Nutrition Practice Manual July2012

Notice to readers
The way in which the following manual refers to DADHC was correct at the time of publication. Any reference in the manual to the Department of Ageing, Disability and Home Care (DADHC) should now be read as Family and Community Services NSW, Ageing, Disability and Home Care (ADHC).
Version 1.0 Accommodation Support Directorate Ageing, Disability and Home Care Department of Family and Community Services NSW July 2012 Final
Nutrition in Practice Manual
Preface
PREFACE
It is with pleasure that I introduce to you the 2nd edition of the DADHC Nutrition In Practice manual. First developed in 2001, the manual includes the Nutrition and Swallowing Risk checklist, a first-level screening tool for use by people providing assistance and support to people with a disability. Healthy food and good nutrition are basic human requirements. However, for many people with a disability, meeting these needs involves careful thought, planning and assistance. The Nutrition in Practice manual has been designed to inform staff and other carers about nutritional health and management of individual needs. Topics include the provision and preparation of nutritious food, weight management, meeting special health and dietary needs and household food management. It is a practical resource to support implementation of the Ensuring Good Nutrition policy, which aims to improve outcomes for people with a disability. The Ensuring Good Nutrition policy applies to both Government and nonGovernment services. Its purpose is to ensure that people with a disability achieve and maintain nutritional health and experience its benefits. The policy includes a commitment to an annual assessment of individual nutritional health needs. The Nutrition and Swallowing Risk checklist included in this manual was developed to assist in that assessment. The health and well-being of people with a disability, including nutritional health, are of paramount importance to us all. Being well nourished keeps us alert, active and able to participate more fully in family and community life. I recommend this resource as a positive addition to any service that has a role in supporting people with a disability.
Margaret Allison Director-General October 2003
NUTRITION IN PRACTICE MANUAL
Acknowledgements
ACKNOWLEDGEMENTS
The Nutrition in Practice manual has been produced as one of several initiatives of the Nutrition Project Disability Services, Department of Community Services. The main authors are: Margaret von Konigsmark, Consultant Dietitian and Lyn Stewart, Senior Project Officer, Nutrition Project Disability Services, NSW Department of Community Services
Contributing authors are:

Monika Kaatzke-McDonald, Consultant Speech Pathologist Tanya Govey, Consultant Speech Pathologist Jenny Dennis, Occupational Therapist, NSW Department of Community Services Jutta Williams, Physiotherapist, NSW Department of Community Services
Thanks go the following people for their advice and helpful suggestions on the manual: Donna White, Julia Filipi, Jill Trainor, Jeff Chan, Jane Meiklejohn, John Wagner, Wendy Dear and many others including the senior speech pathologists, senior occupational therapists and senior physiotherapists of the Department of Community Services. Grateful acknowledgement is also made to those people on the working groups who contributed to the development of the Nutrition and Swallowing Risk checklist. Particular thanks are due to all members of the Nutrition Working Party from June 1998 to October 2000 in their oversight of the project and for their unwavering dedication to the improvement of nutritional care of people with an intellectual disability.
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Working Groups
Nutrition and Dysphagia Working Groups February 1998

Dr Beverley Wood Ms Wendy Dear Dr Surinder Baines Mr Jeff Chan Ms Karen Hayes Ms Narelle Smith Ms Nicole Circuitt Dr Helen Beange Dr Sarita Sachdev Mr Darren Fittler Ms Lyn Williams Ms Hilary Lawler Ms Lyn Stewart Ms Georgina Loughnan Ms Jutta Williams Dr Berenice Mathisen Ms Chris Couts Dr Ted OLoughlin Ms Bronwyn Hemsley Ms Cathryn Herden Ms Michelle Lane Dr Helen Somerville Ms Anne Slater Ms Mary MacPherson Ms Anne-Carole Michaud-Gazal Mrs Margaret Von-Konigsmark Ms Monika Kaatzke-McDonald
Nutrition Working Party June 1998 October 2000

Ms Margaret Oldfield Ms Anne Campbell Ms Ethel McAlpine Ms Margaret Andersen Ms Lyn Stewart Dr Helen Beange Ms Margaret Bail Mrs Jeanette Moss Mrs Maria Circuitt Ms Wendy Dear Ms Anna Christou Ms Suzanne Pierce Mr Phillip Morath Ms Helen Seares Mr Darren Fittler Dr Berenice Mathisen Ms Jenny Klause Ms Cheryl Abrams Ms Michelle Hayter Mr Jeffrey Chan Ms Lyn Williams Mr Graham Smith Dr Helen Somerville Ms Julia Filipi Ms Margaret Anderson Ms Bernice Daher Ms Margaret von Konigsmark Ms Carolyn Campbell-McLean
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Contents
NUTRITION AND SWALLOWING RISK CHECKLIST Checklist instructions Part 1 Preliminary profile Part 2 Nutrition and Swallowing Risk checklist Part 3 Summary of results INTRODUCTION Who is this manual for? What is the aim of this manual? What is in the manual? SECTION 1 ASSESSMENT PROCEDURES How to use the Nutrition and Swallowing Risk checklist Guidelines for Part 1 Preliminary profile Guidelines for Part 2 Nutrition and Swallowing Risk checklist SECTION 2 GOOD NUTRITION FOR GOOD HEALTH Duty of care Healthy eating Vegetarian diets Dietary fibre Fluids Oral hygiene Food skills SECTION 3 WEIGHT MANAGEMENT Sensible weight loss Promoting weight gain
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SECTION 4 DIET AND SPECIAL HEALTH CONDITIONS 87

Food and drugs 89
Diet and diabetes 91
Food allergies & intolerances 94
Cholesterol 96
Enteral nutrition 98
SECTION 5 MEALTIME ASSISTANCE The normal eating process Eating difficulties Assessment of dysphagia Mealtime management Positioning for mealtimes Equipment Food textures Modifying fluid consistency 101
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Contents
SECTION 6 INDIVIDUAL PLANNING The Individual Plan (IP) Developing an eating and drinking plan Sample eating and drinking plan Suggested meal outline SECTION 7 MANAGING FOOD IN A HOME Menu planning Shopping tips Sample daily meal plan Sample menu for one week of a cycle Multicultural considerations Food safety in the home Dining out GLOSSARY RESOURCES
Publications Professional resources
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APPENDICES
APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX 1 NUTRITION AND SWALLOWING RISK CHECKLIST 2 WEIGHT CHART 3 ORAL CARE PLAN 4 SAMPLE FOOD DIARY 5 SAMPLE SOFT DIET WITH THICKENED FLUIDS 6 EATING AND DRINKING PLAN (sample format)
Second Edition 2003 Department of Ageing, Disability and Home Care Level 5 83 Clarence Street Sydney NSW 2000 www.dadhc.nsw.gov.au First Edition ISBN 0 7130 4311 1 December 2000 Department of Community Services www.community.nsw.gov.au
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Nutrition and Swallowing Risk Checklist
Instructions
CHECKLIST INSTRUCTIONS
The Nutritional and Swallowing Risk checklist forms part of the Nutrition in
Practice manual which has been produced by DADHC.
This copy of the checklist is perforated to allow it to be removed from the manual and photocopied easily. A plastic holder is at the back. A master copy is provided at Appendix 1.
What is the purpose of the checklist?

The Nutrition and Swallowing Risk checklist is a way of screening people for difficulties related to nutrition and swallowing. It cannot make a diagnosis of a medical condition. A diagnosis can only be made by a health specialist. The checklist was developed as a means of raising awareness of nutritionrelated problems in people with a disability. It has been developed to be used by people who care for people with a disability. By asking questions about a persons health, weight and their ability to eat and drink, the checklist will help you decide if further assessment and action is needed, including advice or assessment by a dietitian, speech pathologist or other health specialist.
Referrals This marker is used throughout the checklist. It indicates where you can find more information about a particular topic in the Nutrition in Practice manual.
Who should complete it?

If you are completing the checklist you should know the person with a disability well. You may be the case manager or person responsible for developing the Individual Plan (IP). Collaboration with a parent or family member may be helpful so that you arrive at the most accurate result. Complete the checklist with the assistance of the person with a disability as much as possible.
How to complete it
Part 1 Preliminary profile Gathers and evaluates information about the persons weight and height. In this section you have to write in the information requested for some questions and tick the relevant box for others. Part 2 Nutrition Risk and Swallowing Risk checklist Assesses if the person has indications of nutritional problems or swallowing difficulties that may affect their nutrition and health. Tick the relevant box for each question. Part 3 Summary of results Summarises your results. Some risks may need notes of explanation or extra information. Write this in the comments column. Decide what actions you are going to take or recommend and write this in the action decided column. NUTRITION IN PRACTICE MANUAL
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Instructions
Do not guess answers

Try to obtain all the information you need to complete the checklist. For example, you may need to look at the persons weight records to work out if they have lost or gained weight over the past three months. If there are no records and you are not able to measure height or weight, you should still complete as much of Part 1 as you can, and then complete Part 2 to the best of your knowledge. Be observant. Do not guess answers. Use your powers of observation to answer questions about how the person eats and drinks. If you are unsure or do not know the answer to a question, you may need to seek another persons opinion. If the answers are still uncertain, tick the Unsure/Do not know box and refer to a health specialist for assistance.
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Part 1
PART 1 PRELIMINARY PROFILE The person with a disability

Name: _________________________________ Gender: Date of birth: ____________ Age: __________
Residential address: _______________________________ Post code: _______
This address is:
Male
Female
Has the Nutrition and Swallowing Risk checklist been used before for this person?
an independent residence a family home a group home a residential centre other (specify) ______________
Yes No If yes, when? Date ____________
The person conducting the checklist

Your name:______________________ Date checklist completed: _________
(person completing the checklist)
Your relationship to the person with a disability:
case worker case manager residential care worker nurse parent other less than 6 months 6 months to 1 year 12 years 25 years more than 5 years the persons home the persons school the persons work a Community Service Centre other (specify) _____________ self the person with a disability parent (of the person with a disability) close relative ______________ close friend _______________ other (specify) _____________
How long have you known the person?
Where is the checklist being completed?
Who is the person providing the information so you can complete this checklist? (tick more than one box if needed)
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Part 1
Weight information
Refer to page 9 of the Nutrition in Practice manual for information on how to measure height and weight. Current weight without shoes (e.g. 69.5 kg): __________ kg.
Date measured: __________
If you have no information on the persons weight, why not? _______________
Weight change over the past three months: _______ kg Do you have weight records for the past three months?
gained or, Yes
lost
No
Height information
Current height (measured standing and without shoes) (e.g.164cm or 1.64 metres): _____________ Date measured: ___________ If you have no information on the persons height or you are not able to measure their height, why not? _______________________________________________________________ Note: For children and young people aged under 18 years, their growth rate should be assessed by a GP, paediatrician, early childhood nurse or dietitian every year. Has this happened? Using the weight and height information If the person is an adult, mark the spot on the chart (below) where their height and weight meet.
Yes
No
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Part 2
PART 2 NUTRITION AND SWALLOWING RISK CHECKLIST

Tick an answer box for each question. The explanations beneath each question and the Nutrition in Practice manual references will help you complete the checklist. There are 24 questions.
Question 1.
If the person is a child (i.e. under 18 years of age) have they lost weight or failed to gain weight over the last three months?
Not applicable Yes No Unsure/Do not know
You will need weight records to answer this question accurately Refer to page 10
Question 2.
Is the person underweight? Tick the Yes box if either of the following apply: The person is an adult and their weight on the Weight for Height Chart is in the underweight or very underweight range; When you look carefully at the person (adult or child), their bone structure is easily defined under their skin. This can indicate significant loss of fat tissue and is easily checked by looking around the persons eyes and cheeks. Other areas to check include the shoulders, ribs and hips.
Refer to page 12 Yes No Unsure/Do not know
Question 3.
Has the person had unplanned weight loss or have they lost too much weight? Tick the Yes box if any of the following apply: The persons weight loss is undesirable or has been unexpected; The person is under 18 years of age and there is weight loss in two or more consecutive months; The person has lost weight in two or more consecutive months and is not on a monitored weight loss program.
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Part 2
Question 4.
Refer to page 16 Is the person overweight? Tick the Yes box if either of the following apply: The person is an adult (i.e. over 18 years of age) and their weight on the Weight for Height Chart is in the overweight or obese range; The person (adult or child) appears to have rolls of body fat (e.g. around the abdomen).
Yes No Unsure/Do not know
Question 5.
Refer to page 18 Has the person had unplanned weight gain or have they gained too much weight? Tick the Yes box if either of the following apply: The persons weight gain is undesirable or has been unexpected; The person is not on a weight gain program and their clothes no longer fit.
Question 6.
Refer to page 20 Is the person receiving tube feeds? Tick the Yes box if the person is receiving naso gastric, naso-duodenal or gastrostomy feeding.
Question 6a.
Refer to page 21 If you answered Yes to question 6, does the person also receive food or drink through the mouth? Tick the Yes box if the person receives any food or drink by mouth, in addition to tube feeding. If the person is receiving tube feeds and no other food by mouth, then answer only questions 10, 13, 14, 16, 18 and 19. Not applicable Yes No Unsure/Do not know
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Part 2
Question 7.
Is the person physically dependent on others in order to eat or drink? Tick the Yes box if: The person cannot put food or drink into their own mouth and someone else is needed to feed them; The person is dependent on assistance during a meal (e.g. guidance with utensils).
Yes Refer to page 22 No Unsure/Do not know
Question 8.
Has the person had a reduction in appetite or food or fluid intake? Tick the Yes box if either of the following apply: The person is not eating or drinking as much as they usually do and this is unintentional; The person appears unwilling to take most food offered to them and the equivalent of six large glasses of fluid each day.
Question 9.
Does the person follow, or are they supposed to follow, a special diet? Tick the Yes box if they are on, or are supposed to be on, any of the following dietary plans: Pureed, minced, chopped or soft foods; Thickened fluids; Weight reduction or weight-increasing; Low fat; Vegetarian; Low cholesterol or cholesterol-lowering; Diabetic; Any other diet which modifies or restricts foods or food choices.
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Part 2
Question 10.
Refer to page 27 Does the person take multiple medications? Tick the Yes box if: The person is usually on more than one type of medication.
Question 11.
Refer to page 28 Does the person select inappropriate foods or behave inappropriately with food? Tick the Yes box if any of the following apply: The person over-consumes alcohol or coffee, tea and cola drinks; The person eats non-food items such as dirt, grass or faeces; The person drinks excessive amounts of fluid; The person steals or hides food.
Question 12.
Refer to page 30 Does the person usually exclude foods from any food group? Tick the Yes box if the person usually excludes all foods from one or more of the following groups of food: Bread, cereals, rice, pasta, noodles; Vegetables, legumes; Fruit; Milk, yogurt, cheese; Meat, fish, poultry, eggs, nuts, legumes.
Question 13.
Refer to page 32 Does the person get constipated? Tick the Yes box if either of the following apply: The persons bowel movements are irregular, painful and sometimes infrequent; Laxatives, suppositories or enemas are required to maintain regular bowel movements.
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Part 2
Question 14.
Does the person have frequent fluid-type bowel movements?
Question 15.
Does the person have mouth or teeth problems that affect their eating? Tick the Yes box if any of the following apply: The persons teeth are loose, broken or missing; The persons lips, tongue, throat or gums are red and inflamed or ulcerated; The person has a malocclusion (upper and lower teeth do not meet) and this affects their ability to chew. Yes Refer to page 34 No Unsure/Do not know
Question 16.
Does the person suffer from frequent chest infections, pneumonia, asthma or wheezing? Tick the Yes box if any of the following apply: The person has had frequent chest infections or pneumonia; The person is usually chesty or has difficulty clearing phlegm; The person has asthma or wheezes.
Question 17.
Does the person cough, gag and choke or breathe noisily during or after eating food, drinking, or taking medication? Tick the Yes box if any of the following apply: The person sometimes coughs or chokes during or several minutes after eating, drinking or taking medication; The persons breathing becomes noisy after eating or drinking or while talking; The person gags on eating, drinking or taking medication.
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Part 2
Question 18.
Refer to page 40 Does the person vomit or regurgitate on a regular basis? (Note:This question is not applicable to infants under 12 months of age)
Tick the Yes box if either:
The person vomits or regurgitates (i.e. brings up) food, drink or medication more than once per day or on a regular basis; The person takes anti-reflux medication; The person clears their throat often or burps often.
Question 19.
Refer to page 41 Does the person drool or dribble saliva when resting, eating or drinking? Tick the Yes box if either of the following apply: The person drools or dribbles saliva at rest or mealtimes; The persons clothes or protective napkins/bibs frequently need changing because of drooling.
Question 20.
Refer to page 42 Does food or drink fall out of the persons mouth during eating or drinking? Tick the Yes box if any of the following apply: The person is unable to close their mouth and this causes food, drink or medication to fall out of their mouth; The person cannot keep their head upright and food, drink or medication falls out of their mouth; The persons tongue pushes food, drink or medication out of their mouth; The persons mouth continuously needs to be wiped or they need to wear a cloth to protect their clothes during mealtime. Note that this question does not relate to the persons manual dexterity or ability to place food in their mouth.
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Part 2
Question 21.
If the person eats independently, do they overfill their mouth or try to eat very quickly? Tick the Yes box if the person eats independently and any of the following apply: The person tries to cram or stuff their mouth before attempting to chew or swallow; The person tries to swallow too much food before they have chewed it properly; The person usually finishes all of their main meal in less than five minutes. Not applicable Yes No Unsure/Do not know Refer to page 44
Question 22.
Does the person appear to eat without chewing? (Note:This question does not apply to people on
a pureed diet)
Tick the Yes box if any of the following apply:
The person sucks their food instead of chewing; The food remains in the person s mouth for a long period of time before being swallowed; The person swallows their food whole without chewing. Not applicable Yes No Unsure/Do not know Refer to page 45
Question 23.
Does the person take a long time to eat their meals? Tick the Yes box if any of the following apply: The person eats independently and they take more than 30 minutes to eat meals; The person is dependent on someone to feed them and it takes a longtime to feed them the whole meal; The person appears to tire as the meal progresses and may not finish their meal.
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Part 2
Question 24.
Refer to page 48 Does the person show distress during or after eating or drinking? Tick the Yes box if any of the following apply: The person appears distressed while they eat or drink; The person appears distressed immediately after or shortly after eating or drinking; Sometimes while distressed the person refuses food or spits out food.
YES to any question?

If you answered Yes to one or more questions, the person may have a nutrition risk or risk to safe swallowing. Summarise your results in Part 3 Summary of Results.
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PART 3 SUMMARY OF RESULTS

(insert date)
Summary of results for ___________________________________________________ on ________________________________
Refer to the relevant question in the Nutrition in Practice manual. The Nutrition in Practice manual outlines things to consider and some simple safe things you can do to manage the problem or risks you have identified. It also helps you decide if the person needs to be referred to a specialist, such as a speech pathologist, dietitian, doctor etc.
If you decide that a specialist referral is the best action, take this completed checklist to the appointment.
A copy of this completed checklist should be kept in the persons files. Comments Action
Nutrition and Swallowing Risks identified
Q.1. Reminder: Children or young people under 18 years of age an annual growth assessment should be completed by a GP, paediatrician, early childhood nurse or dietitian. Has this occurred? If you are not able to measure height and weight, refer to a specialist professional for measurement of height and weight and an estimate of the persons healthy weight range.
Q.2. Reminder: Weigh regularly and record changes. Does this happen?

Example Weight gain over the last year. Difficulty walking because of excess weight.
Example The person is overweight
Example Make appointment with dietitian
Part 3
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Introduction
How to use the Nutrition in Practice Manual
Introduction
WHO IS THIS MANUAL FOR?

This manual has been written for: People who assess the needs of people with a disability; People who provide care for people with a disability.
WHAT IS THE AIM OF THIS MANUAL?

The Nutrition in Practice manual aims to assist service providers to provide food and nutritional care which meets the needs of their clients or family member with a disability. Specifically, the manual provides information to be used with the Nutrition and Swallowing Risk checklist. Copies of the checklist accompany this manual. Using the Nutrition and Swallowing Risk checklist is recommended as a way of identifying problems (or risks) that are related to nutrition and swallowing difficulties. This manual provides information on how to use the checklist and offers guidelines on steps that may be taken when the checklist results indicate that a person may have a nutrition or swallowing difficulty. The manual also provides information on a range of topics that could be useful in helping people to achieve good health through good nutrition. As you read the manual, most medical and technical terms are explained in plain english in the text. If an explanation does not appear in the text, look it up in the Glossary on page 149.
WHAT IS IN THE MANUAL?

SECTION 1 of the manual is about assessment procedures. It explains how to use the Nutrition and Swallowing Risk checklist to help identify nutrition and swallowing problems in a person with a disability. Each question in the checklist is explained and information provided to guide further assessment of a possible nutrition or swallowing risk or problem. Icons show which question the information is about, where you will find more information in the manual and who to consult for advice or assessment.
The See also icon indicates where you will find more information in the manual about issues raised in that question. The Referrals icon indicates which health specialists can give you more advice about the issues raised in the question.
See also Referrals
Introduction
How to use the Nutrition in Practice Manual
SECTION 2 of the manual provides general guidelines on nutrition. Healthy eating, dietary fibre, adequate fluids and oral hygiene are important subjects for all people. Information on vegetarian diets is included here because of the popularity of vegetarian eating. An introduction to teaching food skills is also included. SECTION 3 of the manual provides guidelines for managing sensible weight loss and for promoting weight gain. SECTION 4 of the manual is about diet and special health conditions. It includes general information about the relationship between food and drugs. Issues relating to diabetes, food allergies and food intolerance, cholesterol and enteral nutrition (or tube feeding) are included. SECTION 5 of the manual is about mealtime assistance for people with eating and swallowing difficulties. An explanation of these problems and how they can be managed is provided. Guidelines are provided for best positioning of the person for eating and being fed by another person. Information about equipment adapted to encourage independence in eating and drinking is provided. General guidelines are given on modifying food and fluid textures to promote improved intake. SECTION 6 of the manual gives guidelines for developing an individual eating and drinking plan. SECTION 7 of the manual provides guidelines for managing food in a group home. It includes information on menu planning, shopping, multicultural considerations, food safety and dining out.
The Glossary provides an explanation of technical terms used in the manual. Most medical and technical terms are explained in plain English in the text.
Section 1
Assessment proceedures
Section 1
HOW TO USE THE NUTRITION AND SWALLOWING RISK CHECKLIST When to use the Nutrition and Swallowing Risk checklist
We recommend the Nutrition and Swallowing Risk checklist is used when the general care needs or health care needs of a person with a disability are being assessed. This can be when the person is first assessed by a service, or it can be when their Individual Plan (IP) is being reviewed or developed. IPs are reviewed annually. Therefore, we recommend that the Nutrition and Swallowing Risk checklist is used annually in preparation for the IP review.
How the checklist and manual work together

The checklist does not, and cannot, make a diagnosis. However, it may alert you to a risk or a problem which needs attention. Any risks or problems identified by the Nutrition and Swallowing Risk checklist should be assessed. The Nutrition in Practice manual provides some guidance to this assessment process by explaining the usual things that should be considered in assessing each identified risk or problem on the checklist. The manual provides some ideas on simple and safe things that can be done about each of the problems. Some problems are serious and need to be assessed by a health specialist. The manual also gives guidance as to what type of health specialist you might refer to for help. REMEMBER the Nutrition in Practice manual is only a guide. It is not a complete do it yourself on nutrition and swallowing. From the outset, the best plan to manage a nutrition and/or swallowing problem is made WITH THE PERSON with a disability themselves, after thorough assessment and with due consideration of the living environment and support system around them.
The checklist
does not, and cannot, make a diagnosis. However, it may alert you to a risk or a problem which needs attention.
Who should fill out the Nutrition and Swallowing Risk checklist?
The case manager or person responsible for developing the IP is the most likely person to be filling out the checklist. In residential services of the Department of Ageing, Disability and Home Care, the Nutrition and Swallowing Risk checklist should be used to assess nutrition and swallowing risks initially and then annually for every client. The case manager or other people involved with the persons care may also fill out the checklist as a way of preparing information for a referral to a health specialist. Make sure you directly involve the person with a disability as much as possible, and that you have their consent where they are capable of providing it. When filling out the checklist discuss your answers with others. A good method is for two people who know the person with a disability well to both fill in the Nutrition and Swallowing Risk checklist. One person could be the case manager or person responsible for developing the IP.
Section 1
Another person could be a family member or service staff member involved in the persons care. The two people could work independently of each other and then compare results, or could work together on the same checklist form. Whatever way you decide to go, discussion and collaboration with others helps you arrive at the most accurate result.
The Nutrition and Swallowing Risk checklist is in three (3) parts:

Part 1 Preliminary Profile where you enter the persons details (name, age and address etc.). In this section you also gather and evaluate information about the persons weight and height. If you are able to measure the persons current height and weight then do so (see page 9 How to measure height and weight). A few details about you, the person filling out the checklist, are also needed in this section. Part 2 Nutrition and Swallowing Risk checklist where you assess if the person is at nutritional risk and if there is a swallowing disorder which may impact on the persons nutrition and health. Refer to this manual to help you understand more about any checklist question. Part 3 - Summary of results where you fill in the back Summary of results page of the checklist. Some risks may need notes of explanation or extra information. Write this in the Comments column. Refer to this manual to help you understand more about any checklist question and the actions you might consider taking. Decide what actions you are going to recommend and write this in the Action decided column.
What to do with the results of the checklist

Discuss your results and any differences of opinion. Come to a conclusion as to which answers best represent the nutritional problems and/or swallowing difficulties of the person. The manual may be useful in helping you come to a decision for action. Remember that an identified risk may mean no action is decided if what is currently happening for the person is meeting their needs. If this is the case then write what is currently happening in the Comments column and Continue current action, or words to that effect, in the Action decided column. On the other hand, you may decide that the checklist has brought to your attention a new risk for which the person has received no attention to date. The manual gives you some ideas to consider before you decide what action to take. Some problems are serious and need to be assessed by a health specialist. The manual gives guidance as to what type of professional person you might refer to for help.
Section 1
GUIDELINES FOR PART 1 PRELIMINARY PROFILE How to measure height and weight
Weighing people You can use weight measurements as a simple tool to track nutritional status. However, measurements must be accurate to give meaningful results. Scales with wheelchair access should be available to every person with a physical disability who receives services. Do not pick up and cradle the person while they are being weighed on bathroom scales. This is an unacceptable safety hazard for both people. Weigh the person without shoes and preferably in light clothes. If they wear a helmet for safety, take off the helmet or subtract the helmets weight from the persons weight. Always use the same scales to weigh the person. Place scales on a hard, firm floor surface, not on carpet. If the person needs to be weighed in a personal wheelchair, ensure the wheelchair weight is the same each time (e.g. remove the table and/or head rests each time they are weighed). Record weight measurement in the Weight Information paragraph on page C6 of the Nutrition and Swallowing Risk checklist. Maintain a regular weight record for the person on a Weight Record Chart. See Appendix 2 for a sample weight chart. Measuring height If the person can stand upright: Remove shoes and hat/helmet if applicable; The person should stand as straight as possible against a wall, with heels as far back as possible against the wall; Mark the point on the wall that is horizontal with the top of the persons head (with their hair flattened down); Measure from this point to the base of the wall in centimetres. If the person cannot stand upright: Their height should be estimated by a health specialist such as a dietitian, GP, paediatrician or early childhood nurse; Ask the health specialist to assess if the person is within a healthy weight range. Tracking the growth of children If the person is a child (under 18 years of age), their height or length should be measured regularly, at least every six months and should be recorded on a growth chart or height graph. NUTRITION IN PRACTICE MANUAL 9
Do not pick up
and cradle the person while they are being weighed on bathroom scales. This is an unacceptable safety hazard for both people.
Section 1
GUIDELINES FOR PART 2 NUTRITION AND SWALLOWING RISK CHECKLIST Question 1.

If the person is a child (i.e. under 18 years), have they lost weight or failed to gain weight over the last three months? Things to consider Childhood and adolescence is a time of rapid growth. However, slower growth is known in children with a disability, especially those with cerebral palsy. Poor growth can be a sign of inadequate nutrition or a more serious health problem. No weight gain in a child is undesirable, except where obesity is a factor. A childs growth rate must be assessed at least once a year by a health specialist. Health specialists include doctors, pediatricians, dietitians and early childhood nurses. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do If the childs growth rate has not been assessed within the past 12 months, refer them to a health specialists. Measure and record their height at least every six months. Weigh them once a month and record their weight on the Weight Chart (Appendix 2). If the child has not gained any weight in the past three months, increase their energy intake and encourage weight gain by: Offering food they like and will eat; Encouraging them to eat nourishing snacks and drinks in-between meals; Offering a second helping when they enjoy a meal or drink; Adding extra milk, butter, margarine, cheese or cream to food; Adding extra full-cream milk powder to milk; Encouraging them to eat at least six small, regular and nourishing meals a day instead of three large meals. If the child is receiving tube feeds, refer to a dietitian. If the child does not gain any weight within one month of trying the above suggestions, refer them to a doctor, pediatrician, dietitian or early childhood nurse.
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Section 1
Diagram 1 below illustrates the steps you need to take. See also SECTION 1 Guidelines for Part 1 Preliminary profile SECTION 3 Promoting weight gain SECTION 2 Healthy eating Referrals Doctor, paediatrician, dietitian, early childhood nurse
Diagram 1. Under 18 and has not put on weight in three months Things you can do
Growth assessment at least once a year
Weigh & record monthly
Measure & record height every six months
If no weight gain in 3 months
If satisfactory weight gain
Increase energy intake
Re-weigh in one month
If no weight gain
Refer to a health specialist
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Section 1
Question 2.
Is the person underweight? Things to consider An underweight person: May be malnourished; May not have energy reserves for times of illness; May have low immunity or resistance to infections and easily become ill; May not be able to use their muscles properly; Is more likely to feel the cold. It is not good for people who are already underweight to lose more weight. A short period of eating poorly can cause severe weight loss which may be difficult to regain. If your answer to the question is Unsure/Do not know, refer to a health specialist. Health specialists include doctors, paediatricians and dietitians. Things you can do Weigh the person once a month. If the person is under 18 years of age and their growth rate has not been assessed within the past 12 months, refer them to a health specialist. If the person is an adult, use the Weight for Height Chart on page C6 of the checklist to confirm if they are underweight. If you confirm they are underweight, increase their energy intake and encourage weight gain by: Offering food they like and will eat; Encouraging them to eat nourishing snacks and drinks in-between meals; Offering a second helping when they enjoy a meal or drink; Adding extra milk, butter, margarine, cheese or cream to food; Adding extra full-cream milk powder to milk; Encouraging them to eat at least six small, regular and nourishing meals a day instead of three large meals. If the person is receiving tube feeds, refer to a dietitian. If the person does not gain weight after two months, refer them to a dietitian.
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Diagram 2 below illustrates the steps you need to take. See also SECTION 3 Promoting weight gain SECTION 2 Healthy eating Referrals Doctor, paediatrician, dietician
Diagram 2. Obviously underweight Things you can do

CHILD (UNDER 18 YEARS) ADULT
Confirm underweight Weight for Height Chart
If weight is satisfactory
If underweight try increasing food intake
Try increasing energy intake
If some weight gain
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Question 3. Has the person had unplanned weight loss or have they lost too much weight?
Things to consider Weight loss may be desirable for adults who are overweight and on a monitored weight loss program. However, when a person loses a lot of weight (e.g. 5 kg or one stone within six months), it may be a sign that their health is declining, even if they were overweight to begin with. Weight loss in someone who is already underweight is very undesirable. Weight loss in a child is always a concern and requires immediate action. If your answer to the question is Unsure/Do not know, refer to a health specialist. Health specialists include doctors, paediatricians and dietitians. Things you can do For children You must take action if someone aged under 18 loses weight from one month to the next. Keep a record of the food and drink the person consumes. Include the sort of food and drink and how much of each they consume. Try to increase energy intake and encourage weight gain by: Offering food the person likes and will eat; Encouraging the person to eat nourishing snacks and drinks in-between meals; Offering a second helping when they enjoy a meal or drink; Adding extra milk, butter, margarine, cheese or cream to food; Adding extra full-cream milk powder to milk; Providing at least six small, regular and nourishing meals a day instead of three large meals. If the person does not gain any weight within two months, refer them to a dietitian. If the person loses weight very rapidly or for any other reason of concern, refer them to a health specialist. If the person is receiving tube feeds, refer to a dietitian. For adults Use the Weight for Height Chart on page C6 of the checklist to confirm if the person is going below the healthy weight range. If the person is underweight, follow the steps listed above to encourage weight gain. If the person continues to lose weight for more than two consecutive months, refer them to a health specialist. 14 NUTRITION IN PRACTICE MANUAL
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If the person loses weight very rapidly or for any other reason of concern, refer them to a health specialist. If the person is receiving tube feeds, refer to a dietitian. Diagram 3 below illustrates the steps you need to take. See also SECTION 3 Promoting weight gain SECTION 2 Healthy eating Referrals Doctor, paediatrician, dietitian
Diagram 3. Weight loss Things you can do

UNDER 18 YEARS ADULT
Confirm underweight on Weight for Height Chart
If weight is satisfactory
If weight loss, try increasing energy intake
If weight loss, try increasing energy intake
If weight loss continues for 2 months
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Question 4.
Is the person overweight? Things to consider If a person is overweight, they may have a health problem such as difficulty breathing, stress on their joints or reduced mobility. Their ability to participate in usual daily activities may be restricted. They may be at greater risk of illnesses such as reflux, diabetes and heart disease. All these things affect a persons quality of life. A childs growth rate must be assessed at least once a year by a health specialist. Health specialists include doctors, paediatricians, dietitians and early childhood nurses.
Do not use
weight-reducing diets with children unless supervised by a dietitian.
Do not use weight-reducing diets with children unless supervised by a dietitian. Aim first to prevent further weight gain and allow for their growth to catch up. Any weight-reducing plan must be based on a healthy eating plan, and where possible, increased activity. A behaviour management program may be helpful. If your answer to the question is Unsure/Do not know then refer to a health specialist. Things you can do Weigh the person once a month. If the person is under 18 years of age and their growth rate has not been assessed within the past 12 months, refer them to a health specialist to confirm they are overweight. If the person is a child, make sure they have a healthy, balanced diet. If their weight remains stable, continue giving them a healthy, balanced diet until their next growth assessment. If the person continues to gain weight, or they lose weight, refer them to a dietitian. If the person is an adult, use the Weight for Height Chart on page C6 of the checklist to confirm they are overweight or obese. Provide regular exercise if possible and commence some simple dietary strategies such as: Providing three meals a day, avoiding high fat foods and minimising foods containing sugar; Choosing low fat dairy products and lean cuts of meat; Increasing consumption of high fibre foods such as fruit and vegetables. If the person is receiving tube feeds, refer to a dietitian. If the person does not lose weight, or loses more than 5 kg in one month, refer them to a dietitian.
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Diagram 4 below illustrates the steps you need to take. See also SECTION 3 Sensible weight loss SECTION 2 Healthy eating Referrals Doctor, paediatrician, dietitian, physiotherapist
Diagram 4. Obviously overweight Things you can do
UNDER 18 YEARS
ADULT
Growth assessment at least once a year confirm overweight
Confirm overweight or obesity on Weight for Height Chart
Ensure a healthy eating plan
Start excercise and dietary srategies
If weight stable
If weight gain or loss
If satisfactory weight loss
If no weight loss or loss greater than 5kg a month
Refer to dietitian
Refer to dietitian
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Question 5.
Has the person had unplanned weight gain or have they gained too much weight? Things to consider If a person is overweight, they may have a health problem such as difficulty breathing, stress on their joints or reduced mobility. Their ability to participate in usual daily activities may be restricted. They may be at greater risk of illnesses such as reflux, diabetes and heart disease. All these things affect a persons quality of life. A health specialist must assess a childs growth rate at least once a year. Health specialists include doctors, pediatricians, dietitians and early childhood nurses. Do not use weight-reducing diets with children unless supervised by a dietitian. Aim first to prevent further weight gain and allow for their growth to catch-up. Any weight-reducing plan must be based on a healthy eating plan, and where possible, increased activity. A behaviour support program may be helpful. It is good for children to gain weight if it is within a healthy growth pattern. It is not good for adults to gain weight if it takes them out of the healthy weight range on the Weight for Height Chart (page C6 of the checklist). Changes in activity, medication, health and moods can all contribute to weight gain. These causes are not always obvious and need to be considered. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do Weigh the person once a month. If the person is under 18 years of age and their growth rate has not been assessed within the past 12 months, refer them to a health specialist to confirm healthy growth. Make sure the person has a healthy, balanced diet. If the person is over 18 years of age, use the Weight for Height Chart on page C6 of the checklist to confirm they are going beyond the healthy weight range. If the person is overweight, follow the steps for sensible weight loss outlined at Question 4. If the person is receiving tube feeds, refer to a dietitian. If the persons weight gain is very rapid or concerns you for any other reason, refer them to a health specialist.
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Diagram 5 below illustrates the steps you need to take. See also SECTION 3 Sensible weight loss SECTION 2 Healthy eating Referrals Doctor, paediatrician, dietitian Diagram 5. Weight gain Things you can do
UNDER 18 YEARS ADULT
Growth assessment at least once a year confirm overweight
Check Weight for Height Chart to confirm overweight
Ensure a healthy eating plan
Start excercise and dietary srategies
If satisfactory weight for height
If too much weight gain
If satisfactory weight loss
If no weight loss or loss greater than 5kg a month
Refer to dietitian
Refer to dietitian
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Questions 6.
Is the person receiving tube feeds? Things to consider Tube feeding can take many forms: Naso-gastric (a tube via the nose into the stomach); Naso-duodenal (a tube via the nose into the duodenum); Gastrostomy (a tube directly into the stomach). A person may be tube fed for a variety of reasons. It may supplement an inadequate diet through the mouth (oral diet) or replace oral feeding because of difficulty swallowing (dysphagia) or food being inhaled or passed into the airway (aspiration of food). Tube feeding does not mean that aspiration cannot occur, however with good care the risks can be minimised. It is essential that people receiving tube feeding be positioned correctly. They should be at a 30 degree angle minimum and not flat in bed. Malnutrition (either under or over nutrition) is a risk with tube feeds. There is a risk of irritation/infection around the stoma (area where tube is inserted into the stomach). Good oral hygiene is important to reduce the risk of respiratory illness from germs (usually bacteria) in saliva. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do Make sure that the tube feeding management plan (or nutritional care plan) for the person is under the direction of a dietitian and is reviewed regularly. Make sure the plan is readily accessible to those people caring for the person, detailing time, type of feed and amount. Make sure the person is seated upright for at least half an hour after feeding. Even though the person is not getting food through the mouth, oral hygiene must be maintained. Aspiration of saliva into the airway is still a risk. Good oral care will reduce bacteria in the saliva. See also SECTION 2 Oral hygiene SECTION 4 Enteral nutrition Referrals Dietitian, stoma therapist, doctor, physiotherapist, dentist
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Question 6a.
If you answered YES to Question 6, does the person also receive food or drink through the mouth? Things to consider Only give food orally (through the mouth) if the person has been specifically permitted by a speech pathologist to receive food this way. Follow the recommended mealtime plan. Do not vary this plan in any way without consulting the speech pathologist or dietitian. How does the person tolerate food or drink being given by mouth? Is there any coughing, choking or distress? If so, try the Things you can do for Question 17 on page 38. If coughing, choking or distress persists, stop oral feeding and seek medical attention. See also SECTION 2 Oral hygiene SECTION 4 Enteral nutrition Referrals Speech pathologist, doctor, dietitian
Only give food
orally (through the mouth) if the person has been specifically permitted by a speech pathologist to receive food this way.
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Question 7.
Is the person physically dependent on others in order to eat and drink? Things to consider A person who cannot put food or drink into their own mouth and who depend on others to feed them or to assist them to eat are nutritionally very vulnerable. The person is not likely to be able to choose what and how much they eat and drink. They depend on others to respond to their needs while at the same time they may not be able to easily express hunger or thirst. This places them at greater nutritional risk than those who can eat and drink independently. It is therefore important to endeavour to communicate with the person as effectively as possible. A speech pathologist with expertise in communication may be able to help. Things you can do Check that the person is seated and positioned appropriately to receive food (see SECTION 5 on Positioning for Mealtimes). If the person can feed himself or herself with assistance, check they are seated appropriately and can reach food and drinks. Ensure that utensils and other equipment needed for eating and drinking are appropriate. (see SECTION 5 on Equipment) Give appropriate verbal encouragement. Give the person enough time to eat and drink at a relaxed pace. If the person is dependent on someone else to feed them, they must be given enough time to take the food and chew and swallow before they are presented with another spoonful. Minimise distractions from other people and the environment. Ensure the texture, taste, temperature and appearance of food and drink are appropriate. See also SECTION 2 Healthy eating SECTION 5 Mealtime assistance Referrals Doctor, dietitian, speech pathologist, occupational therapist, dentist, psychologist, physiotherapist
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Question 8.
Has the person had a reduction in appetite or food or fluid intake? Things to consider A lack of appetite and reduced food intake over a short period can quickly lead to severe weight loss. Medication, ill health and behavioural changes (including mood) can all affect a persons appetite. If someone continues to eat very little or refuses to eat food they usually enjoy, you must take action. Is the persons fluid intake usually low? If yes, this is also a nutrition risk. Things you can do If the persons reduced food intake is easily explained by a short-term illness (such as a cold), offer light foods they usually enjoy. Nutritional supplements may also be useful. If you believe medication is affecting their appetite, discuss this with their doctor. It is important to give medication at the right time, especially in relation to meals. Always follow the instructions accompanying the medication. Keep a record of food and drink the person consumes. Include the type of food and drink and how much of each they consume (see Appendix 4). Sometimes a change of scene makes all the difference. Everyone likes to go out for dinner or on a picnic occasionally. Even changing the dining area decor may lift jaded appetites. Ask yourself these questions about the food being served: Is the menu varied and appealing? Is the food appropriately cooked and well presented? Is the temperature of the food appropriate? Does the food taste good? Are there any distractions in the dining area? Is the person being encouraged to eat in a positive way?
Is the persons
fluid intake usually low? If yes, this is also a nutrition risk.
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Fluids Inadequate fluid intake can lead to dehydration and, if severe and sustained, can be life threatening.
Some causes of dehydration Lack of thirst, particularly in the elderly Communication problems Swallowing problems Use of diuretics Abuse of laxatives Uncontrolled diabetes Inadequate supervision of tube feedings Spillage of drinks
Some signs of dehydration Deterioration in cognitive status, skills or abilities Urinary tract infections Dizziness /vertigo Constipation Decreased urine output Dry lips and mouth Sunken looking eyes Swollen tongue Hypotension Poor appetite
Adults should have at least six large glasses of fluid each day. They may need more in very hot weather. Fluids include: water tea coffee gelato milk jelly custard ice cream soup cordial fruit juices yoghurt
Some people may not be able to communicate their thirst and need for a drink, especially in hot weather. Make sure the person is offered a drink with each meal, and at least once in between meals and at supper time. Adequate hydration is also important for people receiving tube feeds. It is essential that instructions given for water flushes be followed. More water may be needed in hot weather. Coffee and cola-based drinks contain caffeine and have a diuretic effect (they make you pass urine). Encourage other drinks if you are concerned the person is not getting enough fluids. Milk is the preferred drink for children, followed by water. Tea and coffee are not recommended for children.
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Ensure the person is alert and focused while drinking. Use an appropriate cup. If you try the above suggestions and the person still has a reduced appetite or reduced food or fluid intake after two months and you are worried about weight loss or inadequate diet, refer them to a health specialist. If a person becomes dehydrated and will not take fluids they should be taken to a doctor or hospital emergency urgently. See also SECTION 3 Promoting weight gain SECTION 2 Healthy eating SECTION 4 Food and drugs SECTION 4 Enteral nutrition Referrals Doctor, dietitian, psychologist
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Question 9.
Does the person follow, or are they supposed to follow a special diet? Things to consider Special diets (some times called modified diets or therapeutic diets) usually restrict the amount or variety of foods that can be offered. Unless care is taken, nutritional problems can occur. Does the person have a medical condition that, to your knowledge requires dietary treatment (i.e. a special diet)? Examples of medical conditions usually requiring special diets are diabetes, heart disease, high blood pressure and Coeliac Disease. There are many special diets. Some are listed below: Texture-modified diets such as pureed, minced, chopped or soft foods; Thickened fluids; Weight-reducing or weight-increasing; Low fat; Vegetarian; Low-cholesterol or cholesterol-lowering; Diabetic; Dairy-free, lactose-free; Allergy diets. Note: Food which is pureed may also be referred to as blended or vitamised. Food is placed in a food processor or is mashed and then sieved. All terms mean food which is smooth but not runny. Things you can do
Only put
someone on a special diet after consulting with them, significant others and with the knowledge and approval of a doctor.
Only put someone on a special diet after consulting with them, significant others and with the knowledge and approval of a dietitian or a doctor. The aims of the diet should be identified and the diets effectiveness checked and reviewed regularly (about every six months). If you are in doubt about the appropriateness of a special dietary program, refer the person to a dietitian. If a special diet is required for a specific treatment, make sure the diet guidelines are followed very carefully. See also SECTION 4 Diet and special health conditions Referrals Doctor, speech pathologist, dietitian
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Question 10.
Does the person take multiple medications? Things to consider Carers need to be aware of the effect of medications on the nutritional status of the person. Some medications (drugs) interact with food or with particular components of food. This may mean that a medication can affect the persons nutrition. The more types of medication a person takes the more complex may be the interaction with the persons nutrition. The dosage of medications and when and how they are taken can also be important factors that affect nutrition. It is worth finding out what possible effects may occur with each medication the person takes. This information is called the drug-nutrient interactions. Medications can depress or increase appetite or thirst. Some also affect the taste of food. Others may cause nausea or vomiting, drooling or a dry mouth which can make it difficult to swallow food. Weight increase, weight decrease, constipation, diarrhoea and difficulty eating should be assessed with relation to the medications the person is taking. Things you can do Be aware that drugs can influence nutrition and check with the doctor if you are concerned. Make sure that a doctor regularly reviews medication, especially when used over a long period of time and in combination with other drugs. Check that you have information on correct administration of drugs, such as the correct timing in relation to meals. Do not assume that a side effect is inevitable or that nothing can be done about it (e.g. a weight-control program may be important while a person takes an anti-psychotic drug). See also SECTION 4 Food and drugs Referrals Doctor, pharmacist.
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Question 11.
Does the person select inappropriate foods or behave inappropriately with food? Things to consider Inappropriate behaviour with food can be harmful to health. Over consumption of alcohol or drinks such as coffee, cola or tea is behaviour indicating a possible addiction. Alcohol and caffeine are damaging to a persons health if taken in large amounts often. Coffee and cola drinks contain caffeine, as does tea to a lesser extent. Other inappropriate food behaviours include: Compulsive-type eating; Aggressive or disruptive throwing of food; Rumination and regurgitation; Eating non-food items such as dirt, grass or faeces; Drinking excessive amounts of fluid (more than 2.5 litres per day); Stealing or hiding food. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do Discuss the apparent addictive behaviour with the person to ascertain their knowledge and understanding of the consequences of their behaviour. Seek advice from professional drug and alcohol counselling services where relevant. Encourage low caffeine or caffeine-free drinks as substitutes for high caffeine drinks (e.g. decaffeinated coffee, caffeine-free soft drinks). Concerning other behaviours with food such as aggression, disruption and eating non-food items, assess the persons environment when this behaviour occurs by asking: Are there any distractions in the dining area? Is the person being encouraged to eat in a positive way? Has there been a change to medication? Is the person constipated? Is the person dehydrated? Is the person in pain? Do they have problems with mouth, teeth or swallowing? Is the person positioned correctly and comfortably? Is the person alert enough to eat? 28 NUTRITION IN PRACTICE MANUAL
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Sometimes these behaviours may be prompted by an underlying medical problem. Assessment by a medical specialist can be helpful. Often these behaviours require support programs. Refer the person to a psychologist or educational programmer. See also SECTION 2 Healthy eating SECTION 5 Eating difficulties Referrals Doctor, drug and alcohol counselling services, psychologist, educational programmer, dietitian, occupational therapist, speech pathologist, dentist, physiotherapist.
Sometimes
these behaviours may be prompted by an underlying medical problem. Assessment by a medical specialist can be helpful.
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Question 12.
Does the person usually exclude foods from any food group? Things to consider
If someone
regularly misses all foods from one or more of the five food
groups their diet is imbalanced and they may develop a nutritional deficiency.
If someone regularly misses all foods from one or more of the five food groups, their diet is imbalanced and may result in nutritional deficiency. If the person does not eat a sufficient variety of foods within any one food group they may also in time develop a nutritional deficiency. The five food groups for healthy eating are: Bread, cereals, rice, pasta, noodles;
Vegetables, legumes; Fruit; Milk, yoghurt, cheese; Meat, fish, poultry, eggs, nuts, legumes. These foods provide all the important nutrients the body needs for good health. We eat other foods (such as cakes, biscuits, lollies, pies, pastries, crisps, margarine, oils and alcohol) for enjoyment. These foods can usually be included in a diet in small amounts or eaten occasionally. Some people are picky eaters or refuse to eat certain groups of foods such as vegetables. If your answer to the question is Unsure/Do not know, refer to a health specialist.
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Things you can do Some people may be picky eaters or routinely refuse to eat foods such as vegetables. If the person is refusing to eat food, ask yourself these simple questions: Is the menu varied and appealing? Is the food appropriately cooked and well-presented? Is the temperature of the food appropriate? Does the food taste good? Are there any distractions in the dining area? Is the person being encouraged to eat in a positive way? Has there been a change to medication? Is the person constipated? Is the person dehydrated? Is the person in pain? Does the person have problems with mouth, teeth or swallowing? Is the person positioned correctly and comfortably? Is the person alert enough to eat? If there continues to be a problem, refer the person to a doctor or dietitian. See also SECTION 2 Healthy eating Referrals Doctor, dietitian.
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Question 13.
Does the person get constipated? Things to consider Constipation can cause reduced appetite, discomfort, pain and sometimes abdominal bloating (swelling of the stomach). The persons distress may cause behavioural problems. Constipation sometimes leads to impaction (food or faeces becoming lodged in the bowel). This can be accompanied by overflow which is sometimes misinterpreted as diarrhoea. Constipation may be due to: Inadequate fluid intake; Insufficient fibre in the diet; Lack of exercise; The side-effects of medication; Neuromuscular dysfunction (the nerves and muscles not working properly). Constipation management should preferably be through diet rather than long term use of laxatives. If there is any sign of blood in the persons stool refer to a doctor immediately. If your answer to the question is Unsure/Do not know then refer to a health specialist. Things you can do You may find it helpful to: Ensure the persons fluid intake is adequate; Increase fibre intake once you are sure that the person is taking adequate fluid; Encourage exercise where possible; Develop a regular routine for toileting. If these simple steps do not work, refer to a dietitian. If constipation does not improve with dietary treatment there may be a serious underlying medical problem. Refer the person to a doctor. If the person is receiving tube feeds and they are constipated a review should occur of feeding program including total volume and type of formula used. See also SECTION 2 Dietary fibre SECTION 2 Fluids Referrals Doctor, dietitian, physiotherapist, educational programmer
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Question 14.
Does the person have frequent fluid-type bowel movements? Things to consider Frequent fluid type bowel movements may mean diarrhoea. Diarrhoea poses a high nutritional risk and risk of dehydration. Fluid and nutrients may not be absorbed well enough from the gastrointestinal tract. If an adult has one or two fluid type bowel movements, it may not be a cause for concern. A sudden occurrence of diarrhoea is usually due to infection, and usually does not last for more than two weeks. Soft formed motions (stools) are not diarrhoea. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do Anyone who gets diarrhoea regularly should have a medical assessment. If a child has diarrhoea for more than one day, seek medical attention within one day. If an adult has diarrhoea for more than two days, seek medical attention within two days. Special diets for diarrhoea should be reviewed by a dietitian if followed for more than two weeks. If the person is receiving tube feeds and they have diarrhoea, a review should occur of the feeding program including feeding procedures and the type of formula used. See also SECTION 2 Fluids Referrals Doctor
Frequent fluid
type bowel movements may mean diarrhoea. Soft formed motions (stools) are not diarrhoea.
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Question 15.
Does the person have mouth or teeth problems that affect their eating? Things to consider Difficulty chewing and swallowing can easily lead to inadequate food and fluid intake and a dietary imbalance. The ability to chew food is generally dependant upon the presence and condition of the persons teeth. Chewing and swallowing problems may be caused by: Loose, broken, decayed or missing teeth; Malocclusion (when the upper and lower teeth do not meet properly); Poorly fitting dentures; Sore, bleeding or ulcerated lips, gums or throat; Poor oral hygiene (leading to gum and teeth problems); Too little or too much saliva; Irregular tongue movement; Poor lip closure; Certain medications; Some nutrient deficiencies; Reflux. If your answer to the question is Unsure/Do not know, refer to a health specialist.
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Things you can do If a person has no teeth and dentures are unable to be fitted, modification to the normal textures of food will be required. Alternative foods should be provided to those that are difficult to break down with gums alone (e.g. pancakes are easier to break with gums than bread). Food may need to be chopped or minced or prepared to a soft texture. See SECTION 5 Food textures. Visit the dentist annually (or more frequently if advised by the dentist). Ensure that teeth are cleaned properly and effectively. Develop an individual oral care plan with the dentist or dental hygienist (see Appendix 3 for suggested format). Change toothbrush every three to four months or when bristles flatten or become worn. Brush teeth after each meal (or as a minimum twice daily). Brush teeth on average for two minutes each time. See also SECTION 2 Oral hygiene SECTION 5 Food textures Referrals Doctor, dentist, dental hygienist, speech pathologist, dietitian
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Question 16.
Does the person suffer from frequent chest infections, pneumonia, asthma or wheezing? Things to consider
Chronic
cough, multiple chest infections or recurrent wheezing could indicate that food, fluid or saliva is being inhaled or passed into the airway (this is called aspiration).
It is often hard to work out the origin of a chest infection or pneumonia. Chronic cough, multiple chest infections or recurrent wheezing could indicate that food, fluid or saliva is being inhaled or passed into the airway (this is called aspiration). Anything that is swallowed has the potential to be inhaled into the airway (food, fluid, medications, bacteria in saliva and refluxed food or vomitus). People who aspirate do not always cough at mealtimes. They may wake up coughing, wheezing or breathing noisily or they may cough, wheeze or breathe noisily sometime after a meal. Asthma or wheezing has been linked to reflux (contents of the stomach coming back up the food passage). Pneumonia may be a consequence of gum disease. If your answer to the question is Unsure/Do not know then refer to a health specialist. Things you can do People at risk (about whom the answer to this question is Yes) need to be assessed by a doctor. In the meantime, make sure the following occurs: Clean teeth after each meal to reduce the amount of bacteria in the mouth; Ensure the person is eating under the best possible conditions. This means that the person is: Seated upright with good support; Able to reach food easily; Able to use the cutlery to feed themselves if they eat independently; Not eating too much at each mouthful or trying to eat too quickly; Not being fed too quickly if they require assistance to eat.
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Sit the person upright for at least half an hour after meals. Follow the prescribed eating and drinking plan. If the person is receiving tube feeds and they have frequent chest infections, pneumonia, asthma or wheezing, a review should occur of their feeding program including feeding procedures, position during feeding and their oral hygiene program. See also SECTION 2 Oral hygiene SECTION 5 Positioning for mealtimes, mealtime management, eating difficulties, equipment Referrals Doctor, speech pathologist, physiotherapist, occupational therapist.
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Question 17.
Does the person cough, gag and choke or breathe noisily during or after eating food, drinking, or taking medication? Things to consider
Coughing or
choking during or several minutes after a meal may indicate that food, fluid or saliva has entered the airway.
Coughing or choking during or several minutes after a meal may indicate that food, fluid or saliva has entered the airway. Gagging will make eating difficult. Noisy breathing suggests that food or fluid may be blocking the airway. People who aspirate do not always cough at mealtime. They may wake up coughing, wheezing or breathing noisily or they may cough, wheeze or breathe noisily sometime after a meal. The texture and consistency of the food may not be appropriate. It is possible that food is refluxing from the persons stomach into their oesophagus. It is possible that weak muscle movement in the oesophagus is slowing the movement of food down to the stomach. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do People at risk (about whom the answer to this question is Yes) need to be assessed by a doctor. In the meantime, make sure the following occurs: At meals Make sure the person is sitting upright. Make sure the persons mouth is clean. Try cleaning the mouth or brushing the persons teeth before as well as after a meal. Make sure dentures are in place for meals. If dentures are loose, a denture adhesive may be needed. You can buy these from the chemist. Feed slowly. You may need to supervise or provide prompts to slow down eating. The person feeding should sit in front of and at the same level as the person. Use a teaspoon to ensure small amounts are taken at a time. Encourage a forward head position with the chin down towards the chest when swallowing. Do not allow the persons head to tilt backwards. Allow time between mouthfuls of food for the person to rest and for food to reach the stomach.
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Food If the person cannot chew, try cutting, chopping or pureeing food. The taste of some foods may cause gagging. Keep a record of food and drink the person consumes to work out their likes and dislikes (see Appendix 4). Dry food and some food textures can cause gagging. Try adding sauces, gravies, margarine or butter to moisten food. Liquids If the person coughs when drinking, try thickening the liquid. However, remember that a decision for on-going use of thickened fluids should be made by a speech pathologist that has thoroughly assessed the persons swallowing ability. Medication If the person coughs when taking medication, ask your chemist if the medication can be crushed and taken with food. Always give medication with sufficient liquid (thickened or otherwise) to ensure it passes down the oesophagus and into the stomach. Some antibiotics should not be given with dairy products. Avoid honey and jam if the person has difficulty taking food from a spoon. See also SECTION 2 Oral hygiene SECTION 5 Mealtime management, positioning for mealtimes, food textures, modifying fluid consistency Referrals Doctor, speech pathologist, chemist, dentist, occupational therapist, physiotherapist
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Note: This question is not applicable to infants under 12 months of age.
Question 18.
Does the person vomit or regurgitate on a regular basis? Things to consider Vomiting or regurgitating (bringing up) food regularly is not normal for anyone older than one year of age. Vomiting or regurgitation may cause pain. Sometimes people develop a habit of vomiting or regurgitating food. Vomiting or regurgitation may indicate a blockage or slow movement down the food passage (oesophagus). Occasionally vomiting or regurgitating food may be a sign that the person has a reflux problem (stomach contents coming back up into the lower oesophagus). Is the person on an anti-reflux medication, and if so, is this being periodically reviewed by a doctor? Vomiting may be associated with eating too quickly, poor chewing or gorging food. Some medications can cause vomiting. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do
If the person
has ever vomited blood, whether bright red blood or old blood such as black flecks or coffee grounds, and this has not been medically investigated, refer them to a doctor immediately.
If the person has ever vomited blood, whether bright red blood or old blood such as black flecks or coffee grounds and this has not been medically investigated, refer them to a doctor immediately. If gagging on food causes the vomiting, try smooth food without lumps, or pureed food. Add sauces or gravy. Make sure the person sits upright while eating and for at least 30 minutes after eating. If vomiting continues seek immediate medical assistance. If vomiting or regurgitation appears to be a habit, a psychologist can help develop a management plan. Refer to a doctor if vomiting is suspected to be a side effect of a medication. If the person is receiving tube feeds and they vomit or regurgitate, a review should occur of feeding procedures including rate of delivery and positioning of the person during and after feeding. See also SECTION 5 Mealtime assistance SECTION 2 Oral hygiene Referrals Doctor, speech pathologist, psychologist, educational programmer, occupational therapist, dietitian
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Section 1
Question 19
Does the person drool or dribble saliva when resting, eating or drinking? Things to consider Drooling may be: Related to lack of awareness to swallow saliva; A side-effect of medication; Associated with reflux (food or drink coming back up from the food
passage or stomach).
Excessive drooling may cause coughing and this can cause saliva to enter the airway. When does the person drool most? If it is after a meal this could be a sign of a reflux problem. If the person is receiving tube feeds and they drool or dribble saliva it is important that they have a good oral hygiene program. Things you can do Remind the person to close their mouth, chew and swallow. Make sure the person is in the right position to allow lip closure. Try closing their lips manually. Reduce mealtime distractions to encourage concentration on swallowing food and saliva. Sit the person upright for at least 30 minutes after meals. Maintain strict oral hygiene, cleaning teeth after each meal. See also SECTION 2 Oral hygiene SECTION 5 Mealtime management, positioning for mealtimes, eating difficulties. Techniques explained in things you can do section for Q 20 (see page 42). Referrals Doctor, pharmacist, specialist dental clinic, speech pathologist, physiotherapist, occupational therapist.
Excessive
drooling may cause coughing and this can cause saliva to enter the airway.
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Question 20.
Does food or drink fall out of the persons mouth during eating or drinking? Things to consider Difficulty closing the mouth can cause food and drink to fall out. The rate of feeding may be too fast causing food or drink to fall from the mouth. The quantity of food or drink may be too much causing food or drink to fall from the mouth. Poor tongue control, such as tongue thrust, can push food out of the mouth. The person may have reduced or increased oral sensitivity. Pain in the mouth can cause a reduced ability to eat and drink. The persons ability to open or close their mouth can affect their ability to hold food in their mouth. When a person is drowsy, their ability to eat well is affected. It may cause food to fall out of their mouth. A person who loses a significant amount of food or liquid from the mouth may not be getting enough to eat or drink. Things you can do General
Do not give
food, drink or medication to a person if they are drowsy.
Do not give food, drink or medication to a person if they are drowsy. If persistent drowsiness prevents the person from eating and drinking enough, or is a new symptom, seek immediate medical advice. If the person cannot chew, check that their dentures fit. You can buy dental adhesive from the chemist. Try cutting up or pureeing food. Avoid dry, crumbly food. If gums are sore, you can apply a topical gel (from the chemist) for temporary pain relief. If this persists, seek dental advice.
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Techniques Remind the person to keep their lips closed when eating, or support their chin with your index finger (the finger next to your thumb) and their bottom lip with your middle finger. Make sure the person is seated upright with their feet firmly supported (on the floor or a footrest). The persons head must be upright, with the chin slightly tucked in, not jutting out. Do not extend the persons head back or feed them from behind. See SECTION 5 Positioning for mealtimes for more information on positioning. Consult a physiotherapist or occupational therapist for further advice on seating. Try different utensils. If the spoon you are using is too big, you may be giving the person too much food at one time. Try a teaspoon. If the problem is mainly with drinks, try a cup with a smaller opening. Do not use spouted cups, as pouring liquid into the mouth will not help in this situation. An occupational therapist can give you advice about utensils. Nutrition Sometimes it is unclear how much food a person is actually eating when they lose some of it from their mouth. If clothing or a protector becomes very wet or covered with food, this is an indication that the person is not swallowing all that is offered. If you are worried about weight loss, see Questions 1, 2 and 3. If the person is an adult and has difficulty eating solids, try softer foods. Use puree only as a last resort as it is more difficult to obtain adequate nutrition from a puree diet. Do not leave someone on a long-term pureed diet without review by a dietitian. See also SECTION 2 Oral hygiene SECTION 5 Mealtime management, equipment, food textures Referrals Doctor, speech pathologist, dietitian, physiotherapist, occupational therapist, dentist.
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Question 21.
If the person eats independently, do they overfill their mouth or try to eat very quickly? Things to consider Overfilling the mouth or stuffing food into the mouth may be a sign of sensory or oral-motor control difficulties. Overfilling the mouth may be one of the ways the person compensates for these difficulties. It may also be related to long-standing behavioural issues. Some people eat very quickly. This may be a learned behaviour or associated with their disability. When people eat too quickly they may not take enough time to chew their food. This can result in large pieces of unchewed food being swallowed. In some cases it can cause choking. Choking can also occur during drinking. Consider the effect of the persons environment (e.g. are others in the mealtime group stealing food? If so, the person may eat quickly because they are afraid someone will take their food). Things you can do Sit with the person at mealtime and encourage them to eat more slowly. Limit the amount of food provided at one time. For example, only give a quarter of a sandwich, then another quarter only after the person has finished eating the first portion. Just cutting the food into smaller pieces may not be enough, as the person may still put two or three pieces in their mouth at one time. If the person is drinking too quickly, put less in their cup at one time. Give the person a teaspoon, rather than a dessert spoon, to slow the rate at which they are eating. Supervise them to make sure they are still not overloading their mouth. Make sure you allow the person enough time to eat their meal at a relaxed pace. If they feel you are rushing the meal they may try to eat quickly. Ensure that the dining environment is relaxed and free of distractions. Allow sufficient time for all meals. See also SECTION 5 Mealtime assistance Referrals Speech pathologist, occupational therapist, psychologist, educational programmer
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Question 22.
Does the person appear to eat without chewing? Things to consider Eating without chewing may occur when a person has: No teeth; Gum disease or a painful mouth; Poorly fitting dentures. Some people may have an undeveloped chewing action. Does the person appear to suck their food instead of chewing it? Does the person hold their food in their mouth for an extended time before swallowing? Does the person appear to swallow their food without preparatory chewing? Rushed meals or fast eating for any reason may also result in food not being chewed. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do Check the persons mouth, teeth and gums for obvious signs of problems. If the person has dentures, check that they fit correctly. Try cutting up food finely and ensure that meat is tender. Sit with the person at mealtime and ask them to slow down if they are eating too quickly. Limit the amount of food given at one time (e.g. give a quarter of a sandwich, then another quarter only after they have finished eating the first portion). Consider the effect of the persons environment (e.g. are others in the mealtime group stealing food? If so, the person may eat quickly because they are afraid someone will take their food. Are you allowing them enough time to eat their meal, or do they feel rushed?). See also SECTION 2 Oral hygiene SECTION 5 Mealtime assistance Referrals Speech pathologist, dentist, occupational therapist
Note: This question does not apply to people on a pureed diet because puree food does not need chewing.
chewing may occur when a person has no teeth, gum disease, a painful mouth or poorly fitting dentures.
Eating without
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Question 23.
Does the person take a long time to eat their meals? Things to consider People eat slowly for a number of reasons. Eating may be associated with pain or it may be difficult because they cannot coordinate their mouth and throat muscles. Does the person eat slowly because they are not hungry at meal times? Sometimes if there is not a long enough period between one meal and the next the person is not hungry. If you have noticed that the person eats best at breakfast, they probably need more time between meals to feel hungry again. Alternatively they may eat better if they can eat smaller meals more frequently. The person may eat slowly because they do not like the food. Some medications can reduce appetite. Some medications can cause nausea which in turn reduces appetite. Eating very slowly may be associated with reflux or with slow movement of food down the oesophagus. Things you can do Try small frequent meals rather than three large meals per day. Does the food need to be substituted with something softer or cut into smaller pieces? Sometimes it helps to enhance the flavour of food with spices, tomato sauce, a squeeze of lemon or sugar. Always endeavour to serve food at the correct temperature to ensure the best flavour. Is the food visually appealing? Food that looks and smells good will stimulate appetite. Keep foods separate, so they can be identified according to shape or colour. For example, do not mix all pureed food into one mass. Keep it separate as carrots, peas and meat. Tell the person what each food is as you give it to them.
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If the person eats independently, do they have the correct equipment? Would they be better off with specialised cutlery or crockery? Talk to an occupational therapist about this. Is lack of teeth, toothache or painful gums stopping them from eating? Is their mealtime environment pleasant? Can anything be changed to make it better? Is the person upset by their environment and therefore reluctant to eat? For example, are others in the group noisy or disruptive? Would the person be better in another group, or can the people causing the disruption be distanced or removed? Is the loss of appetite unusual and associated with other symptoms of illness? Seek medical advice if you are concerned. See also SECTION 5 Mealtime management, equipment Referrals Speech pathologist, dietitian, occupational therapist, doctor.
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Question 24.
Does the person show distress during or after eating or drinking? Things to consider
showing distress during eating or drinking or shortly afterwards may be aspirating food or drink. (i.e. food or drink may be going into the airways).
A person
A person showing distress during eating or drinking or shortly afterwards may be aspirating food or drink. (i.e. food or drink may be going into the airways). If the person does not choke, gag or cough they still could be aspirating food or drink. Another reason for the persons distress may be pain associated with meals, particularly if they cannot communicate their pain in any other way. The person may be showing their distress by refusing food or spitting out food. Their distress is unlikely to be simply attention-seeking behaviour. If your answer to the question is Unsure/Do not know, refer to a health specialist. Things you can do Investigate causes of possible pain whilst the person is eating. Look inside the persons mouth for obvious signs of mouth, teeth or gum problems. If the person is dependent on others to feed them make sure that they have an up to date eating and drinking plan and that all carers follow the plan. If the person has not been assessed for swallowing problems consider referring them to a speech pathologist for assessment. Supervise meals. Be aware of food likes and dislikes. Avoid distractions. Arrange different mealtimes to others. Offer small regular meals. Offer flavoursome, attractive meals that will stimulate the persons appetite. Reassure and guide the person in appropriate mealtime behaviour. See also SECTION 5 Mealtime management
Referrals Speech pathologist, doctor, dentist, dietitian, occupational therapist.
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Good nutrition for good health
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DUTY OF CARE: What is it?

Duty of care is the obligation to take reasonable care to avoid causing harm to another person. Reasonable in this context means the degree of care that could be expected from a competent and skilled person in the particular job. Duty of care is breached if the action taken does not reach the required standard of care, or if there is a failure to act when it could reasonably have been expected. This means that care workers should think sensibly about what they are doing and the needs of the client. The care worker may not intend to cause harm but if they do something that is likely to cause harm (e.g. laying a person down to eat their meal, rushed feeding, not monitoring an eating and drinking plan), they may be held to be negligent. A breach of a duty of care may occur where reasonable steps have been taken to avoid harm or injury. This can occur by a carer doing something that they should not have done (e.g. using inappropriate positioning of a person being fed) or failing to do something that they should have done (e.g. failure to implement a prescribed special diet). In delivering a service to people with a disability care workers should: Use common sense, and respect the person and his/her rights. Ensure that recommendations by health specialists (e.g. psychologists, dietitians, physiotherapists and speech pathologists) are carried out to the best of their ability. Ensure that staff for whom they are responsible are competent to assist a dependent person to eat and drink adequate amounts of food in a safe manner. If you are in doubt as to your responsibilities, you should discuss this with your supervisor. Consider the scenarios on the following pages.
If you are in
doubt as to your responsibilities, you should discuss discuss this with your supervisor.
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Scenario One A person sits in a wheelchair for meals and requires assistance with eating and drinking. The person is on a soft diet and thickened fluids. Once a month you take the person out for an activity and lunch. A popular fast food outlet is the choice of restaurant and you purchase a hamburger, chips and cola. Question: How is this compatible with a duty of care? Considerations Texture and consistency of foods if inappropriate for a person, can increase the risk of choking and potential aspiration pneumonia. You are a role model to those people in your care. A person with a disability can experience different food flavours without changing from the recommended consistency of their diet. The consistency of food recommended for the person by the speech pathologist or dietitian is for their own benefit and other consistencies may have detrimental effects or increase the persons risk of choking.
Answer
It is not compatible. A duty of care requires each of us to take such steps as are reasonably possible to avoid foreseeable harm to someone for whom we have responsibility. By choosing this type of fast food, it is foreseeable that the person may be placed at risk if consuming foods that are not of the recommended consistency. The cola is not a thickened drink and therefore places the person at risk of inhaling the fluid and potentially developing aspiration pneumonia. The hamburger and chips would also not usually be considered as part of a soft diet. It is easy to avoid this by eating elsewhere or choosing a different menu. Elements necessary for the duty of care to be breached are therefore present. Possible Actions Discuss appropriate activities and meals with the persons dietitian or speech pathologist. Take food with you (picnic style) that is consistent with dietary recommendations and the needs of the person. Take thickening agents with you to add to drinks. Select a food court where often a variety of soft foods can be found to purchase. Request further professional development to improve understanding of the recommendations.
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Scenario Two A person consumes at least one can of cola each day and large quantities of coffee. This has been his habit for years and he has a clear preference for these drinks. Question: How is this compatible with a duty of care? Considerations The ability of the person to make decisions using available information is relevant. Having the habit for years does not make it right to continue this behaviour. It will be challenging for both staff and the person, but this should not deter endeavours to improve the persons health.
Answer
It is not compatible. Large quantities of caffeine (found in coffee and cola) are detrimental to the persons health. This is particularly the case for people who take psychotropic medications and those with reflux. Even though the person appears to enjoy drinking cola and coffee we know that it is foreseeable that this could harm him. You can take action to avoid this harm by consulting with a dietitian and the behaviour intervention and support staff regarding management of what appears to be a caffeine addiction. Not taking this action could be the breach of the duty of care. Possible Actions Refer to a dietitian for substitutes/alternatives for gradual reduction in the persons caffeine intake. Refer the person to behaviour intervention and support staff for strategies to change the persons behaviour.
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Scenario Three A person sits in front of the television to eat their meals. The health specialist has recommended the removal of distractions to reduce the risk of the person choking and developing potential aspiration pneumonia. However, the person prefers to watch the television during meals and you continue to let him or her do so. Question: Should you respect the persons preference or does your duty of care to reduce their risk of choking override this? Considerations Informed decision making entails having a general understanding of the consequences of a decision. The maturity and ability of the person can have a significant bearing on whether an informed decision has been made. Consider having an independent person involved to help the person make a decision if they do not understand the recommendation.
Answer
Better practice would be to provide alternatives to watching television during mealtimes and trial different situations that may appeal to the person, but also reduce risks. Possible actions Suggest that the television program be taped and viewed later so the meal can be eaten in safety. Could mealtime be moved so meal times and the television program do not clash? Provide education to the person about risks associated with eating in front of the television and alternatives to minimise risk. Request further professional development for improved understanding of the recommendations.
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Scenario Four A person who requires assistance to be fed and has severe gum disease. In order to treat the gum disease, the person requires physical support, sometimes with restraint, to carry out oral hygiene procedures. Question: How is this compatible with a duty of care? Considerations What is the persons dental history?
Answer
As oral hygiene is paramount in controlling/reducing gum disease, these procedures are consistent with duty of care. Active oral hygiene management is essential to prevent further medical complications. However, any type of restraint or physical assistance program for oral hygiene will require appropriate consent. Furthermore, the need only justifies the minimum form of restraint which will permit oral hygiene it does not give carte blanche for any type of restraint. It is also important to get advice about the best way to provide support to ensure correct positioning and techniques to assist with oral hygiene. Possible actions Refer the person to behaviour intervention and support staff for an oral hygiene program to make the activity less traumatic for the person, and if possible increase independence. Refer the person to dentist to receive an oral hygiene plan for advice on alternative techniques.
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HEALTHY EATING
Good nutrition is essential for good health for people of all ages. Healthy eating: Promotes growth and development in children and adolescents; Helps prevent deficiency states such as iron-deficiency anaemia; Reduces the risk of chronic (long-term) diseases such as heart disease, diabetes, hypertension, and osteoporosis; Helps prevent constipation; Improves awareness and concentration; Increases resistance to infection; Improves blood circulation; Helps improve muscle function. The five food groups The five food groups are represented in the Australian Guide to Healthy Eating on page 57. They are: Bread, cereals, rice, pasta and noodles;
Vegetables and legumes;
Fruit;
Milk, yoghurt and cheese;
Meat, fish, poultry, eggs, nuts and legumes.
These foods provide all the important nutrients the body needs for good
health. Other foods such as cakes, biscuits, lollies, pies, pastries, crisps, margarine,
oils and alcohol are consumed for enjoyment. These can usually be included in
a healthy diet in small amounts or if eaten infrequently.
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The Australian Guide to Healthy Eating.
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Variety
Variety is a key to good nutrition. Eating from a wide range of different foods within each of the food groups helps ensure a person gets all the nutrients they need. Foods also contain substances other than nutrients which may have health benefits. For example, antioxidants may help the bodys resistance to certain diseases. Food variety is truly the spice of life. Different colours, tastes, smells and textures make life more interesting and enjoyable.
Bread, cereals, rice, pasta and noodles

Most people should have a minimum of five serves each day from this group.
Food Serving Tips

Serving tips for bread, cereals and rice Try different types of bread including rye, rolls, foccacia, pita breads, lavash and other flat breads. Eat more wholegrain bread, high fibre cereals, brown rice and wholemeal pasta. Add cereals such as oats to recipes, or breadcrumbs to meatloaf, or pasta or barley to soups. Try cereal foods which may be unfamiliar such as couscous, polenta or cornbread. Replace white flour with 50/50 wholemeal flour in baked products such as scones, muffins and slices. Very well cooked rice blended with egg makes an ideal base for savoury baked dishes.
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Vegetables and legumes

Most people should eat a minimum of five serves of vegetables each day. Vegetables should be cooked lightly and stored hot for short periods of time only. Many vitamins are destroyed when vegetables are over cooked or stored hot for too long. Include raw or fresh vegetables if they can be safely chewed and swallowed. Frozen and canned vegetables are nutritious if not overcooked. Choose a mixture of colours such as green, yellow and orange varieties.
Frozen
Food Serving Tips

Serving tips for vegetables Serve as finger foods for those who have the motor skills to manage these. Add to soups, stews and casseroles. Add to omelettes, scrambled eggs and quiches. Add to stir fry dishes. Grate and add to baked foods such as carrot cakes and zucchini slices. Mash and add to cooked foods such as pumpkin scones. Add legumes such as lentils, mixed beans and chick peas to soups and casseroles.
and canned vegetables are nutritious if not overcooked.
The information on smooth vegetables and fruits which follows in this section has been reproduced with permission from: Lane, M. & McLaughlin, L. (1999) Smooth Food Practical Food and Nutrition Guide for Parents and Carers of Children with Eating and Swallowing Problems, Disability Services Commission, Government of Western Australia.
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Smooth food vegetable hints Cook fresh, peeled vegetables in a small amount of water until soft, then mash or blend. Cook frozen vegetables (e.g. carrot, cauliflower and broccoli) in a small amount of boiling water until soft (they will cook faster than fresh vegetables), then mash or blend. Some canned vegetables (e.g. potato, tomato or asparagus) may already be soft enough. Others may need mashing or blending. Common problems with smooth vegetables Vegetables may still have hard pieces after cooking. You can overcome this by sieving. Some vegetables, (e.g. celery), are stringy even when cooked and should be avoided. Some vegetables with husks (e.g. peas and corn) are not softened by cooking and should be avoided by those on a Smooth Thick diet (see SECTION 5 Food textures). Avoid raw vegetables with a high water content. These are liquid with fibrous lumps when blended (e.g. lettuce, cucumber and other salad vegetables). Add interest to smooth vegetables Cook vegetables in small amounts of water and use the liquid to add flavour to gravies and sauces (the vegetable water does not add to the nutritional value). Add fresh or dried herbs and spices for flavour when boiling, steaming, microwaving or soft roasting vegetables. Add interesting sauces such as white sauce, BBQ, plum, soy, hoi sin, tomato or chilli sauce. Add a squeeze of lemon or lime juice just before serving this lifts broccoli and green beans. Add margarine, butter or mayonnaise to mashed or other cooked vegetables. Use strongly flavoured vegetables (e.g. garlic, onion or leek) to lift the taste of other vegetables.
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Smooth vegetable recipe ideas Frittata use leftover cooked vegetables (e.g. potato, leek, pumpkin and sweet potato), pour over whisked eggs, cheese and herbs, then bake. This is delicious hot or cold. Au Gratin boil, steam or microwave vegetables (e.g. cauliflower, broccoli or mixed vegetables) until tender, pour over white sauce, top with cheese, then bake in the oven. Soft stir fry use ingredients for stir-fry avoiding stringy vegetables (e.g celery and snow peas). Cut vegetables finely and when steaming with stock in the last stage, cook until very soft. (Note: Not suitable for a Smooth Thick diet. See SECTION 5 Food textures). Soft roasted vegetables roast vegetables in a little fat such as olive oil, add some stock and cook until tender. If browning or crisping pour on more stock or cover with a lid or aluminium foil. Potato, pumpkin, carrot, sweet potato, tomato, leek and capsicum are all delightful cooked in this way. Vegetables in casseroles add vegetables (e.g. pumpkin, carrot, sweet potato, onion, tomato and spinach) to casseroles. Salads with mayonnaise combine soft cooked vegetables (e.g. potato, carrot, sweet potato) with mayonnaise, herbs and spices. Hearty vegetable soups use boiled, steamed, microwaved or oven-roasted vegetables combined with stock or add milk and a little cream for a delicious cream soup. Other ideas for vegetables Try stuffed potato, pumpkin or capsicum. Add pesto sauce to your mashed potato. Add honey and parsley to your carrots. Mash avocado into your potato. Make a moussaka (the eggplant is soft and delicious). Make bubble and squeak with leftover vegetables, steam or lightly pan fry the patties and serve with a tangy sauce.
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Fruit
Most people
should eat at least two serves of fruit a day.
Most people should eat at least two serves of fruit a day. Fresh fruit, canned or stewed fruit are generally better choices than juices. Fruit bought in season is usually the least expensive.
Food Serving Tips

Serving tips for fruit Use in drinks such as smoothies. Add fresh or tinned fruit to jelly, flummeries and mousses. Chop or grate and add to pancakes, crepes or fritters. Add to muffins (e.g. crushed pineapple, chopped or grated apple and mashed banana). Add to baked desserts such as fruit crumble and apple charlotte. Add to savoury dishes (e.g. chicken & apricots, pork & prunes). Add to salads (e.g. pineapple slices and orange pieces). Freeze fruit segments (e.g banana chunks, rockmelon pieces and grapes).
Smooth food fruit tips Soft fresh fruit (e.g. banana, kiwi fruit, mango, pawpaw, soft pear, soft peach and strawberries) may be simply well mashed or blended. Stew peeled and seeded fruit (e.g. apple, pear, stone fruit - apricot, nectarine, peach, plum and rhubarb) in a minimum of water then mash or blend. Canned or frozen fruit (e.g. apricots, plums, pears, mangoes and berries) can be drained of syrup or juice and well mashed or blended. Use canned smooth fruit. Common problems with smooth fruit When fresh fruit is blended it can separate into fruit and liquid which is difficult to swallow. You can get around this by thickening the fruit with a little commercial thickener, cornflour, arrowroot, thick custard or thick whipped cream. Some fruit, (e.g. pineapple) is too stringy to blend to a smooth consistency. Crushed pineapple mixed with custard may be suitable for a soft diet.
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Some fruit is too watery to blend (e.g. citrus fruit such as orange, lemon, lime, grapefruit mandarin, watermelon and rockmelon). Use these fruits as juices for stewing or combined in a jelly. Bananas may be slimy and have lumps. Mash or blend bananas well to overcome this problem. Add interest to fruit Add spices when stewing, poaching or baking fruit (e.g. apple and cinnamon, pears and ginger). Add sweetness (e.g. white, brown or raw sugar or honey). Combine fruit (e.g. stewed rhubarb and strawberries, mixed berries). Add different flavours (e.g. lemon, lime or orange juice on bananas). Smooth fruit recipe ideas Baked fruit baked apple, apricot, nectarine, banana or gingered pear (try them on the BBQ). Fruit fool mix equal quantities of pureed fruit and either thick custard or whipped cream. Jellied fruit set fruit in a soft jelly and blend (e.g. canned black cherries in red jelly, pears in lime jelly). Fruit and flavoured sauces blend bananas with chocolate or caramel sauce with ice cream to make banana split; blend peaches with raspberry sauce and ice cream to make peach melba. Fruite mousee or bavarois. Fruit sponge stewed fruit with a sponge topping. Blend fruit and serve with mashed sponge with a little milk or custard. Fruit crumble stewed fruit with a soft crumble without nuts, coconut or other hard pieces. Use flour, sugar, margarine/butter and spices. Mash or blend crumble topping with a little milk or custard. Fruit cake made with fresh or canned fruit (e.g. apple, banana or with dried fruit such as dates or dried mixed fruit without nuts or coconut). Mash or blend with a little milk, fruit juice, custard or other sweet sauce. Trifle layer soft fresh, canned or stewed fruit with custard, cream, soft jelly and sponge.
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Milk, cheese and yoghurt

This group of foods provides an excellent source of calcium and other important nutrients. This group is especially important for children, adolescents and women. Everyone should include milk, cheese or yoghurt in their diet every day. The recommended quantity depends on age and whether or not a woman is pregnant or breastfeeding. The table below is a general guide.
Recommended serves Children Adolescents Men Women Women 60 years and over 2 3 serves 3 5 serves 2 serves 2 serves 3 serves
Examples of one serve of dairy food 1 cup milk 1/2 cup evaporated milk 2 slices (40g) pre-sliced cheese 1 small carton yoghurt 1 cup custard
You can buy milk in many forms fresh, powdered, UHT (long-life), tinned evaporated, sweetened condensed and flavoured. Many varieties of fatmodified milks such as skim, reduced fat, Shape, Rev and Farmers Best are also available. Always provide full-cream milk for children under five years of age, unless otherwise advised by a dietitian. For many people aged five years and over, reduced fat milk products are best. However, when weight loss and undernourishment are of concern, full-cream milk products are the best choice.
Excess mucus
or saliva can occur for many reasons including dehydration, reflux and aspiration and should be investigated by a doctor.
Sometimes people need to follow a milk free diet. They may have difficulty absorbing the lactose in milk, either for a short while after a gastrointestinal upset or illness, or long-term due to permanent lactose intolerance. Consult with a dietitian in these situations to ensure the total diet remains balanced and healthy. Sometimes milk intake is restricted in the belief that it causes an overproduction of mucus. A link between dairy products and mucus has never been scientifically proven. Excess mucus or saliva can occur for many reasons including dehydration, reflux and aspiration and should be investigated by a doctor. A true milk allergy is not common, particularly in adults. Only a specialist allergy doctor or clinic can diagnose a true milk allergy (see SECTION 4 Food allergies & intolerances).
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Meat, fish, poultry, eggs, nuts and legumes

The foods in this group are good sources of protein and some vitamins and minerals. Most adults and children over eight years of age should eat at least one serve each day. Children under eight years may only need a half serve. Examples of one serve from this group include: 2 slices roast meat (65-100g); 2 small chops; 1/2 cup lean mince; 1 small thigh fillet chicken; 1/2 cup cooked (dried) beans, lentils, chick peas or baked beans; 1 small fish fillet; 2 small eggs; 3 tablespoons peanut butter. Red meat is a particularly valuable source of iron and zinc. Red meat should be eaten three to four times each week. Make sure someone who eats a vegetarian diet, or is unwilling to eat red meat, gets sufficient iron in their diet. See SECTION 2 Vegetarian diets. The following information on smooth meat has been reproduced with permission from: Lane, M. & McLaughlin, L. (1999) Smooth Food Practical Food and Nutrition Guide for Parents and Carers of Children with Eating and Swallowing Problems, Disability Services Commission, Government of Western Australia. Smooth food hints for meat, chicken, fish, eggs, beans, peas and nuts Getting the right texture and retaining moisture are the two most important considerations when preparing meat for people who need smooth food. Use the right cuts of meat and cooking methods to gain the best results. Steam chicken, fish and minced meat using a steamer basket over gentle simmering water until meat is cooked and tender. Make casseroles (using gravy beef, round steak, blade steak, chuck steak, topside mince, lamb shank, chicken, turkey or pork) in the microwave, on the stove top, in the oven or pressure cooker. Roast fillets of rump, topside beef, loin, leg, shoulder or lamb shank, chicken, turkey or pork use the moist, inside slices. Pan fry fish.
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Common problems with smooth meat, eggs, beans, peas and nuts Some meat becomes stringy when blended, so always cook meat long and slow so it is moist and tender. Minced meat can become tough and form lumps. To avoid this, cook in a thick sauce (e.g. bolognaise sauce) or combined with other ingredients (e.g. meatballs or meatloaf). Family meals, particularly grills and stir-fries, are unsuitable for people who need smooth food. A good alternative is to freeze suitable meals, defrost them in the refrigerator and reheat in a small pan or microwave. Make sure the meat is thoroughly heated and the heat is distributed evenly. Cooked eggs may be difficult for someone on a thick smooth diet as they are often lumpy or rubbery (e.g. boiled, poached or scrambled eggs). To successfully use eggs for a thick smooth diet, try eggs in combined dishes like custard or sweet or savoury frittata. Dried peas and beans (e.g. chick peas, kidney beans and lentils) often have outer husks which need to either be sieved out or avoided altogether (Note: lentils will cook down to a soft consistency without any husks). Whole or chopped nuts are not suitable, however nut butters (e.g. peanut butter) may be combined in meals and sauces (e.g. smooth satay sauce). (Note: peanut butter is too thick and sticky to have by itself or even in a sandwich). Add interest to smooth meat Add tasty sauces and ingredients when casseroling meat (e.g. onion, garlic, ginger, capsicum, stock and soy sauce). Use a variety of meats and minces (e.g. beef, lamb, pork, veal, chicken or turkey, rather than always using minced beef). Add tasty sauces as an accompaniment (e.g. lamb with plum sauce, chicken with satay sauce). Make individual serves in souffl pots to give the meat some form (e.g. cottage pie and moussaka).
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Smooth meat, chicken, fish, egg and cheese recipe ideas Roasted meat use the moist inside pieces of roast beef, lamb, veal, pork, chicken or turkey. Minced meat use a variety of minces to make meatballs and cook in a thick sauce or meatloaf. Make cottage pie, moussaka, spaghetti or macaroni bolognaise, chilli con carne (remember to mash kidney beans and remove husks), cannelloni, lasagna or ravioli in thick sauce. Meat and poultry casseroles apricot chicken, beef burgundy, beef and mushroom casserole, lamb in satay sauce, curried beef, lamb, pork and chicken, lamb hot pot and chicken cacciatore. Fish ideas baked, grilled, pan fried, steamed or poached, steamed smoked fish, tuna or salmon patties, fish pie and fish mornay. Egg and cheese ideas savoury custard, frittata, egg and asparagus mornay, pastryless quiche and spinach and cheese filling.
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VEGETARIAN DIETS
There are many different vegetarian diets. Broadly, vegetarian diets are based on plant foods which include cereals, vegetables, fruit, nuts and seeds. Some people may include fish, chicken, eggs or milk products. Many animal foods provide valuable sources of nutrients. If these foods are excluded from a persons diet, make sure these nutrients are provided in other foods. Below are some examples.
Protein
Individual plant proteins lack some of the important building blocks (called amino acids) necessary for health. It is therefore important to include at least two plant protein sources each day. For example, you could include cereals and dried beans, lentils and nuts, cereals and nuts, or tofu and pasta.
Iron
Red meat is the best and most efficiently absorbed source of iron. Fish, poultry and eggs provide less iron. If none of these foods is eaten, increase dietary iron intake by: Choosing wholemeal cereals such as bread, rice and pasta; Including legumes (e.g. lentils) in the diet; Including dark green vegetables (e.g. silverbeet and broccoli), to be eaten with food rich in vitamin C (e.g. citrus fruit, kiwi fruit, rockmelon, tomato, capsicum and cauliflower). This will help increase iron absorption.
Calcium
People with a disability, especially those with limited mobility and on certain medication, have a higher risk of developing osteoporosis. These people need an adequate intake of calcium, which is essential for healthy bones and teeth. Dairy foods provide valuable amounts of calcium. Many vegetarians include milk and other diary products in their diet. If this is not the case, dark green vegetables, tofu set with calcium and soy milk fortified with calcium will supply some calcium. If you are worried that someone on a vegetarian diet is not eating well, refer them to a dietitian.
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DIETARY FIBRE Why it is important

Dietary fibre is a vital factor in good health. Dietary fibre is made up of a range of plant-based substances. When consumed, fibre passes undigested into the intestines where it improves bowel function. Dietary fibre helps prevents illnesses such as bowel cancer, obesity, diabetes, heart disease and irritable bowel syndrome.
How to eat more fibre

There are two major groups of dietary fibre, soluble and insoluble. Soluble fibre is found in oats, barley, legumes, apples and some other fruits and vegetables. Insoluble fibre is found in wholegrain cereals. Most foods contain a mixture of both types. It is important to eat a variety of fibre sources.
Fruit
Fresh fruit is a great source of fibre. Canned, frozen and dried fruit are also good sources. Include the skin of the fruit if you can. Fruit juice contains much less fibre.
Food Serving Tips

Serving tips for fruit Include it in smoothies. Add it to breakfast cereals. Serve it frozen as fruit blocks. Bake it in muffins, scones and pikelets. Serve a fruit salad selection topped with yoghurt or ice cream. Serve baked apple stuffed with dried fruit. See pages 62-63 for more fruit serving tips.
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Vegetables
Include at least five serves of vegetables each day. The more variety, the better. Legumes such as lentils, peas, baked beans, kidney, navy, soya, black-eyed and butter beans, chick peas or mixed beans are especially good sources of fibre.
Food Serving Tips

Serving tips for vegetables Add a can of beans to casseroles and soups. Add corn to stir fry dishes. Blend beans (e.g. mixed, chick peas and baked beans etc) with onion and soy sauce for tasty spreads or dips. Include more legume-based dishes in the menu selection. Cooked chick peas make a great snack. Include mixed beans in salads.
See pages 59-61 for more vegetable serving tips.
Cereals
Cereals contribute greatly to both soluble and insoluble fibre intake. Wholegrain varieties are better, as highly processed cereals often have no fibre. Good choices include: Rolled oats (traditional and one minute); Bran-based cereals such as All Bran, Branflakes, Sultana Bran and Bran Plus; Wholegrain cereals such as WeetBix,Vita Brits and Bran Bix; Ready Weats and Mini Weats; Wheatgerm; Unprocessed bran (up to 2 tablespoons a day); Wholemeal pasta; Brown rice.
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Food Serving Tips

Serving tips for cereals Add wholemeal breadcrumbs or oats to meatloaf or meatballs. Add oats or barley to soups. Use wholemeal flour for baking (50% wholemeal flour and 50% plain four is sometimes more successful). Add oats or bran to muffins. Add unprocessed bran or wheatgerm to breakfast cereals. See page 58 for more cereal serving tips
Breads and related products

Bread often contributes the most significant amount of fibre to the diet. Wholemeal bread is a better choice, as it has four times as much fibre as ordinary white bread. Wholemeal breads also contain more vitamins and minerals. Wholegrain biscuits (e.g. Ryvita, Wholemeal Cracker Bread, Bran and Malt Cruskits, Shredded Wheatmeal and Scottish Oatcakes) can add variety to a diet. If a person is unwilling to eat wholemeal bread, a high fibre white variety is a good selection.
Nuts
Nuts can provide fibre, but be careful if the person has difficulty chewing or swallowing. Whole nuts may cause choking. Slivered or crushed nuts can be added to muffins, cakes and stir-fries if safely swallowed.
Fluids
An adequate fluid intake is particularly important when increasing the fibre content of a diet. Make sure the person has at least six to eight large glasses of fluid each day.
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FLUIDS
Inadequate fluid intake can lead to dehydration and, if severe and sustained, can be life threatening. Some causes of dehydration Lack of thirst, particularly in the elderly Communication problems Swallowing problems Use of diuretics Abuse of laxatives Uncontrolled diabetes Inadequate supervision of tube feedings Spillage of drinks Excessive drooling Some signs of dehydration Deterioration in cognitive status, skills or abilities Urinary tract infections Dizziness /vertigo Constipation Decreased urine output Dry lips and mouth Sunken looking eyes Swollen tongue Hypotension Poor appetite
Adults should
have at least six large glasses of fluid each day. they may need more in very hot weather.
Adults should have at least six large glasses of fluid each day. They may need more in very hot weather. Fluids include: water tea coffee gelato milk jelly custard ice cream soup cordial fruit juices yoghurt
Some people may not be able to communicate their thirst, especially in hot weather. Make sure the person is offered a drink with each meal, and at least once in between meals and at supper time.
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Coffee and cola-based drinks contain caffeine. These have a diuretic effect (they make you pass urine). Encourage other drinks if you are concerned the person is not getting enough fluids. Milk is the preferred drink for children, followed by water. Tea and coffee are not recommended for children. Offer drinks when people are alert, not tired. Use an appropriate cup.
Energy powders (carbohydrate)

Examples are Polycose and Polyjoule. These add energy without changing taste. Add them to drinks, soups, casseroles, mashed vegetables, soft fruits and desserts.
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ORAL HYGIENE
Oral hygiene is especially important for people with a disability. The condition of a persons mouth, teeth and gums influences their ability to chew and swallow. A person with no teeth, missing teeth or teeth in poor condition may not be able to chew food properly.
Poor oral
hygiene leads to loss of teeth, gum disease and a build up of bacteria in the mouth.
Poor oral hygiene leads to loss of teeth, gum disease and a build up of bacteria in the mouth. If a person with poor oral hygiene aspirates food, drink or saliva they can develop aspiration pneumonia, especially if they have lots of bacteria in the mouth.
General steps for good oral hygiene

Good Oral Hygiene
Proper Brushing
Healthy Diet
Dental Reviews
Indications of poor oral hygiene may include: Bad breath; Red, swollen, or bleeding gums; Sore or painful mouth on touching or chewing; Receding gums; Plaque, tartar. People who are at risk of poor oral hygiene include those: Who regularly consume sugary food or drink; With a dry mouth ( medication may contribute to this); Who can not easily clear their mouth of food or drink after eating; Who clean their teeth less than two times per day; Who are unable or unwilling to clean their teeth properly; Strategies to maintain good oral care include: Visiting the dentist annually (unless dentist advises otherwise); Ensuring that teeth are cleaned properly and effectively; Developing an individual oral care plan with the dentist ( see Appendix 3 for a suggested format); Changing the persons toothbrush every three to four months or when bristles flatten or become worn;
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Brushing teeth after each meal (a minimum of twice per day); Brushing teeth on average for two minutes each time. For people challenged by or resistant to oral care, discuss the following options with their dentist: More regular fluoride application; Antibacterial mouth sprays; Mouth swabs; Trial different toothpastes (e.g. flavourless); Electric toothbrushes.
Dentures
Whether a person has full or partial dentures, care may often be forgotten. Care includes: Ensuring proper and effective cleaning;
Annual visits to the dentist.
Poorly fitting dentures can cause:
Ulceration or discomfort;
Accumulation of food under the denture;
Ineffective chewing.
Use of denture adhesives may be useful.
Dentures may not fit when: There is increased saliva or drooling; The person has a dry mouth; The person has lost or gained weight.
The Special Care Dentistry Unit at Westmead Hospital cares exclusively for people who have special needs, including those with a disability. For appointments and/or information contact: Westmead Centre for Oral Health Westmead Hospital Darcy Road Westmead NSW 2145 Tel: (02) 9845 7423 Fax: (02) 9893 8671 For information regarding private dentists contact the Secretary, Special Care Dentistry Association at the above address.
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FOOD SKILLS
Learning food skills is a very important component of independent living. This includes meal planning, grocery shopping and food preparation. Good health includes eating a selection of nutritious and healthful foods. The teaching of food skills should focus on foods which promote good health. For most people this means an emphasis on a varied diet, with the inclusion of a wide range of foods from each food group. Lots of foods which are high in complex carbohydrates such as bread, cereals, rice, pasta, fruit and vegetables should be included. A reduction in foods which are high in fat, sugar and salt is also important in healthy food choice. Some people are known as fussy eaters and often will not eat a wide range of foods. The basis for this could be inappropriate use of food rewards, lack of opportunities to experience different foods and tastes in the past or a behavioural issue.
What are the benefits of learning food skills?

Increased independence. Increased self esteem. Improved nutrition. Cost effectiveness.
Some ideas for teaching food skills

Be a positive role model. Eat well yourself. Provide a wide variety of food experiences. Visit a fruit and vegetable section of a large supermarket. Talk about the different colours, shapes and sizes. Visit a bakery and talk about the different breads. Buy some different bread for tasting later. A vegetable garden, either commercial or domestic, is a great introduction to new foods. It is even better if the person can actually help with growing vegetables. Cueing systems using picture and colour, and food models . A speech pathologist can help with other communication ideas. Sometimes the traffic light system helps people to choose foods wisely.
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For example:
Red light foods are those which should only be eaten occasionally and include
fried foods, those high in sugar, alcohol;
Yellow light foods should be eaten in moderation and include milk products,
lean meat, fish, poultry;
Green light foods can be eaten in quantity unless a person is overweight or on
a special diet. They include bread, cereals, fruit and vegetables.
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Section 3
Weight management
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Section 3
SENSIBLE WEIGHT LOSS Exercise

Adequate exercise is often vital for weight control. Any exercise that contributes to an active lifestyle is beneficial. The right kind of exercise improves blood circulation and strengthens the heart. Regular exercise also: Improves concentration; Helps you relax and reduces tension; Helps you sleep more soundly at night; Can help prevent lower back pain; Improves posture; Improves digestion; Makes your bones stronger. Any regular exercise, such as walking is a good start. Get advice from a doctor before starting more intense exercise programs, especially for people who have specific health problems such as epilepsy or heart disease.
Healthy eating
Crash diets or very restricted food intake can easily lead to nutritional imbalances and temporary weight loss. Regular meals with average serving sizes from each of the food groups are important.
Reduce fat intake

Reduce fat intake by: Choosing low fat or reduced fat dairy products; Buying lean cuts of meat and skinless chicken; Avoiding high fat delicatessen products such as salami; Using minimal or no fat spreads on bread and toast; Avoiding oil and other fats in cooking; Choosing fruit for snacks instead of potato crisps; Being careful when choosing take away foods (these are usually high in fat).
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Weight management
Better choices for take away food Grilled fish or battered fish with most if not all of the coating removed; Have either grilled beef, cheese or egg on burgers, but not all three. Request more salad on the burger; Try vegetarian toppings & less cheese on pizza; Barbecue chicken without the skin; Jacket potatoes instead of chips; Large serve of pasta with a small portion of sauce; Lean meat, chicken or seafood stir fry with steamed rice.
Increase fibre intake

Increase fibre intake by eating plenty of cereals, rice (brown rice preferably), pasta without added fats (such as creamy sauces), wholegrain bread and lots of fruit. See SECTION 2 about dietary fibre.
Reduce sugar intake

Tips to reduce sugar intake: Use artificial sweeteners in drinks; Serve low joule soft drinks and cordial water is best of all; Serve low joule jellies; Serve fruit canned in natural juice fresh fruit is even better; Avoid confectionery and chocolate or serve them infrequently; Low fat cracker biscuits or rice cakes are better than sweet biscuits, cakes and pastries; Be aware that jam and honey in small amounts contain less calories than butter or margarine spreads.
Alcohol
Alcoholic drinks are high in calories. Low calorie/joule soft drinks or water are better for people trying to lose weight.
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Getting co-operation
It is not always easy to get the person to cooperate in reducing their weight. Sometimes small, realistic goals are needed to help people achieve and maintain weight loss. The strategies below may be helpful: Do not use food as a punishment or reward; Make sure the person has a supply of low energy foods, particularly as snacks; Try to serve food similar in appearance to food served to others at the table; If take away food is a problem, try outlets with more low fat choices, or visit take away food places less often.
Do not use
food as a punishment or reward.
Behaviour modification
Many people eat for reasons other than hunger or appetite. Food may be part of a compulsive behaviour pattern or may comfort people when they are stressed or bored. Make sure people who are trying to lose weight have sufficient non-food orientated activities during the day. Exercise-based programs such as walking, dancing or playing sport are ideal. In some cases, you may need to refer the person to a psychologist.
Medication
Some medication can have a dramatic impact on weight gain. Seek advice from a doctor if you suspect this (see SECTION 4 Food and drugs).
Prader-Willi Syndrome
Among the characteristics of this disorder are excessive over-eating, food seeking and obesity. The tendency for uncontrollable eating develops in early childhood. Optimal care requires an experienced multidisciplinary team. Dietary management is very important in preserving the health of a person with Prader-Willi Syndrome. Regular counselling by a dietitian or through a speciality clinic is advisable.
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Weight management
PROMOTING WEIGHT GAIN

Sometimes you decrease the energy (calorie or kilojoule) content of food by modifying its texture. This is particularly the case when extra fluids are added for blending. The following suggestions will boost the energy of foods and help to prevent weight loss.
Milk and dairy foods

Always use full-cream milk and whole milk dairy products. Do not choose low fat or skim milk products for someone trying to gain weight, unless a dietitian specifically recommends it. Enrich milk by adding 6 tablespoons of full-cream milk powder to 1 litre of full-cream milk. Add grated cheese to sauces, scrambled eggs, soups, vegetables, mashed potato and baked beans. Blend cream cheese with fruit. Use evaporated milk to make soups, fruit mousse and sauces. Use enriched milk instead of ordinary milk for cereals, drinks and in cooking. Add cream to smoothies, milkshakes, soups, sauces, potatoes and desserts.
Bread and cereal foods

Try to use wholemeal bread. This will add fibre and other valuable nutrients. Add plenty of butter or margarine to bread and toast. Choose high energy sandwich fillings such as those based on cheese, meat, eggs, canned tuna in oil, sardines and smooth peanut butter. Adding mayonnaise, jam or honey to these fillings will boost the energy content even further. Add oats or breadcrumbs to soups and casseroles. Use baby rice cereal as a thickening agent in fruit drinks or add it to soft, cooked fruit. Oats cooked in fruit juice with sugar make a pleasant soft dessert. Make cooked savoury sandwiches with soft fillings such as grated cheese, savoury dips or avocado spread. Use crustless sandwiches. Cook these in a milk and egg mixture (the method is similar to bread and butter custard, but without sugar). Soften honey or jam sandwiches, sponge cake or other soft cakes even further by adding warm and thin pureed fruit. Cook rice until it is very soft and use it as a base for soups. Add bran cereal to meat soups and casseroles, muffins and other baked goods. Soften bran cereal with a little warm water and add it to smoothies, milk shakes and fruit based drinks.
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Fats and Oils

Be generous when using butter, margarine or oil. Vegetables baked or fried in oil are higher in energy. Add mayonnaise or oil dressings to salads. Add butter or margarine to hot vegetables.
Drinks
Encourage milk and juice-based drinks. Use enriched milk. Add honey, malt, glucose syrup, flavoured toppings, cocoa or flavoured drink powder to drinks. Add ice cream, cream or fruit. Add glucose polymers such as Polyjoule or Polycose. Use nutritional supplements such as those below.
Oral nutritional supplements

Powders A number of commercial products are available e.g. Sustagen, Ensure. Mix these with milk or water and use as a drink or instead of milk (e.g. on breakfast cereal). Mix them into soups and porridge. Sprinkle them over breakfast cereal and desserts. Ready-to-drink A number of commercial products are available e.g. Sustagen, Ensure, Fortisip. These are available as milky drinks or juice-based drinks. They come in a variety of flavours and are conveniently packaged in a range of sizes. Puddings These are available as powders to mix with milk or water or ready-to-eat in individual cans (e.g. Sustagen Instant Pudding, Sustacal Pudding, Ensure Pudding).
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Weight management
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Section 4
Diet and special health conditions
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FOOD AND DRUGS

Both prescription and non-prescription (over the counter) drugs can influence nutrition in a variety of ways.
How drugs can alter food intake

Increased appetite Many anti-psychotic drugs increase appetite and may contribute to undesirable weight gain. If you are concerned, discuss this with the doctor who prescribed the drug. You may need to implement sensible weight control strategies (such as increased exercise) to maintain a healthy body weight. See SECTION 3 about sensible weight loss. Decreased appetite Many drugs cause a decrease in appetite and unintentional weight loss. The weight loss may be due to side-effects such as nausea, vomiting, abdominal pain, diarrhoea, constipation, decreased saliva production, sore mouth and an altered sense of taste. Swallowing problems (dysphagia) Some drugs influence the nerve connections to the mouth and throat and can increase problems with the eating and swallowing process, particularly salivation. The persons doctor should monitor long-term use of drugs for these side-effects. Alertness and cognition Drowsiness, confusion, dizziness, headache and blurred vision are all unpleasant side-effects of some drugs. These side-effects impact on the desire and ability to eat. Drug-nutrient absorption Many drugs prevent or reduce the absorption of nutrients. For example, thyroxine can affect iron absorption and cimetidine can affect vitamin B12 absorption. Long-term use of laxatives can affect electrolytes and vitamin status. Caffeine, although not recognised by many people as a drug, can reduce the absorption of iron and calcium. Alternatively, some nutrients or foods can reduce the absorption and effectiveness of some drugs. For example, the effectiveness of warfarin is reduced by a high intake of certain vitamins. Drug-nutrient metabolism Some drugs increase nutrient metabolism and increase a persons nutrient requirements. For example, thioridazine can affect riboflavin, while anticonvulsant drugs can affect folic acid metabolism.
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Ask the doctor, dietitian, nurse or other health specialist to check how the drugs a person takes might influence their nutrition.
How to minimise these problems

Be aware that drugs can influence nutrition. Record any observations you make which you think may be due to side effects of drugs and seek a professional opinion. Make sure that a doctor regularly reviews medication, especially when used over a long period of time and in combination with other drugs. Check that you have information on correct administration of drugs, such as the correct timing in relation to meals. Ask the doctor, dietitian, nurse or other health specialist to check how the drugs a person takes might influence their nutrition.
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DIET AND DIABETES

Good nutrition, attention to meal planning and adequate exercise are essential for successfully managing both insulin dependent diabetes and non-insulin dependent diabetes. The major goals of dietary management for a diabetic person include: Optimal overall health; Maintaining desirable blood glucose levels; Achieving optimal blood lipid levels; Providing adequate energy for growth in children and adolescents; Maintaining or reaching desirable weight for height in adults; Preventing problems such as hypoglycaemia and long term complications such as renal disease and heart disease. Every person with diabetes should have an individual dietary management plan developed by a dietitian. This plan should be reviewed regularly. The Principles of Lifestyle and Nutritional Management of Diabetes on page 92 were developed by the NSW Health Department. They will also assist people with a disability who have diabetes. What about sugar? Eating foods that contain some sugar is not a problem, as long as the sugar concentration is not high. Foods selections with a reasonably moderate sugar content include: Jam or honey on toast with a thin spread of mono or polyunsaturated margarine; Fruit salad with ice cream; Porridge with a light sprinkle of sugar; Canned fruit and custard; Banana cake, carrot cake, fruit cake or plain sponge cake. Use a sweetener in tea or coffee and choose low joule soft drinks, cordials and jelly. Lollies, chocolate and other confectionery (even those labelled diabetic) have high sugar concentration and are not recommended.
Every person
with diabetes should have an individual dietary management plan developed by a dietitian.
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Principles of Lifestyle and Nutritional Management of Diabetes

Source: Principles of Lifestyle and Nutritional Management of Diabetes (NSW Health Department 1997). Principle 1: Small, regular meals based on a wide variety of foods Eat at regular intervals throughout the day.
Eat something before you start the day.
Eat small amounts of food, often, rather than large amounts all at once.
Look at when you eat to see if food could be more evenly spaced.
Try new foods where you can, e.g. fruit & vegetables, breads and cereals.
Principle 2: Regular Activity Start slowly. Build fitness gradually.
Increase all forms of activity: move more.
Think about how to be more active throughout the day.
Choose a form of activity you like and are comfortable with.
Plan your activity.
Principle 3: Reduce the amount of fat in the diet, particularly saturated fat Eat less fat overall.
Reduce the use of cooking fats and oils, butter and margarine, fried and fatty foods.
Increase the use of low fat dairy foods, lean meats, skinless chicken and fish.
Use monounsaturated (e.g. olive and canola) or polyunsaturated fats for
cooking and for spreads.
Watch out for hidden fats in foods such as biscuits, muffins, oil-based dressings,
mayonnaise
When eating away from home, order low fat choices.
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Principle 4: Include mostly carbohydrate and fibre foods Eat mostly: Fruit and vegetables; Breads; Cereal foods such as rice, oats, pasta, and breakfast cereals; Legumes such as baked beans, split-peas, lentils. Eat wholegrain and wholemeal foods. Eat some of these foods at every meal, spreading them across the day. Principle 5: Moderate alcohol Moderate drinking is defined as two (for women) to four (for men) drinks per day.
When you drink alcohol, eat some carbohydrate food.
If reducing alcohol intake is difficult, seek guidance.
Principle 6: Smoking control Quitting smoking for people with diabetes is important in reducing the risk of cardiovascular disease. Consider referral to quit smoking groups or clinics or other support services.
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FOOD ALLERGIES & INTOLERANCES

Food allergy and food intolerance can cause problems for some people. Though they are very different disorders and require different management strategies, they are often confused.
Food allergy
True food allergies involve the immune system. If an allergy exists, quite obvious signs usually occur within minutes of eating the food. Food allergy is more common in infants and young children, but can occur in adults. The most common food allergies are to proteins in milk, eggs, soy, wheat, nuts, fish and other seafood. Reactions can vary and include swelling or itching around the mouth and throat, widespread hives or eczema, gastrointestinal symptoms (nausea, vomiting, abdominal pain or diarrhoea) and asthma. In extreme cases allergies can cause severe difficulty in breathing and death. Diagnosis of a true food allergy requires expert assessment. RAST or skin prick tests are used to test for allergies. Seek advice from a dietitian about the effectiveness and nutritional adequacy of dietary management. Someone with a true food allergy needs to avoid eating or touching that food, completely. Some food allergies can be life threatening, particularly those involving the respiratory system. The severity of a persons allergic reaction to a food can vary. Someone who has had only mild symptoms in the past can still have a severe reaction to the food. It is therefore essential and a duty of care that dietary instructions are followed closely.
Food intolerance
Food intolerances are more common than food allergies and can appear at any age. They occur when chemicals contained in food cause adverse reactions similar to the side-effects of medications. It is thought that food intolerance involves the nervous system, not the immune system. Symptoms can be very diverse and include skin rashes, digestive problems (nausea, diarrhoea or stomach pain), respiratory signs (asthma, nasal congestion or runny nose) and nervous system complaints (headaches, hyperactivity, fatigue and irritability). Someone who has an intolerance to a food chemical can eat a certain amount (their threshold) without symptoms. If they eat more than their threshold amount they develop symptoms. Symptoms can take a long time to develop and depend on the amount of chemical eaten and confounding factors such as stress, hormone levels, allergies or infection. Diagnosis and management are therefore difficult and require expert assistance.
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Most people with food intolerance are sensitive to more than one chemical. These chemicals can be either artificial or natural substances. Artificial substances (for example, colourings and preservatives) are added to commercial foods. Natural substances are found in the food as it is grown. For example, salicylates are found in fruit, vegetables and herbs, while MSG (monosodium glutamate) is found naturally in many foods including tomatoes, mushrooms, strong cheeses and savoury sauces. There are no valid laboratory tests that can be used to test for food intolerance, making diagnosis difficult. Food intolerance is investigated using an elimination diet and subsequent chemical challenges. Once the chemical intolerances are identified, these chemicals are slowly added back into the diet one at a time to discover the individuals tolerance threshold for each one. This should only be done under experienced medical and dietetic supervision. If you suspect food allergy or intolerance If you suspect someone has a food allergy or intolerance, ask their doctor (GP) to refer them to a specialist allergy clinic. If a food allergy or intolerance is diagnosed, obtain written guidelines for dietary management and incorporate these into the persons eating and drinking plan. Make sure these are reviewed and evaluated at regular intervals.
If you suspect
someone has a food allergy or intolerance, ask their doctor (GP) to refer them to a specialist allergy clinic.
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CHOLESTEROL What is it?

Cholesterol is a fatty substance produced by the body. It is needed for cell production and other important uses. Some peoples bodies make too much cholesterol or absorb too much from food. High blood fats, including cholesterol, can contribute to heart disease. Making permanent changes to diet can help to control blood fats and lessen the risk of heart attacks and other forms of heart disease.
One of a number of factors

Cholesterol levels are only one of a set of factors that influence heart disease. Others include high blood pressure, smoking and a family history of heart disease. Discuss a persons overall risk of heart disease with their doctor. A low cholesterol diet may not always be appropriate, especially if a person is very underweight or frail.
A low
cholesterol diet may not always be appropriate, especially if a person is very underweight or frail.
A common problem
High blood cholesterol is a common problem in Australia. Sometimes people that have a high blood cholesterol level need to go on a low cholesterol diet. Others may need to take tablets, as well as changing their diet in order to lower their blood fat levels. In either case, dietary changes should be lifelong to ensure that the risk of heart disease is reduced.
What causes high blood cholesterol?

The main causes are: Eating too much fat, especially saturated fat; Being overweight; Eating too much cholesterol from foods.
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Lowering cholesterol and heart disease risk through diet

Essentially, a persons diet should include: Lots of bread, cereals, fruit and vegetables; A moderate amount of lean meat, skinless poultry, eggs, fish, nuts, seeds and low fat dairy products; Small amounts of monounsaturated oils (e.g canola oil and margarines) or polyunsaturated oils (e.g safflower oil and polyunsaturated margarines). It also helps to maintain a healthy weight. A persons intake of saturated fat should be low. Saturated fats are often hidden in processed foods such as biscuits and cakes. They are also in take away foods. It is important to choose foods carefully and check labels if possible.
What about alcohol?

Some alcohol in a persons diet is okay. In some cases a little alcohol (particularly red wine) may even help reduce the risk of heart disease. However, always check with a doctor, as people on certain medication should not have any alcohol.
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ENTERAL NUTRITION What is it?

Enteral nutrition refers to the delivery of food via a tube into a persons gastrointestinal tract If a tube is used for a few weeks only, it may be passed through the persons nose into their stomach (naso-gastric or NG tube). For longer periods, the tube is usually passed directly into the persons stomach (gastrostomy) or occasionally into other sites in the small intestine. The doctor who places this tube often uses an instrument called an endoscope (percutaneous endoscopic gastrostomy). Therefore these tubes are often called PEGs. Liquid formula food and water can be given to the person in various ways. A special pump is often used. Always get advice from a health specialist or hospital about the most suitable method of delivery for a person, especially if you have any concerns.
Why is it needed?
A person may need this form of nutrition when they are unable to eat sufficient food to ensure adequate nutrition or if they have swallowing problems which make it dangerous for them to continue to eat and drink by mouth. For some people tube feeding is a temporary procedure. For others it will be long term. Sometimes it is possible for people to continue to have food and drink by mouth in addition to the formula and fluid provided via the tube. For people being tube fed always check with a doctor or speech pathologist before offering food or fluid by mouth.
Important goals for a person receiving Enteral Nutrition

To reach and maintain appropriate body weight in adults and adequate growth and development in children and adolescents. To maintain optimal nutrition, including hydration. To minimise problems of delivering the liquid formula feed. To return to oral food and fluids where this is possible. To ensure optimal oral hygiene.
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Important things to consider

The decision to commence enteral nutrition and the type of delivery will be made by the appropriate health specialists and the person requiring enteral nutrition or their representative (parent(s), person responsible or legal guardian). Nutritional status and requirements must be assessed and reviewed by a dietitian at least once every six months. A medical assessment must be performed at least once per year. Care in relation to enteral equipment must follow best practice guidelines. Care in relation to oral hygiene must follow best practice guidelines. Care in relation to stoma care and care of the nose with nasogastric tubes must follow best practice guidelines. Documentation will include date of initial tube placement, type and size of tube and details of tube changes. Only commercial formulae should be used, as recommended by a dietitian or medical officer. Best practice guidelines in relation to hygiene and safety must be followed in all aspects of storage and handling for enteral nutrition. Delivery recommendations for enteral nutrition must include consideration of the persons needs in terms of medical history, daily routines and community access. Their personal needs for modesty and dignity should be respected at the same time. Procedures must be clearly documented for the re-insertion of PEG tubes. Responses to any other problems should also be clearly documented, as considered necessary. An individual nutrition care plan will be provided for each person.The plan will detail positioning, type and amount of formula to be provided, the rate of delivery, extra water requirements and oral food & fluids, if permitted.
Nutritional
status and requirements must be assessed and reviewed by a dietitian at least once every six months.
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Possible problems
Get professional advice if the person has any of these problems: Diarrhoea or constipation; Nausea or vomiting; Appearance of distress; Blocked tube; Dislodged tube; Stoma site which is inflamed or leaking; Unsatisfactory weight changes (see SECTION 1).
Support for people receiving tube feeding and their carers is available from the Gastrostomy Information and Support Society (GISS). Contact details are as follows: GISS NSW Central Organising Committee c/o The Spastic Centre of NSW PO Box 184 Brookvale NSW 2100 Tel: (02) 9451 9022
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THE NORMAL EATING PROCESS

People who are physically dependent on others in order to eat or drink need mealtime assistance that is tailored to their particular needs. Before reading this section on mealtime assistance, it is important to understand how normal eating and swallowing occurs. Swallowing is a complex process. It can be simply described as a sequence of three stages or phases. Each of these has an impact on the other, to allow a smooth and efficient swallow.
Phase 1
The first stage of the swallow is the oral phase. It involves the preparation of the food or liquid into a ball or bolus in the mouth. Strong muscles in the lips and cheeks are needed to stop the food from falling out of the mouth. Food is bitten and chewed. This requires an adequate number of teeth, of good condition and healthy gums. Chewing involves breaking the food into small pieces, which are mixed with saliva.This allows it to pass easily from the mouth and into the throat. An insufficient number of teeth or rushing through a meal can result in the swallowing of large pieces of unchewed food. This can lead to discomfort and even choking.
Phase 2
Food is moved from the mouth into the throat by the tongue. As it does this it triggers a swallow. This is the beginning of the pharyngeal (throat) phase, the second stage of the swallow. During this stage a number of things occur. The soft palate (at the back of the mouth) rises, preventing food or liquid from entering the nose. The larynx rises. The epiglottis closes over the airway, the true and false vocal cords close and breathing is briefly stopped. In this way the airway is protected. As this is occurring, the muscles of the throat contract and a wave of muscle squeeze the food through the throat.
Phase 3
The third phase begins as the muscle at the top of the oesophagus opens, allowing the bolus to pass through the oesophagus and into the stomach. This carefully timed and coordinated manoeuvre involves several cranial nerves and muscles, yet takes less than one second to complete. See diagram on page 105.
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Swallowing involves more than good muscle function. To fully assess the swallowing process we must look at the person holistically. For example a person must want to eat, must be able to recognise the need to eat and know what is and is not edible. A person also needs to be aware of the eating process, that is, that you have to open your mouth to get food and that you need to chew before you swallow. There are many factors, which may influence a persons intention to eat. These may include: The persons environment; Their motivation; Their ability to taste and feel food in their mouth; Their ability to think and solve problems. When assessing and treating swallowing disorders, it is important to be aware of how these factors may affect swallowing.
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EATING DIFFICULTIES What is dysphagia?

Dysphagia is difficulty in swallowing. Dysphagia may affect any part of the eating process beginning with the mental preparation for each of the three phases of swallowing. Listed below are some of the ways in which swallowing may be affected. Surroundings
Being able to
share a meal with friends or family is important.
A persons surrounding may influence their eating and swallowing. Eating is a social event. Being able to share a meal with friends or family is important. A persons surrounding should be comfortable and pleasant. The area should not be too hot or cold and should be well ventilated. Distractions should be minimised. For example, it is advised that the television be switched off at mealtime. A radio with quiet relaxing background music can be just as enjoyable and allows people to concentrate on eating and drinking. Other distractions may include people with challenging behaviour at meal times. It is important to consider how this may be affecting other people and how these distractions can be reduced. Alertness Although swallowing may be fairly automatic, eating requires some degree of planning and insight. Decisions regarding the choice of food to eat, the quantity and when to take another mouthful are all crucial for safe and effective eating. Co-ordination of muscles and visual and spatial perception (the ability to be aware of where things are in relation to one another) will allow a person to eat independently, to judge how far the food is from their mouth, when to open their mouth and when to start chewing. The skills of planning, insight, coordination and perception must be looked at in the assessment and management of goals. A person, who is drowsy, confused or has difficulty understanding or talking may have difficulty with eating. Posture When eating, a person should be sitting up straight with their head bent slightly forward. Extending the head backwards or not having control of head movements can affect eating and may be unsafe as the persons airways can be left unprotected. Breathing The person must also be able to coordinate the acts of breathing and swallowing. During swallowing, breathing stops very briefly. However, in cases of reduced coordination the breathing cycle continues as the bolus (the soft ball of chewed food) passes into the throat. At this time, food may be inhaled into the lungs.
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Muscles of the mouth and throat The tongue, lips and cheeks need to be strong and move well to allow for good chewing and also to stop food, drink or saliva from falling out of the mouth. The ability to feel food in the mouth is also an important part of swallowing. If feeling is affected it can result in drooling/dribbling, or swallowing some food without realising that the remaining food is left in the mouth or on the lips. Teeth It is important to have a sufficient number of healthy teeth in order to chew well. Some people maintain they can get by without teeth and this may be true up to a point. However, it is important to be aware of how other factors can then impact on the persons eating. For example, a person who has no teeth and eats very quickly may be at risk of choking on a large or unchewed piece of food. Difficulty with chewing may also influence a persons choice of food and may restrict their diet. Dentures Dentures can be a problem if they do not fit well. The shape of a persons mouth may change after a stroke, when they have lost a lot of weight, or after surgery to the mouth. Dentures may also be loose if the person has a very dry mouth. Advice from a dentist can often easily solve many so-called swallowing difficulties. Cough A good cough is needed to be able to remove any food or drink from the airway. Entry of food or drink into the airway is called aspiration. It should not be assumed however that just because a person does not cough that he or she does not aspirate. Silent aspiration is a very real risk. Voice A persons voice gives information about the condition of their vocal cords. Vocal cords act like valves, which vibrate during talking and close during swallowing. They prevent food and liquid from entering the airway. A weak or breathy voice suggests that these valves are not working well and may therefore not be able to protect the airway. The gag Many people assess the gag as a way of assessing swallowing. There is no evidence to prove that a person with a gag will be able to swallow or that a person without a gag will be unable to swallow. Swallowing is more complex and all of the above factors need to be considered.
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Compensation The degree of dysphagia varies between people. Many people who have mild dysphagia manage to eat and drink with minimal discomfort because they have been able to make some changes to part of their eating process. In this way they are compensating for their difficulties. Case example A person who is short of breath will have some difficulties with eating and may make some changes to make eating easier. During eating there are brief periods when the breath is held.The bigger the mouthful of food being swallowed, the longer it takes to pass through the throat. Hence, the breath will need to be held for a longer period of time. This can be very difficult for someone who has severe asthma or chronic airways limitation. The larger the mouthful of food they eat, the more short of breath they become and the more likely they are to need to breathe before the food has passed into the food passage. Breathing at this point can result in inhalation of food. What can be done to improve this? One strategy to minimise inhalation of food is by eating soft food where chewing is minimal, and taking small bites which can be chewed with less effort and swallowed quickly. Using this method of compensation, many people with breathing difficulties are able to maintain near normal diets. What happens when the person is sick? A person who is making compensations in order to swallow is especially at risk if he or she becomes ill. A person who is short of breath is likely to have greater difficulty eating if they have a chest infection, or an asthma attack. In the same way a person with a neurological problem or a developmental disability may be at greatest risk: Shortly after a seizure; If their medication is changed; or If they become drowsy. When a person who has dysphagia becomes ill, it adds to an existing number of difficulties and their ability to compensate will be affected. People need to be aware that symptoms of dysphagia may increase during these times. Correct identification of problems and prompt implementation of strategies is required in order to minimise any complications that can arise from dysphagia.
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Ageing Dysphagia may occur during an acute illness and then improve. In other cases it may degenerate over time. The process of ageing can affect swallowing in a gradual way. The condition of teeth and gums often declines with age and this affects the persons ability to chew. As people age they lose taste buds and food may seem less tasty or even bland. Saliva flow reduces or changes to become thick. Nerve impulses slow a little. Posture changes. Muscles in the food passage may become less efficient with food taking longer to pass through to the stomach. The incidence of stroke and other neurological disease increases. Age itself does not cause dysphagia but the many medical conditions associated with it do. Medication As a person ages he or she is more likely to be on multiple forms of medication. Many medications have side effects. They can make the mouth feel dry, they can reduce appetite or cause nausea or they can affect the function of the muscles for swallowing. When medications are thought to be the cause of dysphagia, consultation with a medical officer, pharmacist or chemist is recommended. Dysphagia and disability Many people with a developmental disability have swallowing difficulties (dysphagia). The severity of their dysphagia ranges from mild to severe. At the mildest level, this may mean that a person has a mild tongue thrust where some food is pushed out of the mouth during the swallow. At a severe level this may mean that a person has no chewing ability and food can only be swallowed with extreme effort. Many people with a disability have been compensating for their swallowing difficulty all of their lives. In some cases they have done well, in others it has resulted in malnutrition, respiratory complications and sometimes death. People with a disability are more likely to die of respiratory related illnesses than the general population, due to the complexity of many associated medical conditions. Many people whose disability is neurological in origin take multiple medications. For these people it is likely that the muscles involved in swallowing will be affected.
The process of
ageing can affect swallowing in a gradual way.
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For people with a severe disability, there are also issues regarding positioning. The importance of positioning during swallowing cannot be overstated and is discussed at greater length on pages 118-119. Poor positioning will affect a persons ability to eat and to protect their airway.
What is aspiration?
Aspiration is commonly agreed to mean entry of material (food, liquid or saliva) into the airway below the level of the true vocal cords. Silent aspiration is aspiration in which there are no observable symptoms such as coughing or throat clearing. To an observer, the swallow has been normal. It has been suggested that if no cough occurs within 20 seconds of material entering below the vocal cords, the person be deemed to have silent aspiration. Prandial aspiration is aspiration of food which occurs as food passes through the throat on its way to the stomach. Salivary aspiration, as the name implies, occurs when saliva is aspirated. Aspiration occurs in healthy people as well as those with dysphagia. It is the feeling that something has gone down the wrong way. In a healthy individual, the immediate reaction is to cough. Coughing moves the aspirated material out of the airway and into the throat, repositioning it in a way that it can be correctly swallowed. In some people, however, the ability to detect the entry of food into the airway is reduced or the cough is weak or ineffective. In many of these cases the lungs are remarkably effective in clearing such foreign material. However over time, damage can occur to the lung. Alternately, if a very large quantity of food or drink is aspirated it can cause respiratory illness. We now know that there are a number of factors which will determine whether a person will develop a respiratory illness. Who is at greatest risk of aspirating? People who: Have a poor cough; Are drowsy; Find it difficult to sit upright and to hold their head up; Have a weak or breathy voice; Are gurgly when they speak or breathe; Cannot swallow their saliva.
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Reflux occurs when stomach contents come back into the oesophagus. Reflux is present in a great number of people with a disability and occurs for a number of reasons including: As a side effect of medication; Poor muscle action which fails to stop food and drink from coming back out of the stomach into the oesophagus; Poor posture causing extra pressure on the stomach; Being overweight; Smoking, drinking too much alcohol or consuming caffeine based drinks such as tea, coffee or cola drinks. Reflux can be extremely painful if left untreated. It can cause a burning feeling in the chest and throat. If severe enough, refluxed material can enter the airway and cause chest infections and possibly asthma. It can cause behavioural problems in people who cannot explain the cause of their pain. It can make people unwilling to eat because of the pain associated with eating. It can contribute to poor sleeping patterns. If you suspect that a person is experiencing reflux and a doctor has not reviewed the person, refer them to a doctor (GP).
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Pneumonia
A diagnosis of pneumonia does not always indicate that a person has aspirated. The cause of the pneumonia needs to be investigated by a doctor. If aspiration is suspected as the cause then a referral is needed to a speech pathologist. The main considerations with aspiration are: The frequency of aspiration; The amount of material that is aspirated; The persons medical condition; The persons ability to clear and tolerate aspiration, that is their respiratory condition and existing lung function. People who are most likely to get pneumonia are those who: Are tube fed; Have an intellectual disability; Are older; Have had pneumonia in the past; Are malnourished; Have low immunity and thus poor resistance to infection; Cannot move around much, are bedridden or in a wheelchair; Need someone else to feed them; Aspirate on more than one food texture; Have poor oral hygiene.
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ASSESSMENT OF DYSPHAGIA
How does a speech pathologist assess swallowing?
There are a number of techniques available but the two most common forms of assessment are: 1. A mealtime assessment a review of the persons medical history, cranial nerve assessment (review of the muscles for swallowing) and observation of the person eating a meal. 2. Modified barium swallow when a mealtime assessment fails to provide the answers to a persons swallowing difficulty, further investigation may be required. A modified barium swallow is the observation of the persons swallowing ability during an x-ray. Food and liquids to which barium has been added are given to the person to swallow. The mouth, throat and food passage are then examined. There is minimal risk to the person involved. The assessment is conducted by a speech pathologist and radiologist.
The dysphagia team

A dysphagia team, whether formal or adhoc, brings together those different professionals who can contribute to a full and thorough assessment of dysphagia in a person. A dysphagia team ideally consists of many members, not all of whom will be involved with every person. Close liaison between medical, nursing and allied health team members should be maintained at all times.
Core members of a dysphagia team

Speech Pathologist assesses and diagnoses swallowing disorders of an oro pharyngeal origin. The speech pathologist has a sound understanding of the entire gastro-intestinal tract and thus understands the relevance of various oesophageal disorders to swallowing function. He/she is able to develop a comprehensive treatment regime based on an understanding of the complete swallowing process. In collaboration with the dietitian, occupational therapist and physiotherapist, the speech pathologist develops an appropriate mealtime management plan. Dietitian assesses the persons nutritional status and nutritional requirements. He/she collaborates with the speech pathologist, occupational therapist and physiotherapist on devising an appropriate mealtime management plan or enteral nutrition plan where appropriate. The dietitian liases with and educates carers about the preparation of food and drinks at recommended consistencies and textures. He/she advises on meals and menus to meet the persons needs.
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Occupational therapist evaluates the persons ability to eat independently. He/she provides strategies (or a treatment plan) to manage sensory, motor, perceptual, physical and cognitive issues that may be affecting the persons eating and drinking. The occupational therapist evaluates posture of the person with other professionals and provides information on optimal positioning. He/she customises seating requirements, eating utensils, splints and straps in order to optimise the persons ability to eat independently or with assistance. Physiotherapist monitors the persons respiratory status and evaluates the effectiveness of their cough. He/she evaluates the persons posture and lung function and determines how these factors may impact on swallowing function. The physiotherapist consults with the occupational therapist on optimal positioning and provides chest physio and postural drainage when required. Nurse provides ongoing monitoring of the persons swallowing. He/she assists in implementing strategies devised by other team members. The nurse may alert the dysphagia team to people who are at risk. Doctor assesses and oversees the persons medical condition and medical treatment. He/she advises on the implications and aetiology of dysphagia. The doctor liases with medical specialists in arranging and interpreting further investigations.
Advisory members of a dysphagia team

Dentist provides ongoing dental hygiene to clients and advises on the persons dental health management. He/she assists in evaluating the suitability of prosthetic intervention to improve behaviours such as drooling or selfstimulation. Ear, nose and throat specialist (ENT) provides expertise on oro-pharyngeal function, and function of the larynx. He/she collaborates with the speech pathologist to conduct a fibre-optic evaluation of swallowing. The ENT provides expert advice on surgical options when required. Gastro-enterologist assesses and treats disorders of the gastro-intestinal tract. Gastroenterologists are also consulted in the evaluation of the suitability of gastrostomy or jejunostomy feeding methods. Neurologist evaluates the effects of underlying neurological condition on the persons swallowing and general health. Pharmacist advises on medication, which may be taken when a person presents with a swallowing difficulty.This includes medications that cannot be taken orally. He/she also advises on potential side effects of medication on swallowing.
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Prosthodontist manufactures prosthetic devices to assist with the persons swallowing. Psychiatrist evaluates and manages psychiatric disorders which interfere with the persons oral intake and nutrition. He/she may assist in behavioural as well as medical management. Psychologist develops behaviour management programs which will reduce undesirable behaviour that prevents the establishment or maintenance of swallowing and nutrition programs. Radiologist conducts the modified barium swallow assessment with the speech pathologist and lends his /her expertise to the interpretation of the swallow. Respiratory physician provides insight into the effect of the persons respiratory status on swallowing. Social worker acts as a liaison person between medically oriented teams and the persons family. He/she provides counselling and support to assist the person and those caring for that person in decisions regarding nutrition.
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MEALTIME MANAGEMENT
Good nutrition involves consideration of available foods and those eaten. However, people eat for many reasons other than health. The following will help enhance the enjoyment, safety and adequacy of mealtimes.
Environment
A noisy dining room with distractions such as a loud radio or TV, or a disruptive resident, makes it hard to enjoy meals and is often a reason for poor food intake. Distractions such as these can also be a safety issue for people with swallowing problems. The general appearance of a room, its lighting, furniture, furnishings and table settings all impact on mealtime satisfaction. Socialisation and communication are important for everyones quality of life, particularly for people with a disability. It is helpful to be relaxed, supportive and positive with the person at mealtimes. Eating with the person provides them with a good role model and encourages socialisation skills and appropriate mealtime behaviour.
Equipment
Make sure the person has appropriate equipment such as adapted cutlery and correct posture chairs to encourage maximum independence. Use clothing protectors which promote the persons dignity and are appropriate for their age.
Challenging behaviours
A persons behaviour may impact on their own and others food intake. Refer people with challenging behaviours to an appropriate psychologist or educational programmer who will develop a behavioural support program.
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Timing
Meal times should reflect those of the general community and be flexible enough to allow people to participate in a variety of activities, in and out of home. Some people may need more time than others to complete their meal and should not be unduly hurried. There should not be more than 14 hours between the evening meal and breakfast unless a substantial supper is provided.
Suggestions for successful mealtimes

Refer to the persons eating and drinking plan for recommendations. Eliminate distractions (for example, turn off the TV and try soft background music). Communicate to the person that it is mealtime. Give the person an opportunity to express any concerns or needs and address these as they arise. Communicate with the person during meals.
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POSITIONING FOR MEALTIMES The optimal position for safe eating and drinking
Individual assessment of the best positioning for safe eating and drinking is always necessary for those people who are fed by others. Refer to an occupational therapist, physiotherapist or speech pathologist for assessment. The following are general guidelines which may apply. Check this with the health specialist that assesses positioning. The optimal position for safe eating and drinking is to sit as upright as possible. The person should be well supported (if they have a physical disability or have difficulty supporting themselves) with head, neck, shoulders and upper body aligned. Their feet should be well supported (that is flat on the floor or on a foot rest). The persons head must be upright, with the chin slightly tucked in, not jutting out. If the persons head tilts back for any reason, there is a serious risk that the airway is opened and choking can occur. Optimal position for safe eating and drinking. Stability is important. This is best achieved when the person is sitting with their feet firmly on the floor or on the footplates of a wheelchair. Their arms should be resting on the table or tray of the wheelchair with elbows bent. If the person is eating in bed, it is equally important for them to sit as upright as possible. Correct positioning is also important for people who are receiving tube feeds. Sitting upright can be tiring for some people. The reasons why people may need help with eating or drinking varies from person to person and could well vary for the same person at different times. Sometimes specific instructions apply to people needing assistance during mealtimes. These instructions may include the use of equipment needed for positioning such as straps to hold feet steady, cuffs to hold arms in place, harnesses, shoulder brackets or a tray. Consult with an occupational therapist about seating issues.
Checklist for preparing a person to eat

Are there written instructions for this person that need to be followed? Are these instructions/guidelines accessible at mealtimes? Are these guidelines included in an eating and drinking plan? Does the person sit as upright as possible? Does the persons bottom reach the back of the chair or wheelchair? Is the person in their own chair or wheelchair, if it has been specially modified for them?
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Are the persons feet supported (on the floor, on a stool, on footrests of the wheelchair)? Is the lap belt firm, not allowing the person to slide forward? Is the table in the right position, not too low, too high or too far away? Are the arms of the person bent at the elbow, close to the body and free to move? The person should not need to support themselves with their arms. Does the person sit comfortably? Is the chin tucked slightly under, not jutting forward from the neck? Does the person breathe easily, without wheezing or undue noise? Can the person participate?
The position of the carer (feeder)

The person helping someone to eat or drink should be sitting at eye level. They should not stand. Food and drink must never be offered whilst standing or sitting behind a person. The person who is assisting also needs to be seated comfortably and in a stable manner. Correct positioning is also important after eating. An upright position for at least 30 minutes helps with digestion and reduces problems for those people who may have reflux. Refer to a physiotherapist, occupational therapist or speech pathologist for help if you notice that during mealtimes the person: Cannot hold their head up or steady while eating or drinking; Cannot sit upright but slides or slumps to one side; Cannot maintain an upright sitting position during mealtime; Arches their back, tilting the head backwards; Runs out of breath, coughs and gags; Cannot hold a spoon/fork; Cannot reach the floor with their feet while sitting at the table; Cannot reach the food on the table; Loses a lot of food and drink on to a bib, napkin or clothing while eating/drinking; Feet constantly slip off the footplates of the wheelchair. The person who is assisting should be sitting at eye level.
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EQUIPMENT
Information in this Section on Equipment is drawn from: 1. Evans Morris, S. & Dunn Klein, M. (1987) Pre-Feeding Skills Therapy Skill Builders,Tucson. 2. Starr, S. (1992) So Your Child Does not Want to Eat and/or has Feeding Difficulties An Information Manual, Westmead Hospital, Western Sydney Area Health Service, Sydney. 3. Resource Support Unit Staff (1986) Mealtimes for Severely Disabled Students, New South Wales Department of Education, Sydney. There are many pieces of equipment available to assist people with eating and drinking. This section provides information on some of the equipment available. It is meant as a guide only. If you are assisting a person with complex needs and have concerns about the mealtime equipment being used, seek assistance from an occupational therapist or a speech pathologist.
Review the basics

Before deciding if a person needs equipment to assist them with their eating and drinking, check the following: That the environment is as calm and ordered as possible. A calm environment will promote positive social interaction and reduce distractions that make concentrating on eating and drinking difficult; That the tray or table being used is at the correct height for the person, that is, not too high or too low; That the person is seated at an appropriate distance from the table. People who are independent or learning to feed themselves should be able to easily reach their meal. People who require assistance should be able to see their meal. Make sure that food and drink are safe from upset by involuntary movements; That the person is appropriately positioned. Appropriate positioning facilitates eating and drinking, decreases the possibility of aspiration (food or liquid going to the lungs rather than the stomach) and increases the persons control over the process. The way in which the person is seated or positioned for eating and drinking strongly influences the movement they have available for feeding and communication. The position of an assistant is also extremely important. See page 118-119 for information on positioning;
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That the type of food and drink offered is appropriate. For example, if someone is learning how to use a spoon, foods that have a firm consistency, like mashed potato, are the easiest to manage. Similarly, eating peas with a fork is hard work when you are in training! Please note: do not alter the consistency of a persons food if it has been prescribed by a speech pathologist. Once the basics have been reviewed, look at whether specific equipment might further assist a person to better manage their eating and drinking. The right equipment makes meal times more relaxed, safe and comfortable. It may also assist in the development of eating and drinking skills.
Cups
Choosing a cup The cup should fit the persons mouth, that is, not be too wide or too narrow, allowing them to close their lips around the rim. The person should be able to drink from the cup without tipping their head back. Tipping the head back opens the airway and increases the risk of liquid entering the airway. Cups with a gradual cut out on one side facilitate drinking without tipping the persons head back as they allow space for the nose. The cup should not shatter or break if the person bites on the edge. An unbreakable plastic cup is generally the most suitable for people who bite down on their cup. Cups with a thick, rolled or rimmed edge provide extra stability for people who need to hold onto the edge of the cup with their teeth. They can also assist lip closure and reduce the amount of liquid spilt out of the mouth. Cups with lids assist in reducing spillage. They can also control the flow of liquids. Lids without spouts promote lip and tongue control closer to that required for drinking from a regular cup. Straws allow better control of the liquid flow for people who have difficulty managing large volumes of fluid. Flexible plastic tubing used as a straw may better resist chewing. Tongue thrust and delayed swallow are two conditions for which straws are not recommended. When a person is dependent on others for full assistance with drinking A clear cup will allow the assistant to see how much liquid is taken and give better control over the flow of liquid.
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When a person is able to or is learning to drink independently The cup should be an appropriate size and shape. For example, not too big or too small, unbalanced or too tall. The cup should provide an appropriate means for the person to hold onto it. Cups with handles may be easier to manage for people with a physical disability. Wide base cups give greater stability and accommodate for less precise placement of the cup back on the table/rest surface.
Cutlery
Choosing cutlery The cutlery should not shatter or break if the person bites down on it. Solid plastic cutlery is better than metal for people with a bite reflex. Metal cutlery may provoke and increase a bite reflex. Plastic coated metal spoons are also available. Plastic cutlery may be better for people who are hypersensitive to temperature or taste. When a person is dependent on others for full assistance with eating The bowl (scoop part of the spoon) should be relatively flat so that food can be easily removed by the upper lip. A strong, plastic, flat bowled spoon called the Maroon Spoon (comes in two sizes) is widely recommended by speech pathologists for use with people who require assistance with eating. When a person is able to or is learning to eat independently A slightly deeper spoon bowl prevents food from falling off a spoon as easily as it does from a flat bowl. Cutlery should be an appropriate length for the size of the persons hand and their skill level. The longer the handle the more coordination is required to bring the spoon or fork to the mouth. Adjustable or built up handles can assist grasp. People with weak grasp or who are learning to hold a spoon, fork or knife may benefit from an adjustable or built up handle. Handgrips or irregular shaped handles may assist a person to hold the utensil more securely, preventing it from turning in their hand as they take it to their mouth. Spoon holders/cuffs can aid with holding cutlery if a person has difficulty with maintaining grasp throughout a meal.
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Shaped or angled spoons can make it easier for the food to reach the mouth if a person has difficulty with coordination or has a limited amount of movement of their arm or hand. Consider the weight of the cutlery. For example, people with reduced strength might find lightweight cutlery easier to use, while those with intention tremors (shaking when moving) might prefer weighted cutlery. Knives that use a rocking rather than a sawing action to cut can assist people with reduced strength or movement. Splayds (a cross between a knife, a fork and a spoon) can help people who use only one hand. Scoop dishes, rimmed plates and plate guards Raised edges on dishes or plates provide something to scoop against. They can help the person to focus on the process of getting the food on the spoon or fork and reduce the amount of food pushed onto the table. Manoy plates are sloped, wide-rimmed plates with an inner lip at the deep end to assist with scooping.They come in two sizes and are commonly used. Plate guards can be added to regular plates, however they can be pushed off by a keen scooper/stabber. Non-slip matting Non slip mats (for example, Dycem) can be used to help prevent utensils, cups or plates from slipping. Dycem is available in individual mats or matting rolls that can be cut to size. A thick quilted fabric tray cloth can offer a stable and aesthetic non-slip surface.
Contacts for equipment

The type of equipment discussed in this section is available through medical and rehabilitation companies and some chemists. The Independent Living Centre provides an information service and display centre for commercially available equipment. This service is able to provide a list of current known suppliers of specific equipment. Contact them at: The Independent Living Centre 600 Victoria Road. Ryde NSW 2112 Phone: (02) 9808 2233
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FOOD TEXTURES
Sometimes there is confusion about the terms used to describe food textures. There are important differences and if a particular texture has been recommended for a person, it is essential that the correct consistency is given. Make sure the food texture recommendation has been made, or confirmed by a speech pathologist, doctor or dietitian.
Soft diet
For a soft diet, foods are well cooked and very little chewing is required. Foods should not require very much cutting if any. Foods should be diced or sliced and should be able to be mashed easily with a fork. Unsuitable foods include those that are hard, stringy, tough or dry. Examples of unsuitable foods are crunchy salads, hard biscuits, grilled meat, nuts, fresh apples, grainy bread and cereals with dried fruit or nuts. See Appendix 5 for a Sample soft diet with thickened fluids.
Minced and mashed diet

For this diet , foods are minced or mashed and do not require chewing. This may require chopping finely, mincing or mashing. Foods should be moistened with sauce or gravy. Inappropriate foods include bread with crusts (unless softened), grainy bread, toast, pastry, unripened fruit, naturally firm fruit (e.g. apples), fruit with seeds (e.g. grapes), dry desserts or cakes, biscuits (unless softened), nuts and seeds.
Pureed diet
Also known as blended, homogenised, vitamised, this diet provides foods which are smooth and free of lumps. Texture should be consistent and should not separate into two states, for example, meat particles and fluid gravy. A pureed diet should be smooth but not too runny. Inappropriate foods to puree include rice, pastry based dishes, stringy vegetables and fruit such as celery and pineapple, salads, toasted or raw muesli, tough or gristly meat and meat which has been grilled or is otherwise dry. Yoghurt should be smooth and free of seeds (as found in passionfruit yoghurt) or fruit pieces. Refer to Resources for publications on texture modified foods.
A pureed diet
should be smooth but not too runny.
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Section 5
MODIFYING FLUID CONSISTENCY

The following information is reproduced with permission from Swallowing on a Plate, a manual produced by Centre for Education and Research on Ageing (CERA), (see Publications).
Thickeners for fluids

Commercial thickeners The table on page 126 provides some examples of commercially available thickeners. These have been rated as most acceptable with respect to flavour, colour, texture and/or cost. They are very easy to use. They do not require cooking and as such, are recommended for routine use. Other thickeners & naturally thick foods There are many naturally thick foods and fluids which may also be suitable, (e.g. thick custard, pureed fruit, junket, cream soups with mashed potato, thickshakes and smoothies). If you are unsure, check with a dietitian or speech pathologist. Thickening agents such as cornflour, plain flour or arrowroot can also be used. However, these are not recommended for regular use as they require cooking and are labour intensive.
Definitions of Fluid Consistencies

Thin Refers to fluids which are naturally very runny (e.g. water, tea, coffee, milk drinks, cordials, juice and nectar). Teaspoon test: Take a level teaspoon of fluid and lift. Tilt the teaspoon. The fluid should flow off very quickly in a continuous stream. Thick Refers to fluids which are thicker than thin but still pourable (e.g. soft yoghurt). Teaspoon test: Take a level teaspoon of fluid and lift. Tilt the teaspoon. The fluid should hold together better and flow more slowly than a thin fluid, that is in a semi-continuous stream. Very thick Refers to fluids which are not easily pourable, drunk from a cup or taken via a straw. These fluids require spoon feeding (e.g. thickshakes, milk puddings). Teaspoon test: Take a level teaspoon of fluid and lift. Tilt the teaspoon. The fluid should hold together well and drop off in a blob.
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Mealtime assistance
Commercial thickeners
Thickener Pregel starch
Supplier J. L. Stewart Unit 1 1B Red Bank Rd Northmead NSW 2152 Tel: (02) 9683 6322
Sizes Available Available in 2 kg bags. Ring for prices and delivery details.
Comments Best for milk drinks but acceptable for all. Thickens on standing and storage. Unsuitable for hot drinks. Does not thicken adequately using standard recipes, therefore more thickener is required.
Karicare Food Thickener
Nutricia Aust P/L PO Box 6745 Baulkham Hills BC NSW 2153 Tel: (02) 9894 6513 1800 060 057
Available in 200g Thickens on standing and and 500g tins. storage. Ring for prices and Unsuitable for delivery details. hot drinks. Does not thicken adequately using standard recipes therefore more thickener is required. Available in 227g Suitable for hot tins. Ring for and cold drinks. prices and delivery Mixes easily. details.
Resource Thicken-up
Axcess Home Health Direct Level 1 3 Smail Street Ultimo, NSW, 2007 Tel: (02) 9212 1402 1800 817 017
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Section 5
Preparation Guidelines
Some thickeners supply mixing instructions. However, it is recommended that the recipes provided below are used to ensure the appropriate consistency is achieved. These recipes will thicken fluids adequately for serving within half an hour of preparation.
What you will need

Blender/Food processor useful to ensure a smooth even consistency.
Particularly important for making up large quantities to prevent lumps forming.
Thickener select one of your choice or combine two to take advantage of
their properties (e.g. PREGEL for milk drinks).
Measuring spoons metric Australian.
Measuring jug clear plastic or glass for easy mixing and testing of consistency.
Fluid for thickening any fluid can be thickened including tea/coffee, juices,
cordials, soft drinks (affects effervescence), supplements (e.g. Sustagen, Ensure),
beer, and liquid medications (check with pharmacist thickeners may interfere
with the action of some medications).
Method
For immediate use 1. Follow the guidelines provided in the table on page 128 regarding the amount of thickener required. (Note: recipes do vary according to the type of thickener, batch of thickener, fluid and temperature of fluid used.). 2. Add half the thickener to half of the fluid. Mix with a blender until smooth. Add the remaining fluid followed by the thickener and blend until totally smooth and lump free (Tip: If making large quantities, it may be easier to weigh the thickener. The proportion of thickener to fluid may need to be adjusted). 3. Leave the thickened fluid for approximately 30 minutes to set. Test the consistency by using the teaspoon test described on page 125. Adjust if required. 4. Heat the thickened fluid in a microwave oven before serving for hot drinks (e.g. thickened tea). For storage and later use Make up thickened fluid by following steps 1 and 2 above. Store thickened fluid in the refrigerator until required. It is recommended that fresh fluids are made up daily and leftover fluids are discarded after 24 hours. Remove the thickened fluid from the refrigerator when required and stir well to ensure a uniform consistency.
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Test the consistency before serving by using the teaspoon test (described on page 125). Thickened fluids tend to get slightly thicker upon storage. Adjust the consistency if required. Stir well. Re-test and serve if it is at the correct consistency. Heat the thickened fluid in a microwave oven before serving for hot drinks (see step 4 on page 127). Amount of thickener required to thicken 500ml orange juice Consistency thick Pregel starch Karicare Food Thickener 7 Tablespoons (39g) 7.5 Tablespoons (44g) very thick 7.5 Tablespoons (41g) 8 Tablespoons (46g)
Amount of thickener required to thicken 500ml milk Consistency thick Pregel starch Karicare Food Thickener 7 Tablespoons (39g) 7.5 Tablespoons (44g) very thick 7.5 Tablespoons (41g) 8 Tablespoons (46g)
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Section 6
Individual planning
129
130
Individual planning
Section 6
THE INDIVIDUAL PLAN (IP)

Nutrition and swallowing risks which are identified by the checklist must be included when goals are developed for the IP. Example 1: A person may have been identified as being obese. A long term goal for that person could be to attain a healthy weight. Short term goals could be (a) to try simple strategies to assist the person to lose weight, (b) to refer to a dietitian if there is unsatisfactory weight loss, or (c) review the impact of the persons medication with the doctor. Example 2: A person may have been identified as gagging when eating. A goal for that person would be to obtain an assessment and management plan from a speech pathologist.
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Individual planning
DEVELOPING AN EATING AND DRINKING PLAN What is an eating and drinking plan?
An eating and drinking plan is an easy to understand record of how to best assist a person to eat and drink. Its purpose is to ensure that good practice standards are maintained at all times for a person with nutritional and/or swallowing difficulties and that their mealtimes are enjoyable, safe and dignified.
Who should prepare an eating and drinking plan?

Carers of people with a disability should prepare the plan from all information that has been prescribed by health specialists (e.g. dietitian, speech pathologist, occupational therapist and physiotherapist). A sample eating and drinking plan is shown on page 133. The eating and drinking plan is not an assessment report but a summary of recommendations for mealtimes. It may provide details on positioning and seating, equipment, assistance required, food and drink preferences, food and drink consistencies and suggested food items and quantities. See Appendix 6 for a suggested format for an eating and drinking plan. Information contained in an eating and drinking plan needs to be updated regularly, depending on the needs of the person. Ensure you write the date for review on the plan.
Where should an eating and drinking plan be kept?

An eating and drinking plan should be kept in the dining area or where those people assisting the person at mealtimes can easily access it. It is also important that a copy of this plan is supplied to all people who may have care of the person with a disability (e.g. family members, holiday providers, school staff and day care providers).
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SAMPLE EATING AND DRINKING PLAN
Name: Date:
John Citizen
Prepared by:
D.O.B.:
15/10/1972 10/9/2000
10/2/2000
Mary Brown
Date for review:
Please note:
John tends to eat very quickly and is easily distracted

Requirements for eating Requirements for drinking
Type of diet: eg: normal, reduction, milk free, vegetarian Texture/consistency eg: soft, minced, puree, nector, thick
Reduction diet
Reduction diet
Soft, easy to chew
Thin fluids
Positioning
Seated upright in dining chair Encouragement to slow rate of eating Spoon with built up handle Meat or chicken Spicy food, fish
Seated upright in dining chair Encouragement to slow rate of drinking Cut out nosey cup
Assistance required
Equipment required
Personal preferences
Personal dislikes
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Individual planning
SUGGESTED MEAL OUTLINE
Name: Date:
John Citizen
Prepared by:
D.O.B.:
15/10/1972 10/9/2000
10/2/2000
Mary Brown
Date for review:
Please note:
John tends to eat very quickly and is easily distracted 2 WeetBix + skim milk + 1 teaspoon of sugar 1 slice wholemeal bread + scraping of polyunsaturated margarine + Vegemite Cut bread into small bite size pieces Tea + skim milk Water or low joule cordial 1 sandwich made with wholemeal bread, scraping of polyunsaturated margarine or none. soft filling (e.g. hard boiled egg mixed with low joule mayonnaise + shredded lettuce). Remove the crusts and cut into bite size pieces 1 soft piece fruit (e.g. banana, mango slices, ripe pear). Water or low joule cordial Tea + skim milk Small serve of soft lean meat or chicken with skin removed 1 potato or small serve of rice or pasta prepared without fat At least 3 serves of soft vegetables Fresh or canned fruit in natural juice Milk based low fat dessert (e.g. low fat custard) Tea + skim milk Tea + skim milk 1 scone or English muffin or 1 slice wholemeal bread with scraping of polyunsaturated margarine and jam, cut into bite size pieces
Breakfast:
Morning tea: Midday:
Afternoon tea: Evening meal:
Supper:
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Section 7
Managing food in a home
135
Section 7
136
Section 7
MENU PLANNING Why plan a menu?

A group home is a little different to a family situation because a number of people are responsible for providing food to the person requiring care. When staff of a group home are on a roster or are temporarily replaced by casual workers, it is difficult to ensure that the important aspects of nutritional care for residents are followed consistently and reliably. A planned, written menu helps to: Make sure that meals are well balanced and nutritious; Save money and time; Make shopping easier; Decrease repetition of meals; Reduce wastage of food; Involve the residents in decision making and choice.
Steps to plan a menu

1. Decide on a sample daily meal plan to suit the needs of the residents. This includes considering balanced nutrition, texture requirements and work commitments. A sample daily meal plan is provided on page 139. 2. Decide how often the menu will be planned. A period of at least two weeks allows for consultation with residents and preparation of shopping lists. It is often effective to have a cycle menu of say four weeks which has flexibility for change. A sample menu for one week of a cycle is provided on page 140. It is a good idea to change the menu cycle options for winter and summer. 3. Set aside definite time with staff and residents to plan the menu. 4. Have sufficient written recipes available to assist in planning. Large photographs or pictures of dishes are helpful to assist residents in making their choices. 5. Check the menu against the questions listed in the menu checklist on page 138. 6. Write down the menu against the questions listed in decisions, prepare a shopping list and make sure that the menu is available in the kitchen. 7. Evaluate the menu regularly. Ask the staff and residents for their comments. 8. Keep a copy of the menu on file for future reference.
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Section 7
Menu checklist
Does the menu follow the guidelines given in SECTION 2 Good nutrition for good health? Does the menu provide variety of taste, colour, temperature and presentation? Is the menu suitable for available food supplies, kitchen equipment and time available? Does the menu reflect modern popular dishes and community eating preferences? Have the residents and staff been included in the menu planning process? Is the menu appropriate for the season? Do the relevant people have the skills to prepare the dishes and are recipes available?
SHOPPING TIPS
Prepare a shopping list. Check the refrigerator and pantry before going shopping. Buy fruit and vegetables in season. Be on the look out for specials which can be used. Frozen and canned varieties can be included. Consider quality and price. Avoid foods that are expensively packaged. Check the use-by dates. Compare the prices of different brand names and generic brands. Check the net weight.
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Section 7
SAMPLE DAILY MEAL PLAN
Breakfast:
Fruit juice or fruit Selection of breakfast cereal and milk on weekdays Hot course on weekend days Toast Drink Fruit Drink Sandwiches/salad with bread on weekdays Light dish on weekends Drink Light snack (e.g. plain cake, muffin, scone, toast, savoury biscuits) Drink Main dish Vegetables Dessert Bread Drink Biscuits Drink
Morning tea: Lunch:
Afternoon tea:
Evening meal:
Supper:
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140
Section 7
SAMPLE MENU FOR ONE WEEK OF A CYCLE
Monday Fruit/Juice Cereal Toast Drink Small salad Bread roll Fruit & custard Drink Mixed sandwiches Tub of yoghurt Drink BBQ lunch Bread roll Milk drink Fruit/Juice Cereal Toast Drink Fruit/Juice Cereal Toast Drink Fruit /Juice baked beans Toast Drink
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday Fruit /Juice Poached egg Toast Drink Savoury pasta Salad Fresh fruit Drink
Breakfast
Fruit /Juice Cereal Toast Drink
Fruit/Juice Cereal Toast Drink
NUTRITION IN PRACTICE MANUAL Chicken curry Rice Beef lasagne Side salad Fried rice & steamed dim sims Fruit salad & ice cream Fresh fruit Baked custard Salmon cakes Mashed potato Carrot sticks Zucchini Bread & butter pudding
Midday
Mixed sandwiches Tub of yoghurt Drink
Filled pita bread Mixed Fresh fruit sandwiches Milk drink Fresh fruit Tub of yoghurt Drink
Evening
Roast lamb Roast potatoes Pumpkin Broccoli Stewed fruit & ice cream
Pork stir fry Rice
Fruit crumble & custard
Beef & lentil caserole with vegetables Steamed potato Stewed fruit & custard
Section 7
MULTICULTURAL CONSIDERATIONS
The following has been reproduced with permission from: Gallegos, D.L. & Perry, E.A. (1995) A World Of Food A Manual to Assist in the Provision of Culturally Appropriate Meals for Older People, Vol. 1, National Food and Nutrition Policy Project, Commonwealth of Australia copyright. Food is much more than a biological necessity. For many people it represents comfort, love, security and a sense of belonging. For others, food may be an expression of religious piety or a strong philosophical statement. It is important to reflect Australias multicultural society in any setting where people reside. This helps people to feel part of a group and affirms their cultural origins and identity. It also encourages people to gain comfort from familiar foods and experience an exciting array of tastes.
Food is much
more than a biological necessity. For many people it represents comfort, love, security and a sense of belonging.
Judaism
A person who practices Judaism is called a Jew. Orthodox Jews have a dietary system called Kashrut. They believe that these laws are the laws of God and cannot be violated. Foods which are permitted are referred to as kosher. As with all religions there are degrees of observance. However many Jewish people take these rules extremely seriously. Food regulations Some examples of Kashrut food regulations are: Certain animals are considered unclean and should not be eaten. These include pigs, any fish without fins or scales including catfish and shellfish, rabbit, camel and birds that seize food in their claws (e.g. wild birds and birds of prey); Animals which are edible are those that have split hooves and chew their cud. They must be properly slaughtered, following strict rules and done by qualified people under the supervision of a rabbi; Milk and meat products are not to be eaten, stored or prepared together. Consequently, most Jewish households have easily identified separate sets of cutlery, crockery, storage facilities and cooking utensils for milk and meat products. Jewish people wait either three or six hours (depending on their individual custom) after having a meat meal, before partaking of any dairy food. The same applies to eating meat after partaking of hard cheese; Separate cutlery and crockery is required at Passover and is not used at any other time of the year.
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Providing meals for a Jewish person. Discuss food requirements with the person and/or their family. Determine which foods they wish to exclude and their degree of observance. Some Jews would, rather than risk the chance of receiving non-kosher meats, prefer to eat meatless meals. Make sure that the diet is healthy and well balanced (refer to SECTION 2 Good nutrition for good health). Contact the local Jewish community to find out the closest supplier of kosher meats and other kosher products. Sometimes it is possible to order cooked/chilled/frozen kosher meals from a supplier. Some special days of observance Sabbath Passover A day spent in prayer, study, rest and family feasting. Lasts from sunset each Friday to nightfall on Saturday. Celebrates the Exodus from Egypt. After a meal on the first night, nothing leavened with yeast must be eaten for eight days. Matzo is often eaten. Is identified as the time of the giving of the Torah on Sinai. Fish is allowed but no meat.
Shavuot
Rosh Hashanah The New Year period which lasts for 10 days. Sweet foods are eaten to symbolise a sweet year. Salads and sour foods are avoided. Yom Kippur The Day of Atonement is the holiest day in the Jewish year and is spent in fasting, prayer and repentance. A 25 hour fast lasts from the hour before sunset until nightfall the next day. After the fast, a family feasts. Festival of Lights, lasting for 8 days in December.
Hannukkah
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Section 7
Islam
A person who practices Islam is called a Muslim. Islamic spiritual, physical and community life is based on the precepts set down in the Quran, the Islamic Holy Book. The Quran also outlines specific food regulations which must be adhered to. Food which is suitable for eating is called Halal. Food which is forbidden is called Haram. As with all religions there are degrees of observance. While the Islamic religion transcends all borders and all Muslims will eat food prepared by another Muslim there are cultural variations. A Malaysian Muslim, for example, will eat different food to an African Muslim. Food regulations According to Islamic faith a Muslim must not: Eat or handle pork products including such items as biscuits, cakes and bread which have pork fat as one of their ingredients; Eat any meat not killed in a lawful way, that is, non-Halal meat; Eat food prepared in pots or with utensils used in cooking non-Halal food; Drink any form of alcohol or food containing alcohol. Other important points to note: A Muslim is expected to eat for survival and therefore is advised not to overeat. Consequently, they may leave an uneaten portion on their plate. Large amounts of untouched food may indicate a problem with food acceptance or a health problem which needs to be monitored; A Muslim will wish to wash their hands before and after a meal; A Muslim may or may not use utensils to eat, depending on ethnic origin. They may choose to eat their meal with their right hand. The left hand is considered unclean and has negative connotations with regards to body hygiene.
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Providing meals for a Muslim person Discuss food requirements with the person and/or their family. Determine which foods they wish to exclude and their degree of observance. Contact the Islamic Council to obtain a list of Halal foods and suppliers of Halal meat. Have on hand ingredients for a vegetarian meal in case the meal provided is not appropriate for that person. Some special days of observance Ramadan Ramadan is the period of fasting undertaken by Muslim. It lasts for approximately 30 days every year. Muslims exempt from fasting include: Menstruating women; Pregnant and lactating women; Those suffering from ill health (e.g. diabetes); Frail older people. No food or drink is taken from sunrise to sunset. The fast must not begin on an empty stomach, so Muslims will eat something before sunrise during Ramadan. Idul Fitri (HariRaya) Idul Fitri commemorates the end of the fasting month. The celebration occurs on the first day after Ramadan and starts with communal prayers at the mosque. It is a family day and it is every parents wish to have their children around them on this day. Relatives and friends get together to ask each other for forgiveness. Remembrance of the Dead Every year in the month preceding Ramadan each family remembers their dead with a short prayer service in the home followed by a meal. Close friends and relatives are invited to participate in prayers and partake of the meal.
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Section 7
FOOD SAFETY IN THE HOME

Reports of food poisoning are on the rise in Australia. Reasons for this include better detection, greater awareness, more imported foods, greater exposure through foods eaten away from home and new strains of bacteria. Twenty percent of food poisoning, however, is the result of eating food at home.
Twenty percent
of food poisoning, however, is the result of eating food at home.
What leads to food-borne illness

For illness to occur: The food poisoning variety of bacteria need to be present in food. They cannot be seen or smelt (unlike food spoilage bacteria) and so it must be assumed that bacteria are present and food should be handled accordingly; Bacteria need to grow and multiply and so need a food source. Typical foods that provide ideal conditions for bacterial growth are meat, poultry, seafood, eggs, dairy products and rice; Bacteria need time to multiply to an infective dose. It takes up to three to four hours before bacteria will have multiplied into a large enough number to cause illness; The growth of bacteria only occurs between 4C and 60C. This is known as the danger zone. Refrigeration does not kill bacteria. Cooking or reheating to 75C will.
Common situations that may lead to food poisoning

Some common situations that may lead to food poisoning are: Food prepared too far in advance; Food cooled too slowly; Food not reheated to high enough temperatures; Food under-cooked; Food thawed inappropriately; Cross contamination; Hot food stored below 60C; Leftovers used inappropriately; Cold food stored above 4C.
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Prevention of food poisoning

Many precautions can be taken to minimise the risk of food-borne illness. They are addressed below under several headings. Food purchase Purchase from a reputable supplier. Check use-by or best-by dates. Check that the packaging is intact. Storage Ensure that food storage areas (including refrigerator) are cleaned on a regular basis and that pests and pets do not have access to these areas. Defrost the freezer on a regular basis. Dry storage areas should be cool and dry. When new stock is purchased, bring the old stock to the front so that it will get used first discard any that is out of date. If raw meat is in the fridge (either stored for immediate use or thawing), place it on a lower shelf so any drips do not contaminate other foods. All other foods should be covered or in containers. Ensure that household chemicals are stored separately from food and kept in their original containers. Food preparation Food preparation should occur quickly. If an interruption is necessary, place all prepared foods in the refrigerator until preparation can resume. Good personal hygiene is mandatory (see Personal Hygiene on page 147). Cook food thoroughly and serve immediately. If a meal is to be saved for later, allow the steam to stop, then cover and refrigerate. Mark with a date and time. Reheat thoroughly and serve. Do not reheat food more than once. If a food, like custard for example, is to be used again the next day, cover and refrigerate as quickly as possible. Mark it with a date and time. Discard if not used in 24 hours. If a prepared food is to be frozen, place it in a sealed container, mark with a date and time and place in the freezer as soon as the steam has stopped. Place foods in small quantities so they will freeze quickly. Never keep food that has been partially eaten. Remove waste from the kitchen regularly. Do not allow pets in the kitchen. Ensure the kitchen is kept clean at all times and free from pests. 146 NUTRITION IN PRACTICE MANUAL
Section 7
Personal hygiene Hands must be washed thoroughly: Before preparation of food commences; After going to the toilet; After handling garbage; After having a cigarette; After feeding or patting a pet; After eating. Clothing should be clean. You should not prepare food if suffering form a gastrointestinal illness. Food should not be eaten while preparing food. Packing food for eating away from home Observe all of the above for preparation of the food. Wrap and place in an insulated container with a cooling brick. Keep in a cool place until ready to consume. If clients are involved in food preparation The information set out above is not meant to exclude clients from the enjoyment of food preparation. Clearly, their personal hygiene is of great importance if they are to be involved. If it is difficult for an individual client to achieve an appropriate level of hygiene, some activities that carry less risk are: Setting the table; Putting bread in a basket using tongs; Preparation of plain cake items (e.g. pikelets); Setting a water jug and glasses; Washing and preparing vegetables that are to be cooked.
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Section 7
DINING OUT
Everyone likes to have a change of eating environment occasionally. Dining out helps residents to experience a wide variety of different foods. Unless people are given regular opportunities and encouragement to try new foods, they will not change their preferences. However, many commercially available meals, especially takeaway and fast foods, are high in fat and salt. It is therefore not healthy to eat these foods too often. Food outlet Take away shop Instead of Fried fish Meat pie, sausage rolls Chips Try this Grilled fish & salad Plain hamburger or steak Sandwich with salad Felafels Filo pastry savouries (e.g. spanokopita) Jacket potato Ask for less cheese and seafood or vegetarian toppings Add salad Grilled seafood Pasta with tomato based sauces Minestrone soup Plain crusty bread Steamed rice or noodles Steamed or braised dishes Steamed dim sims or spring rolls Clear soups Barbecued chicken (take the skin off) Skin free chicken A taco, burrito or enchilada with salad, beans and a small serve of lean meat, chicken or cheese. Muffins, plain cake, finger buns, fruit scones, fruit loaf
Pizza parlour
Fatty toppings such as salami or pepperoni
Italian restaurant
Lasagne, pasta with cream sauces Garlic bread
Chinese or other Asian restaurant
Fried rice Deep fried and battered foods
Chicken
Deep fried chicken Chicken nuggets Dishes with lots of cheese or sour cream
Mexican restaurant
Bakery /cake shop
Pastries and rich cakes
148
Glossary
149
Glossary
150
Glossary
Adult in this manual, adult refers to anyone 18 years of age or over Aspiration food, fluid or saliva going into the airway, below the vocal cords Child in this manual, child refers to anyone under 18 years of age Congee type of porridge made from rice, which is cooked until very soft Diuretic something that makes you pass more urine Duodenum the first portion of the small intestine Dysphagia difficulty in swallowing Eczema itchy skin which does not produce a rash unless scratched Enteral feedings a method of delivering nutrients to the body directly to the gastrointestinal tract via a tube Gastrointestinal tract the passage which starts at the mouth and goes down the oesophagus, stomach, duodenum, small and large intestine, rectum and anus Health specialist the term is used in this manual to refer to any professional person providing a specialised health service. They may be an allied health professional such as a dietitian, speech pathologist, occupational therapist or physiotherapist. They may also be a clinical nurse specialist, dentist, doctor or medical specialist. For the purposes of this manual, psychologists and educational programmers are also included in the term health specialist Hives itchy rash on the skin Hypoglycaemia an abnormally low concentration of glucose in the blood Hypertension high blood pressure Hypotension an abnormally low blood pressure Impaction when there is a large compacted mass of faeces which cannot be passed Intestine general term used for the small intestine (which helps the body absorb nutrients) and the large intestine (which forms, stores and expels waste from the body) Laxative a substance which assists emptying of the bowel Metabolism changes concerned with the use of food by body organs Oesophagus tube connecting the back of the mouth with the stomach or gut Oral by mouth Osteoporosis thin and brittle bones which are easily broken
151
Glossary
Paediatrician a medical doctor who treats children and infants Pharyngeal throat RAST special type of skin test used to diagnose allergies Rectum last portion of the large intestine before the anus Reflux food or fluids flowing back up into the oesophagus from the stomach Regurgitate to bring back into the mouth after swallowing Rumination habitual regurgitation of food from the stomach after it has been swallowed Stoma therapist someone who helps people who have an artificial opening into their gastrointestinal tract Vertigo giddiness, dizziness
152
Resources
153
154
Resources
Publications
PUBLICATIONS Nutrition
The Healthy Homes Guide is a joint project between the Blue Mountains
District Anzac Memorial Hospital, Wentworth Area Health Service, the
University of Newcastle and the Blue Mountains Residential Services.
To order a copy contact the Community Dietitian
Blue Mountains Hospital
Locked Bag No 2
Katoomba NSW 2780
Phone 02 47894 6595
Fax 02 4784 6980.
The Healthy Homes Guide is a nutrition guide that aims to improve the food
and nutrition standards of the group homes environment. It acts as a reference
on nutrition and exercise, healthy recipes, menu planning, and food safety.The
manual contains a food and nutrition survey that staff can use to assess the
standards of food in their group home.
Community Nutrition Unit, Community Health Services, Hunter Area Health
Service (1999) The Food Guide: A nutrition guide for group home staff.
To order a copy contact Dietitian, Eastlakes Community Health
Cnr South & Cherry Street
Windale NSW 2306.
Phone 02 4948 7044
Fax 02 4948 8063.
The Food Guide covers general nutrition and physical activity information. It
focuses on how to increase clients fibre intake and lower their fat intake.
These dietary principles are important for general well being and for the
prevention and management of the following conditions: obesity, high
cholesterol, maturity onset Diabetes and constipation.
Dick, M. The Food Book, Central Sydney Area Health Service (CSAHS), Boarding
House Team.
Available from the Boarding House Team of CSAHS.
Phone 02 9556 9313.
This is a practical guide to menu planning and food provision in residential
services such as licensed residential centres (licensed boarding houses), small
residential facilities, group homes. It is suitable for people with poor literacy
skills.
155
Resources
Gallegos, D.L. & Perry, E.A. (1995) A World Of Food A Manual to Assist in the Provision of Culturally Appropriate Meals for Older People, Vol. 1 & 2 Australian Government Info Shop 32 York Street Sydney NSW 2000 Tel 02 9242 8500
Dysphagia
Lane, M. & McLaughlin, L. (1999) Smooth Food Practical food and nutrition guide for parents and carers of children with eating and swallowing problems Martin, J. & Backhouse, J. Good Looking, Good Swallowing Creative Catering for Modified Texture Diets. JFC Foundation PO Box 221 Unley SA 5061
Smooth Food Recipe booklets

Set of 7 Breakfast Desserts Lunch Party foods Vegetables Main meals Thickened drinks
Disability Services Commission PO Box 441 West Perth WA 6872 Fax: 08 9226 2307
Equipment
Swallowing on a Plate The Centre for Education and Research Agency 6/A Concord Hospital Hospital Road Concord NSW 2139 Phone 02 9767 7212 E-mail cera@med.usyd.edu.au Evans Morris, S. & Dunn Klein, M. (1987) Pre-Feeding Skills Therapy Skill Builders, Tucson. Resource Support Unit Staff (1986) Mealtimes for Severely Disabled Students, New South Wales Department of Education, Sydney. Starr, S. (1992) So Your Child Does not Want to Eat and/or has Feeding Difficulties An Information Manual, Westmead Hospital, Western Sydney Area Health Service, Sydney.
156
Resources
PROFESSIONAL ORGANISATIONS
Dietitians Association of Australia (NSW Branch)
1/8 Phipps Street
Deakin ACT 2600
Tel/fax (02) 6282 9798
1300 658 196 (excluding mobiles)
GISS (Gastronomy Information Support Service) NSW
Central Organising Committee
c/o The Spastic Centre of NSW
PO Box 184
Brookvale NSW 2100
Tel: (02) 9451 9022
The Independent Living Centre
600 Victoria Rd
Ryde NSW 2112
Tel 02 9808 2233
Nutrition Australia
(Formerly The Australian Nutrition Foundation)
c/- The Exercise Science and Rehabilitation Centre
University of Wollongong
Northfields Avenue
Wollongong NSW 2522
Ph: (02) 4221 5346
Fax: (02) 4221 5717
E-mail: nsw@nutritionaustralia.org
Westmead Centre for Oral Health
Westmead Hospital
Darcy Road
Westmead NSW 2145
Tel: (02) 9845 7423
Fax: (02) 9893 8671
157
158
Appendices
Appendix 1
CHECKLIST INSTRUCTIONS What is the purpose of the checklist?

The Nutrition and Swallowing Risk checklist is a way of screening people for difficulties related to nutrition and swallowing. It cannot make a diagnosis of a medical condition. A diagnosis can only be made by a health specialist. The checklist was developed as a means of raising awareness of nutritionrelated problems in people with a disability. It has been developed to be used by people who care for people with a disability. By asking questions about a persons health, weight and their ability to eat and drink, the checklist will help you decide if further assessment and action is needed, including advice or assessment by a dietitian, speech pathologist or other health specialist.
Who should complete it?

If you are completing the checklist you should know the person with a disability well. You may be the case manager or person responsible for developing the Individual Plan (IP). Collaboration with a parent or family member may be helpful so that you arrive at the most accurate result. Complete the checklist with the assistance of the person with a disability as much as possible. Referrals This marker used throughout the checklist. It indicates where you can find more information about a particular topic in the Nutrition in Practice manual.
How to complete it
Part 1 Preliminary profile Gathers and evaluates information about the persons weight and height. In this section you have to write in the information requested for some questions and tick the relevant box for others. Part 2 Nutrition Risk and Swallowing Risk checklist Assesses if the person has indications of nutritional problems or swallowing difficulties that may affect their nutrition and health. Tick the relevant box for each question. Part 3 Summary of results Summarises your results. Some risks may need notes of explanation or extra information. Write this in the comments column. Decide what actions you are going to take or recommend and write this in the action decided column.
Instructions
Do not guess answers

Try to obtain all the information you need to complete the checklist. For example, you may need to look at the persons weight records to work out if they have lost or gained weight over the past three months. If there are no records and you are not able to measure height or weight, you should still complete as much of Part 1 as you can, and then complete Part 2 to the best of your knowledge. Be observant. Do not guess answers. Use your powers of observation to answer questions about how the person eats and drinks. If you are unsure or do not know the answer to a question, you may need to seek another persons opinion. If the answers are still uncertain, tick the Unsure/Do not know box and refer to a health specialist for assistance.
Part 1
PART 1 PRELIMINARY PROFILE The person with a disability

Name: _________________________________ Gender: Date of birth: ____________ Age: __________
Residential address: _______________________________ Post code: _______
This address is:
Male
Female
Has the Nutrition and Swallowing Risk checklist been used before for this person?
an independent residence a family home a group home a residential centre other (specify) ______________
Yes No If yes, when? Date ____________
The person conducting the checklist

Your name:______________________ Date checklist completed: _________
(person completing the checklist)
Your relationship to the person with a disability:
case worker case manager residential care worker nurse parent other less than 6 months 6 months to 1 year 12 years 25 years more than 5 years the persons home the persons school the persons work a Community Service Centre other (specify) _____________ self the person with a disability parent (of the person with a disability) close relative ______________ close friend _______________ other (specify) _____________
How long have you known the person?
Where is the checklist being completed?
Who is the person providing the information so you can complete this checklist? (tick more than one box if needed)
Part 1
Weight information
Refer to page 9 of the Nutrition in Practice manual for information on how to measure height and weight. Current weight without shoes (e.g. 69.5 kg): __________ kg.
Date measured: __________
If you have no information on the persons weight, why not? _______________
Weight change over the past three months: _______ kg Do you have weight records for the past three months?
gained or, Yes
lost
No
Height information
Current height (measured standing and without shoes) (e.g.164cm or 1.64 metres): _____________ Date measured: ___________ If you have no information on the persons height or you are not able to measure their height, why not? _______________________________________________________________ Note: For children and young people aged under 18 years, their growth rate should be assessed by a GP, paediatrician, early childhood nurse or dietitian every year. Has this happened? Using the weight and height information If the person is an adult, mark the spot on the chart (below) where their height and weight meet.
Yes
No
Part 2
PART 2 NUTRITION AND SWALLOWING RISK CHECKLIST

Tick an answer box for each question. The explanations beneath each question will help you complete the checklist in addition to the Nutrition in Practice manual references. There are 24 questions.
Question 1.
If the person is a child (i.e. under 18 years of age) have they lost weight or failed to gain weight over the last three months?
You will need weight records to answer this question accurately Refer to page 10
Question 2.
Is the person underweight? Tick the Yes box if either of the following apply: The person is an adult and their weight on the Weight for Height Chart is in the underweight or very underweight range; When you look carefully at the person (adult or child), their bone structure is easily defined under their skin. This can indicate significant loss of fat tissue and is easily checked by looking around the persons eyes and cheeks. Other areas to check include the shoulders, ribs and hips.
Question 3.
Has the person had unplanned weight loss or have they lost too much weight? Tick the Yes box if any of the following apply: The persons weight loss is undesirable or has been unexpected; The person is under 18 years of age and there is weight loss in two or more consecutive months; The person has lost weight in two or more consecutive months and is not on a monitored weight loss program.
Part 2
Question 4.
Refer to page 16 Is the person overweight? Tick the Yes box if either of the following apply: The person is an adult (i.e. over 18 years of age) and their weight on the Weight for Height Chart is in the overweight or obese range. The person (adult or child) appears to have rolls of body fat (e.g. around the abdomen).
Question 5.
Refer to page 18 Has the person had unplanned weight gain or have they gained too much weight? Tick the Yes box if either of the following apply: The persons weight gain is undesirable or has been unexpected. The person is not on a weight gain program and their clothes no longer fit.
Question 6.
Refer to page 20 Is the person receiving tube feeds? Tick the Yes box if the person is receiving naso gastric, naso-duodenal or gastrostomy feeding.
Question 6a.
Refer to page 21 If you answered Yes to question 6, does the person also receive food or drink through the mouth? Tick the Yes box if the person receives any food or drink by mouth, in addition to tube feeding. If the person is receiving tube feeds and no other food by mouth, then answer only questions 10, 13, 14, 16, 18 and 19. Not applicable Yes No Unsure/Do not know
Part 2
Question 7.
Is the person physically dependent on others in order to eat or drink? Tick the Yes box if: The person cannot put food or drink into their own mouth and someone else is needed to feed them; The person is dependent on assistance during a meal (e.g. guidance with utensils).
Question 8.
Has the person had a reduction in appetite or food or fluid intake? Tick the Yes box if either of the following apply: The person is not eating or drinking as much as they usually do and this is unintentional; The person appears unwilling to take most food offered to them and the equivalent of six large glasses of fluid each day.
Question 9.
Does the person follow, or are they supposed to follow, a special diet? Tick the Yes box if they are on, or are supposed to be on, any of the following dietary plans: Pureed, minced, chopped or soft foods; Thickened fluids; Weight reduction or weight-increasing; Low fat; Vegetarian; Low cholesterol or cholesterol-lowering; Diabetic; Any other diet which modifies or restricts foods or food choices.
Part 2
Question 10.
Refer to page 27 Does the person take multiple medications? Tick the Yes box if: The person is usually on more than one type of medication.
Question 11.
Refer to page 28 Does the person select inappropriate foods or behave inappropriately with food? Tick the Yes box if any of the following apply: The person over-consumes alcohol or coffee, tea and cola drinks; The person eats non-food items such as dirt, grass or faeces; The person drinks excessive amounts of fluid; The person steals or hides food.
Question 12.
Refer to page 30 Does the person usually exclude foods from any food group? Tick the Yes box if the person usually excludes all foods from one or more of the following groups of food: Bread, cereals, rice, pasta, noodles; Vegetables, legumes; Fruit; Milk, yogurt, cheese; Meat, fish, poultry, eggs, nuts, legumes.
Question 13.
Refer to page 32 Does the person get constipated? Tick the Yes box if either of the following apply: The persons bowel movements are irregular, painful and sometimes infrequent; Laxatives, suppositories or enemas are required to maintain regular bowel movements.
Part 2
Question 14.
Does the person have frequent fluid-type bowel movements?
Question 15.
Does the person have mouth or teeth problems that affect their eating? Tick the Yes box if any of the following apply: The persons teeth are loose, broken or missing; The persons lips, tongue, throat or gums are red and inflamed or ulcerated; The person has a malocclusion (upper and lower teeth do not meet) and this affects their ability to chew. Yes Refer to page 34 No Unsure/Do not know
Question 16.
Does the person suffer from frequent chest infections, pneumonia, asthma or wheezing? Tick the Yes box if any of the following apply: The person has had frequent chest infections or pneumonia; The person is usually chesty or has difficulty clearing phlegm; The person has asthma or wheezes.
Question 17.
Does the person cough, gag and choke or breathe noisily during or after eating food, drinking, or taking medication? Tick the Yes box if any of the following apply: The person sometimes coughs or chokes during or several minutes after eating, drinking or taking medication; The persons breathing becomes noisy after eating or drinking or while talking; The person gags on eating, drinking or taking medication.
Part 2
Question 18.
Refer to page 40 Does the person vomit or regurgitate on a regular basis? (Note:This question is not applicable to infants under 12 months of age)
Tick the Yes box if either:
The person vomits or regurgitates (i.e. brings up) food, drink or medication more than once per day or on a regular basis; The person takes anti-reflux medication; The person clears their throat often or burps often.
Question 19.
Refer to page 41 Does the person drool or dribble saliva when resting, eating or drinking? Tick the Yes box if either of the following apply: The person drools or dribbles saliva at rest or mealtimes; The persons clothes or protective napkins/bibs frequently need changing because of drooling.
Question 20.
Refer to page 42 Does food or drink fall out of the persons mouth during eating or drinking? Tick the Yes box if any of the following apply: The person is unable to close their mouth and this causes food, drink or medication to fall out of their mouth; The person cannot keep their head upright and food, drink or medication falls out of their mouth; The persons tongue pushes food, drink or medication out of their mouth; The persons mouth continuously needs to be wiped or they need to wear a cloth to protect their clothes during mealtime. Note that this question does not relate to the persons manual dexterity or ability to place food in their mouth.
Part 2
Question 21.
If the person eats independently, do they overfill their mouth or try to eat very quickly? Tick the Yes box if the person eats independently and any of the following apply: The person tries to cram or stuff their mouth before attempting to chew or swallow; The person tries to swallow too much food before they have chewed it properly; The person usually finishes all of their main meal in less than 5 minutes. Not applicable Yes No Unsure/Do not know Refer to page 44
Question 22.
Does the person appear to eat without chewing? (Note:This question does not apply to people on
a pureed diet)
Tick the Yes box if any of the following apply:
The person sucks their food instead of chewing; The food remains in the person s mouth for a long period of time before being swallowed; The person swallows their food whole without chewing. Not applicable Yes No Unsure/Do not know Refer to page 45
Question 23.
Does the person take a long time to eat their meals? Tick the Yes box if any of the following apply: The person eats independently and they take more than 30 minutes to eat meals; The person is dependent on someone to feed them and it takes a longtime to feed them the whole meal; The person appears to tire as the meal progresses and may not finish their meal.
Part 2
Question 24.
Refer to page 48 Does the person show distress during or after eating or drinking? Tick the Yes box if any of the following apply: The person appears distressed while they eat or drink; The person appears distressed immediately after or shortly after eating or drinking; Sometimes while distressed the person refuses food or spits out food.
YES to any question?

If you answered Yes to one or more questions, the person may have a nutrition risk or risk to safe swallowing. Summarise your results on the last page of this form.
PART 3 SUMMARY OF RESULTS

(insert date)
Summary of results for ___________________________________________________ on ________________________________
Refer to the relevant question in the Nutrition in Practice manual. The Nutrition in Practice manual outlines things to consider and some simple safe things you can do to manage the problem or risks you have identified. It also helps you decide if the person needs to be referred to a specialist, such as a speech pathologist, dietitian, doctor etc.
If you decide that a specialist referral is the best action take this completed checklist to the appointment.
A copy of this completed checklist should be kept in the persons files. Comments Action
Nutrition and Swallowing Risks identified
Q.1. Reminder: Children or young people under 18 years of age an annual growth assessment should be completed by a GP, paediatrician, early childhood nurse or dietitian. Has this occurred? If you are not able to measure height and weight, refer to a specialist professional for measurement of height and weight and an estimate of the persons healthy weight range.
Q.2. Reminder: Weigh regularly and record changes. Does this happen?
Example The person is overweight
Example Weight gain over the last year. Difficulty walking because of excess weight.
Example Make appointment with dietitian
Part 3
Appendix 2
Weight chart
WEIGHT CHART Name: Address: D.O.B.
Example
DATE
52.0 51.5
Instructions: Weigh the person monthly; When recording weight for the first entry, mark the weight where the arrow indicates; Each time the person is weighed mark their weight with a dot on the appropriate line (each line represents 0.5kg).
DATE
WE I G HT
51.0 50.5 50.0 49.5
WE IG HT IN K I LO GR AMS
2/5 6/6 4/7 1/8
Oral care plan
Appendix 3
ORAL CARE PLAN Name: Completed by: Assistance required None/independent Location: Date: Some supervision/ prompting Full assistance
Toothbrush: (e.g. Small, soft, electric)
Toothpaste: (e.g. Flavourless)
Frequency or oral care
After all meals
After breakfast and before bed
Other
COMMENTS/REFERRAL (teeth erosion, gingivitis, cares, etc)
Oral care should be maintained regardless of whether the person has teeth or not.
Appendix 4
Sample food diary
Name: Date & time Food & drink offered Be specific e.g. 1 cup porridge + 1/2 cup milk 200ml thickened cordial Amount e.g. all, 1/2, none
Sample soft diet with thickened fluids
Appendix 5
SAMPLE MEAL PLAN
Soft Diet and Thickened Fluids (No thin fluids)
Breakfast Suitable cereal choice Bread + margarine + suitable spread Scrambled egg (CHOPPED)/baked beans/ canned spaghetti (CHOPPED)/creamed corn Thickened drink Soft meat/poultry/seafood with sauce/gravy Potato (CHOPPED OR MASHED)/rice/pasta (CHOPPED) Vegetables (CHOPPED) Bread + margarine Canned fruit (CHOPPED AND DRAINED) Thickened drink Thickened soup Sandwich (soft, moist filling) Canned fruit (CHOPPED AND DRAINED) Suitable milk pudding Thickened drink
Lunch
Dinner
Between Meals Thickened drinks Ensure at least 6 x 250 ml thickened drinks are consumed daily. Note: three drinks should be milk based (e.g. thickened milkshakes).
Produced by the Department of Nutrition and Dietetics, Prince Henry, Prince of Wales Hospitals April 2000
Appendix 5
Bread and cereals

Foods to include Bread white or wholemeal Sandwiches (with soft, moist fillings) Rice, barley Pasta, spaghetti, macaroni, noodles (CHOPPED) Sago, tapioca, arrowroot, flour, cornflour Rolled oats, semolina Weetbix and similar biscuit-type cereal Cake Crepes, pikelets, pancakes (CHOPPED) Other cereals Cereals with nuts, dried fruit or coconut (e.g. muesli) Cakes containing nuts or coconut Pies, pastries Biscuits Foods to avoid Fruit or grain breads Toast, bread rolls, muffins & crumpets, pocket bread
Appendix 5
Fruit and vegetables

Foods to include Stewed fruit or canned fruit (DRAINED & CHOPPED) (e.g. apples, pears, peaches, apricots, two fruits, plums, pineapple) Soft fresh fruit (CHOPPED) (e.g. banana, strawberries, kiwi fruit, paw paw, mango, rockmelon) Stewed or fresh fruit with pips or seeds removed (e.g. cherries, grapes) All varieties of cooked vegetables (CHOPPED) Salad vegetables (as listed below): shredded lettuce, grated carrot, tomato (PEELED AND CHOPPED), beetroot (CANNED OR COOKED) Creamed corn Cooked legumes Baked Beans Raw vegetables Salads (except those in foods to include) Foods to avoid Hard fresh fruit (e.g. apple)
Coconut Corn niblets, corn cob
Appendix 5
Meat and alternatives

Foods to include MEAT NEEDS TO BE TENDER once cooked All meat, fish or chicken if cooked in casserole or with sauce or gravy and cut into small pieces Sliced delicatessen meats Grilled fish, canned salmon or tuna (no bones) Skinless sausages (CHOPPED) Minced or finely chopped seafood (e.g. prawns, scallops) Oysters Eggs Cooked legumes Baked beans Pate, hummous, taramasalata Tofu Mussels, calamari, squid Nuts Pies, sausage rolls Foods to avoid Tough meats
Milk, milk products and alternatives

Foods to include Milk, milkshakes (IF THICKENED) Soya drinks (IF THICKENED) Boiled or baked custard Milk pudding, creamy rice Yoghurt (if suitable thickness) Cheesecake (without base) Cheese, cheese spreads Drinking yoghurts Yoghurt with nuts or muesli Cheese containing fruit or nuts Dry, hard cheeses Foods to avoid Ice cream
* Soy products may be substituted where appropriate.
Appendix 5
Fats
Foods to include Butter, margarine Oil (for cooking) Whipped cream, sour cream, thickened cream Mayonnaise Foods to avoid
Miscellaneous
Foods to include Sugar, cocoa, drinking chocolate, flavoured syrups SPREADS Golden syrup, treacle, honey,Vegemite, Marmite, smooth peanut butter, meat and fish paste, lemon butter, jam and marmalade IN COOKING salt, pepper, stock cubes, vinegar, mustard, curry powder, herbs & spices,Worcestershire sauce, soya sauce, etc Gravy, sauces (if suitable thickness) Relishes, pickles, chutney, tomato sauce Bonox, Bovril (in cooking or thickened to drink) Soft chocolate bars Boiled sweets, lollies Hard chocolate, Liqueur chocolates, chocolate bars with coconut, nuts or dried fruit Foods to avoid Jelly Crunchy peanut butter
Appendix 6
Eating and drinking plan
Eating and drinking plan (suggested format)
Name: Date: Please note: Prepared by:
D.O.B.: Date for review:
Requirements for eating Type of diet: eg: normal, reduction, milk free, vegetarian Texture/consistency eg: soft, minced, puree, nector, thick
Requirements for drinking
Positioning
Assistance required
Equipment required
Personal preferences
Personal dislikes
Eating and drinking plan
Appendix 6
Eating and drinking plan (continued)
Name: Date: Please note: Prepared by:
D.O.B.: Date for review:
SUGGESTED MEAL OUTLINE
Breakfast
Morning Tea
Midday
Afternooon Tea
Evening Meal
Supper

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Notice to readers

Nutrition in Practice Manual

Nutrition in Practice Manual

Margaret Allison Director-General October 2003

NUTRITION IN PRACTICE MANUAL

Nutrition in Practice Manual

Contributing authors are:

NUTRITION IN PRACTICE MANUAL

Nutrition in Practice Manual

Nutrition and Dysphagia Working Groups February 1998

Nutrition Working Party June 1998 October 2000

NUTRITION IN PRACTICE MANUAL

Nutrition in Practice Manual

SECTION 4 DIET AND SPECIAL HEALTH CONDITIONS 87

NUTRITION IN PRACTICE MANUAL

Nutrition in Practice Manual

NUTRITION IN PRACTICE MANUAL

Nutrition in Practice Manual

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

What is the purpose of the checklist?

Who should complete it?

Nutrition and Swallowing Risk Checklist

Do not guess answers

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

PART 1 PRELIMINARY PROFILE The person with a disability

Yes No If yes, when? Date ____________

The person conducting the checklist

Your relationship to the person with a disability:

How long have you known the person?

Where is the checklist being completed?

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

gained or, Yes

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

PART 2 NUTRITION AND SWALLOWING RISK CHECKLIST

Not applicable Yes No Unsure/Do not know

Refer to page 12 Yes No Unsure/Do not know

Refer to page 14 Yes No Unsure/Do not know

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

Yes No Unsure/Do not know

Yes No Unsure/Do not know

Yes No Unsure/Do not know

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

Yes Refer to page 22 No Unsure/Do not know

Yes Refer to page 23 No Unsure/Do not know

Yes Refer to page 26 No Unsure/Do not know

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

Yes No Unsure/Do not know

Yes No Unsure/Do not know

Yes No Unsure/Do not know

Yes No Unsure/Do not know

NUTRITION IN PRACTICE MANUAL

Nutrition and Swallowing Risk Checklist

Yes Refer to page 33 No Unsure/Do not know

Yes Refer to page 36 No Unsure/Do not know

Summary of results for ___________________ on