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PURÉE DIET

'The Eatwell plate is reproduced with the kind permission of (IDDSI LEVEL 4) the Food Standards Agency. This Crown copyright material is reproduced with the permission of the Controller of HMSO and Queen's Printer for Scotland.'

Produced by: The Nutrition Support Team Birmingham Community Nutrition and Dietetic Service In conjunction with the Birmingham Community Speech and Language Therapy Department.

Birmingham CommunityNutrition & DieteticService CHEESE (Serves 2) INTRODUCTION

2oz (60g) breadcrumbs (fresh) Dysphagia is a difficulty or discomfort swallowing food or drink. Dysphagia can range from mild discomfort/difficulty, 1/2 pint (300ml) milk to a complete inability to swallow. 1/2 teaspoon (2.5ml) salt 3oz (90g) grated cheese Sometimes changing the texture or consistency of food or 2 eggs drink can make swallowing easier if you have Dysphagia. A Pepper Speech and Language Therapist should provide advice on which texture is best for you. The texture of food and drink 1. Heat the milk, pour over the breadcrumbs, and allow required will vary depending on the type of swallowing to soak for about 30 minutes. problem. 2. Add the grated cheese, seasoning and egg yolks. 3. Fold in the stiffly whipped egg whites and pour into a Often people lose weight when they are following a pureed greased pie dish. diet. There may be a number of reasons for this. Getting 4. Bake in a moderate oven, gas mark 4, 180◦C for half used to eating a pureed diet can be very difficult, particularly an hour until well risen and golden brown. if food looks unappetising,. Food can be left behind in the preparation process meaning ultimately a person gets less HIGH PROTEIN MILK PUDDING to eat. ½ pint ‘fortified’ milk We also recommend that you regularly check your weight. 1 tablespoon dry semolina/ground rice, 2 tablespoons evaporated milk, This booklet aims to give suitable food choices for a pureed diet and provide practical tips to make meal times more Cover semolina/rice in milk, add evaporated milk when enjoyable. slightly cooked. Blend/Sieve to ensure a smooth consisten- cy. Can be served with seedless jam. THICKENED FLUIDS

* When you see this star throughout the booklet please note that if you are advised to thicken your fluids please make sure the consistency is right. Certain foods and fluids may not be appropriate depending on your swallowing ability e.g. more liquid foods or foods that melt to a liquid (e.g. ice- cream). SEE FLUIDS SECTION FOR MORE INFORMATION

PUDDINGS FOOD PREPARATION

All food must be smooth and not contain lumps. BANANA WHIP (Serves 3) You can use an electric blender/food processor to puree 2 bananas foods. If you do not have an electric blender, then a fine 2 tablespoons (2 x 15ml) yogurt or fromage frais metal sieve e.g. to strain soups and some and vege- 2oz (60g) cream cheese tables is useful. 1 teaspoon (1 x 5ml) honey 1 teaspoon (1 x 5ml) lemon juice Most foods can be pureed by adding additional fluid for example milk, or you can add extra or sauce. 1. Chop bananas 2. Place ingredients in blended. Blend until smooth. It is easier to puree large portions of food than individual servings. If you have a freezer, make up a large quantity FRUIT FOOL (Serves 3) and freeze individual portions which can be reheated.

1/2 pint thick pureed fruit (tinned or fresh) If food is to be served hot, return to the pan/microwave 1/2 pint , made with fortified milk and heat thoroughly after it has been pureed.

Whip the pureed fruit and custard together until smooth and When pureeing the diet, a meal looks more appetising if sweeten to taste. Sieve to remove lumps. you keep items of food separate rather than mixing them together. Provide plenty of variety in colour and flavour i.e. season with herbs/ spices, syrups/ essences.

FOODS TO BE INCLUDED IN YOUR PURÈE DIET: CHICKEN PARMIGIAN (Serves 4)

MEAT, CHICKEN, FISH: Remove any skin, bones, fat or 8 oz (240g) chopped chicken gristle. Puree to a paste with a food processor/hand held 1/2 pint (300ml) stock blender. To achieve a smooth consistency blend with liquid. 4 oz (120g) spaghetti You may need a sieve to remove lumps, gristle or bone 1 oz (30g) flour NB: When pureeing fish be careful to avoid bones being left 1 oz (30g) margarine behind in the meal. Medium can spaghetti sauce Grated cheese for topping EGGS: Well cooked scrambled eggs puree well. Cheese can be added before cooking. 1. Fry chicken in margarine. 2. Add Flour. POTATOES: Mash until smooth with butter and milk. Pota- 3. Slowly add stock, stir continuously toes should not be pureed with a blender as the starch 4. Boil for 30 minutes makes them sticky. 5. Boil spaghetti in water as instructions on the packet. 6. Puree the spaghetti and chicken separately RICE: Boiled rice can be puréed. It should be cooked until it 7. Spread the spaghetti on a plate and top with the chicken. is soft. If you are having this with a dish such as curry they 8. Top with canned spaghetti sauce (liquidised and sieved to should be blended together. remove lumps) and place grated cheese on top 9. Put under grill until the cheese melts PASTA: Soft pasta dishes blend well if extra sauce is added. Try spaghetti bolognaise, lasagne, ravioli and macaroni MACARONI CHEESE (Serves 1) cheese 1 small tin 8oz/200g macaroni cheese VEGETABLES: Cook until tender and drain and puree— 1 spoon cornflour Cream, cheese, butter or milk based sauces can be added. Suitable vegetables to use are carrots, cauliflower, swede, 1. Place both ingredients I the liquidiser. spinach, courgette, Brussels sprouts, tinned tomatoes (no 2. Blend until completely smooth then heat gently in a skin or pips) onions, okra, aubergine, gindola, spinach. saucepan. NOTE: use vegetable water to make up gravy/sauces to in- 3. Extra cheese can be added to improve flavour. crease the nutrient content COD AND SAUCE (Serves 1) FRUIT: Tinned and stewed fruit—puree well by adding juice or water. Avoid pineapple in any form. Fresh fruit should be 3 oz (90g) poached cod (remove all skin or bones) peeled and any seeds removed. Add a little lemon juice to 5-7floz (150-210ml) savoury sauce e.g. white, onion, cheese prevent browning. 2oz (60g) mashed potato

1. Blend together fish and sauce.

SMOKED FISH PATE (Serves 2) However the following is a list of foods that should not be eaten when following a purèe diet 7oz (210g) tinned fish 6oz (180g) butter  Chapattis, naan, bread Pinch of cayenne pepper  Husks/skin/pips/shell of Vegetables e.g. peas, 2 tablespoons (2 x 15ml) chopped parsley beans, kidney beans, sweetcorn, mixed vegetables. 1 tablespoon (1 x 15ml) lemon juice (These will all need to be sieved after puréeing as the skins should be avoided) 1. Drain fish and flake  Very dry foods e.g. hard block of cheese, meat with- 2. Blend butter and cayenne. out sauce or gravy, pakoras, samosas, pastries i.e 3. Add fish, parsley, sherry and lemon juice, blend to roll required texture.  Mithai (Indian sweets)/sweets 4. Season with salt, pepper and nutmeg. 5. Spoon into dishes and serve. THICKENERS FOR FOOD: It is important that the food DAHL (Serves 2) you eat does not contain lumps but it must be thickened as advised by your Speech and Language Therapist. The 4oz (120g) lentils following are useful to thicken food: cornflour, custard 3/4oz (20g) butter powder, mashed potato, instant potato powder and instant 1 oz (30g) onion gravy granules. 1 teaspoon (1x 5ml) ginger turmeric 1/2 teaspoon (1x5ml) salt spices Commercial thickeners may be prescribed by your Speech Chilli powder and Language Therapist. 1 1/4 pint (750ml) water for cooking Some of the commercial thickeners can be poured over 1. Soak lentils in water for 10-15 minutes biscuits, cake, etc to transform the foods into 2. Strain and sieve to remove skin a suitable puree consistency which can then be eaten with 3. Add the water, salt and turmeric. Bring to the boil a spoon. This can help to increase the range of foods a and simmer for 40 minutes person on a puree diet is able to eat. 4. Cook the chopped onions in butter with garlic, ginger, spices and chilli powder Please note: It is important that instructions provided by 5. Add cooked dahl. Simmer for 5 minutes. the companies that produce the thickener are followed 6. Blend into a smooth paste. correctly, please see the packaging for full instructions before trying this.

MEAL AND SNACK IDEAS SHEPHERDS PIE (Serves 4) BREAKFAST 8 oz (240g) minced beef Blended and sieved porridge/Ready Brek made with lots of 8 oz (240g) boiled vegetables e.g. carrots ‘fortified’ milk* 8 oz (240g) mashed potato 1 oz (30g) margarine MID MORNING 1/2 pint (300ml) stock 1 oz (30g) flour Biscuits (made to correct consistency with commercial thickener) 1. Fry mince in margarine until brown. Add flour and stir until mixed in. MIDDAY 2. Slowly add stock. Stirring continuously . 3. Bring to boil and simmer for 20 minutes. Stir occasion- ‘Fortified’ soup* (see recipe), ally. Blended curry and rice 4. Puree the meat and vegetables separately. Slice of cake (made to correct consistency with commercial 5. Place a layer of meat and a layer of vegetables in a cas- thickener) serole dish. 6. Place a layer of mashed potato on top. MID AFTERNOON 7. Heat in oven until potatoes are lightly browned.

Smooth full fat yogurt (Serves 4) Stew apples/mango blended with custard or cream 1lb (500g) cauliflower EVENING MEAL 1 tablespoon (15g) cornflower 3/4 pint (400ml) milk Pureed meat or fish with gravy or sauce 4 oz (120g) grated cheese Pureed potato with ‘fortified’ milk 1 oz (30g) butter Puree Mashed potatoes/Bombay potatoes Pureed vegetables with margarine 1. Boil cauliflower until tender Pureed milk pudding made with ‘fortified’ milk and plenty of 2. Make cheese sauce: Mix flour with a little milk in a sugar. saucepan. Pour in remainder of the milk into a jug. Boil Shrikhand without fruit milk, remove from heat and pour into the blended corn- Banana Whip flour, stirring all the time. 3. Return the milk and cornflour to the pan and simmer BEDTIME Place cauliflower and sauce in liquidiser and liquidise until smooth for 3-4 minutes until thickened. Nourishing milky drink* 4. Remove from heat and stir in cheese and butter.

ENRICHING YOUR FOOD MAIN MEALS If you are losing weight you can fortify the foods that you are SPICY MINCED BEEF PUREE (Serves 4) managing to eat. By doing this you will take in more calories and protein which will help you gain weight. 8 oz (240g) minced beef 1 oz (30g) margarine Note: make sure you are not using any low fat or diet 1 oz (30)g flour products 1/2 pint (300ml) stock 1 tablespoon (1 x 10ml) tomato puree FORTIFIED MILK*: 1/2 teaspoon (2.5ml) chilli powder Add 4 tablespoons of milk powder to 600ml (1 pint) of full fat 2 oz (60g) mashed potato milk. Mix powder with a small amount of milk to ensure there are no lumps and whisk in the remaining milk. Use this 1. Fry mince in margarine until brown fortified milk in place of ordinary milk or water to make up hot 2. Add flour and stir well until mixed in drinks, packet soups, sauces, jelly, milk pudding, porridge, 3. Slowly add stock, stirring continuously . mashed potato, breakfast cereals, kheer, sago, custard, or 4. Add tomato puree, chilli powder and seasoning. ground rice. 5. Bring to the boil and simmer for 15-20 minutes. Stir occasionally. SOUP*: 6. Remove from heat, transfer to liquidiser and liquidise Add 2 tablespoons of milk powder to thick smooth soup, until smooth. blend/sieve soup that contains lumps. If advised to thicken 7. Take 1 portion of the beef and mix with 2 oz (60g) your fluids please make sure the consistency is right. mashed potato. Serve with pureed vegetables. (See fluids section).

MINTY LAMB PUREE (Serves 4) CHEESE: Add grated cheese to cooked vegetables, mashed potato, Follow recipe and instructions as above but use lamb in- soups and sauces and make sure they are blended/sieved to stead of beef and instead of chilli powder. remove lumps.

Pork and apple sauce can also be used. BUTTER OR MARGARINE: Use liberally on potatoes and vegetables before blending.

CREAM*/EVAPORATED MILK/FULL CREAM YOGHURT: Use to make or serve with desserts for example whip desserts, milk , stewed/tinned fruit blended down.

BREAKFAST CEREALS: Make Ready Brek, Weetabix or porridge with ‘fortified’ milk* and then blend.

NOTE: If relying on food fortification methods long-term it is advisable to include more monounsaturated fats for example, rapeseed oil or olive oil and spreads made from these fats (olive oil or butter style spreads are high in monounsaturated fats). These can be used generously to help get more energy from your food as they do not harm the heart.

RECIPES

Birmingham CommunityNutrition & DieteticService  Ensure you are sitting as upright as possible whilst FLUIDS eating and drinking - do not lie down immediately after a

meal Some people need to have fluids thickened , your Speech

and Language Therapist will be able to advise you on the ap-  If you feel you need to cough, do - it helps to protect the propriate consistency for you. If advised to thicken your lungs. If coughing persistently with meals stop eating and fluids please make sure the consistency is right before contact your Speech and Language Therapist or Doctor drinking.

 Make sure that food has been completely swallowed Certain foods and fluids may not be appropriate depending before taking the next mouthful - if you feel that some on your swallowing ability e.g. more liquid foods or foods that food is still at the back of your throat, swallow again melt to a liquid like ice-cream or jelly are not suitable if you before continuing to eat - slowing down can often lead to have to have fluids that are thicker than this. You may need dramatic improvements in swallowing to thicken some soups to get the right consistency.

 If you are assisting a person to eat make sure the person Getting enough to drink is really important and not get- can see the food to be eaten as this can help with ting enough each day can lead to constipation, head- swallowing aches and dehydration. We should all be aiming to have

8-10 drinks each day.  It is worthwhile developing a sensible swallowing

routine, i.e. take a small amount of food and ‘over-chew’ Drinks can be a really useful way of getting extra nour- each mouthful or use specific advice recommended by ishment if your appetite is poor. Below is a list of nour- your Speech and Language Therapist ishing fluids.

 If your appetite is poor try to drink more nutritious drinks PLEASE NOTE MILK CAN BE DIFFICULT TO THICKEN e.g. ‘fortified’ milk, Build Up shakes , milkshakes, fruit AND YOU SHOULD ALWAYS MAKE SURE THE CON- juices, milky tea/coffee SISTENCY IS CORRECT BEFORE DRINKING

 Weigh yourself weekly to check that you are not losing

weight. If you are contact your Dietitian/GP who will be

able to advise you further and suggest prescribable

products for you to try.

HELPING HINTS NOURISHING DRINKS

 If you cannot manage 3 large meals per day, try smaller  FIZZY DRINKS amounts, little and often

For example, lemonade/sports drinks will provide  Take advantage of when your appetite is good to com- extra energy but do not fill up on these. pensate for days when your appetite is poor

 COMPLAN/BUILD UP drinks or powders  Presentation can help improve appetite and may in- crease your interest in food - in particular, blend foods Available from chemists and some supermarkets separately and serve separately on the plate to retain in- dividual flavours  ‘FORTIFIED MILK’ (See over the page for recipe)

 Some foods lose colour when pureed - adding bovril,  MILKSHAKES marmite, tomato puree and tomato sauce can help to im- prove the appearance Flavour with milkshake syrup or milk shake powders. Coffee powder/essence, cocoa powder/drinking choco-  When food is pureed it loses a little of its flavour, so it is late, best to taste and season after it has been pureed - salt vanilla and other essences OR liquidised fruit e.g. and a small amount of pepper can be used to improve banana with nutmeg/cinnamon. flavour

 FRUIT JUICES Serve food at the correct temperature to bring out the  Fruit juices - 1 glass daily counts towards your fruit and flavour - foods which are too hot or too cold could cause vegetable intake. you to cough or choke

 HOT CHOCOLATE/MALTED MILK DRINKS  Convenience foods can be useful - make sure you keep a stock Make with fortified milk  If you are troubled with constipation take more fruit and If advised to thicken your fluids please make sure the fruit juices, add sugar and custard/cream/yoghurt to consistency is right before drinking. increase the energy in the food.

 A quiet relaxed atmosphere is best - concentrate, do not talk whilst eating

FOOD SUPPLEMENTS* DRINKS FORTIFIED MILK Build up and Complan and other own branded drinks are en- riched drinks available from pharmacies and super- 2 tablespoons (30ml) dried milk powder markets in sweet and savoury flavours. They may be taken 1/2 pint (300ml) milk as a drink between meals or be used to replace a meal occasionally. There are other supplements available which 1. Whisk together. have to be prescribed, these can be recommended by your This can be used as a drink or added to tea, coffee, on cereals, GP/Dietitian if appropriate. to make milk puddings and sauces.

HIGH PROTEIN MILKSHAKE NB. You may be tempted to try commercial baby foods, but these are expensive and do not provide adequate nourish- ½ pint of ‘fortified’ milk, ment for adults or older children. 1 generous scoop of ice cream, Flavouring, e.g. drinking chocolate. READY MEALS/PRE-PREPARED FOODS Put all ingredients into a blender and mix well. If you find it easier to use pre-prepared foods just make sure that they are served at the correct consistency, you may still YOGURT DRINK need to blend/;sieve the food to make sure that it is pureed correctly. ⅓ pint ‘fortified’ milk, 1 Carton of smooth fruit yogurt (no bits)  Make sure you do not choose meals containing high risk 1 teaspoon (5ml) clear honey foods such as sweetcorn, stringy vegetables etc.  Some stews may contain dumplings which would not Mix all ingredients together and chill thoroughly. Use creamy blend to a puree consistency and are best avoided. yogurt instead of low fat varieties to help increase calories.  Make sure potatoes etc are well cooked, and avoid roast potatoes/chips BANANA MILK

There are some companies who deliver pre-prepared meals 1/3 pint (200ml) enriched milk that are already pureed for you, please see contact details 1 Small ripe banana below; 1 scoop ice-cream 1 teaspoon (1x5ml) sugar Wiltshire Farm Foods: www.wiltshirefarmfoods.com Brochure Request & Customer Careline 1. Peel and mash banana 0800 077 3100 / 0800 066 3366 2. Mix in other ingredients until blended 3. Serve chilled. Mrs Gills Kitchen: www.mrsgillskitchen.com Telephone Number: 020 8807 6584 If advised to thicken your fluids please make sure the con- sistency is right before drinking. RICE, PASTA AND OTHER STARCHY FOODS FRUIT AND VEGETABLES .

Aim to have 3-5 servings per day Aim to have 5 portions per day for for example: example:  Blended smooth Porridge  Fruit Juice*  Weetabix or Ready Brek  Stewed/puree fruit  Puree soft pasta with sauce  Puree Tinned fruit  Mashed potato, Kitcherie  Puree banana  Puree Boiled Sweet potatoes  Puree vegetables  Ground rice pudding  Smooth Vegetable soup* (See fluids Section)

MEAT, FISH, EGGS AND OTHER NON DAIRY SOURCES OF PROTEIN

Aim to have 2-3 servings per day for example: FOODS AND DRINKS HIGH IN FAT AND/OR MILK AND DAIRY FOODS  Puree Fish in sauce SUGAR— See ENRICHING YOUR FOOD  Lentils, dahl SECTION Aim to have 3 servings per day  Pureed scrambled egg   Puree meat dish Concentrated sources of energy (calories) which Milk* (aim for 1 pint (568ml) a day)   Puree eggs are useful to help you maintain a healthy weight Yoghurt/fromage frais   Smooth Cheese sauce when on a puree diet for example: Custard  Fats added to potatoes and vegetables  Soft cheese  Mousses or smooth full fat yogurt  Cheese on potatoes/in soup  Sugar/syrup  Cream or cheese added to dishes