommended by the SLT. Your SLT department will also be able to provide specific information about preparing drinks to the correct consistency.
Some companies also produced ready to drink, single use, pre-thickened drinks which can be prescribed to patients. There are also thickeners available which are drink-specific eg. for tea, coffee etc.
It is important to remember that thickening drinks is not suitable for everyone and should not be considered the only solution if someone is coughing on Level 0 drinks (thin).
There is evidence which indicates that if thickened fluids are aspirated, they are more likely to cause pneumonia than unthickened plain water would. In some health boards there have been consensus statements devised which discusses this further.
For information on how to thicken drinks for patients like Connie select the Additional Information button.
Remember – to monitor the patient’s fluid intake whilst on thickened drinks to make sure they are meeting their requirements.
As we stated earlier, Connie is on a Level 5 food (minced and moist) and Level 0 drinks (thin), as defined by the IDDSI framework.
IDDSI is an international classification framework and is being implemented worldwide. The framework aims to be culturally sensitive, measurable, and applicable to individuals of all ages and groups in all care settings. See www.iddsi.org/framework/ for further information about the framework and translations into other languages.
(These are NOT official IDDSI resources, educational materials or education programs and they are NOT meant to replace materials and resources on www.IDDSI.org)
It is lunchtime and you go into the ward to help Connie with her meal. Before you would start assisting Connie, there are some thing you need to consider. As you work through the task, each correct action will reduce the patient’s risk.
Remember – to monitor the patient’s fluid intake whilst on thickened drinks to make sure they are meeting their requirements.
