The diets included here are not exhaustive by wuyunyi


									Special Diets, Dietary Supplementation and Conditions
     where Special Dietary Considerations Apply
                                                    Table of Contents

DOCUMENT OVERVIEW .......................................................................................... 4

SECTION 1 - SPECIAL DIETS .................................................................................. 4

1.1 Vegetarian diets.................................................................................................. 4

1.2 Ethnic Diets ........................................................................................................ 6
   1.2.1 Asian diets ................................................................................................................ 8
      1.2.1a Hinduism .............................................................................................................................. 8
      1.2.1b Islam ..................................................................................................................................... 8
      1.2.1c Sikhism ................................................................................................................................. 9
   1.2.2 African- Caribbean diets ........................................................................................... 9
   1.2.3 Diets for Jewish Residents...................................................................................... 10

1.3 Diets for Overweight and Obese Residents ................................................... 11
   1.3.1 Diets for Overweight Residents (BMI 25-29.9) ........................................................ 12
   1.3.2 Diets for Obese Residents (BMI 30 and above) ...................................................... 13

1.4 Food Allergies and Intolerances ..................................................................... 13
   1.4.1 How to deal with food allergy and intolerance in a care home setting ..................... 15
   1.4.2 Gluten-free diet ....................................................................................................... 16
   1.4.3 Lactose-free diet / Milk-free diet .............................................................................. 21
   1.4.4 Nut-free diet ............................................................................................................ 23
   1.4.5 Egg-free diet ........................................................................................................... 26

1.5 High Fibre Diet .................................................................................................. 28

1.6 Diabetic Diets.................................................................................................... 29
   1.6.1 Type 1 diabetes ...................................................................................................... 29
   1.6.2 Type 2 diabetes ...................................................................................................... 30
   1.6.3 Hypoglycaemia ....................................................................................................... 31
   1.6.4 Hyperglycaemia ...................................................................................................... 32

1.7 Modified consistency diets ............................................................................. 33
   1.7.1 What types of modified consistency diets exist? ..................................................... 33
   1.7.2 When would a modified consistency diet be required?............................................ 34
   1.7.3 Foods which are not recommended for modified consistency diets ......................... 38
   1.7.4 Tips for successfully pureeing food ......................................................................... 38
   1.7.5 Tips for encouraging residents to eat pureed meals................................................ 40
   1.7.6 Soaking solution ..................................................................................................... 40
   1.7.7 Eating safely with dysphagia................................................................................... 41
   1.7.8 Administering medication to individuals requiring modified consistency diets ......... 42

1.8 Fortification of Food and Fluids...................................................................... 42
   1.8.1 Eating a high energy diet ........................................................................................ 43
   1.8.3 Tips on fortifying food ............................................................................................. 44

SECTION 2 - DIETARY SUPPLEMENTATION ....................................................... 47

2.1 Vitamin D and Calcium Supplementation ...................................................... 47

2.2. Iron Supplementation ..................................................................................... 49

2.3 Multivitamin (and Mineral) Supplementation ................................................. 50

2.4 Oral Nutritional Supplements .......................................................................... 51
      2.4.1 Handy tips when using oral nutritional supplements ............................................................ 52
      2.4.2 Caution when using oral nutritional supplements ................................................................ 52

2.5 Enteral Tube Feeding ....................................................................................... 53
   2.5.1 Care of residents receiving enteral tube feeds and prevention of complications ..... 55

APPLY ..................................................................................................................... 57

3.1 Dementia ........................................................................................................... 57
   3.1.1 Nutritional concerns with dementia ......................................................................... 59
      3.1.1a Energy intake ..................................................................................................................... 59
      3.1.1b Dehydration ........................................................................................................................ 60
   3.1.2 Medication .............................................................................................................. 60
   3.1.3 Practical tips for achieving a balanced diet for people with dementia ...................... 60
   3.1.4 Finger Foods .......................................................................................................... 62

3.2 Learning Disability ........................................................................................... 64

3.3 Feeding and Hydration for Residents Receiving Palliative Care ................. 69

SECTION 4 - USEFUL CONTACTS ........................................................................ 71

SECTION 5 – BIBLIOGRAPHY ............................................................................... 74

Document Overview

This document covers special diets which are followed for medical, religious or
cultural reasons; dietary supplementation, which covers vitamin and mineral
supplementation and appropriate use of oral nutritional supplements (prescribed and
over-the-counter preparations) and enteral tube feeds; and conditions where special
dietary considerations apply - in this case focussing on learning disabilities, dementia
and the needs of residents receiving palliative care.

Section 1 - Special Diets

The special diets included in this section are not an exhaustive list and the
information is not intended to replace any specific guidance provided by individual
professionals for residents. This section does not cover more complex special diets,
such as those recommended for kidney failure, for eating disorders or guidelines for
residents on parenteral feeding regimens (being fed intravenously). They also do not
account for a mixture of requirements (for example a Muslim requiring a fortified diet
or an individual requiring a modified consistency diet who is also intolerant to milk
etc). If more information or support is required for these or more complicated
scenarios, then further guidance should be sought from the local Dietetic Team or
the resident‟s GP.

1.1 Vegetarian diets

A vegetarian diet is one which excludes animal flesh (meat, poultry, fish and
shellfish) and other products from the animal carcass, such as gelatine. People
adopt vegetarian diets for many different reasons, including ethical, environmental,
religious, cultural and health reasons. Thus there is not one type of diet that will suit
all vegetarians. Asking the individual what their dietary preferences are is the best
way to find out what they do and don‟t eat.

There are six main types of vegetarian diet. The table below explains what each will
and won‟t eat:-

Table 1: Foods avoided and foods consumed by vegetarians

Type of             Foods avoided                        Foods consumed
Semi- vegetarian    Red meat                             Fish, Poultry, and all other

Lacto-ovo-          Meat –beef, lamb, pork, venison      Eggs, milk, cream,
vegetarian          and offal                            yoghurt, butter
                    Poultry and game                     All other foods including
                    Fish and shellfish                   soya, textured vegetable
                    Lard and dripping and foods made     protein and Quorn
                    from these such as pastry and
                    fried foods
                    Stocks and gravies made form
                    Gelatine and any product made
                    with jelly

Ovo – vegetarian    All of the above AND                 Eggs and will use soya
                    Milk, cheese, yoghurts, cream and    milk
                    milk chocolates                      Cakes and biscuits made
                                                         with vegetable margarine
                                                         All other foods

Lacto vegetarian    All of the above AND eggs and     Fruit and vegetables,
                    mayonnaise and salad cream        beans and pulses,
                                                      Cakes and biscuits made
                                                      with no eggs and
                                                      vegetable margarine or oil
Vegan               The same as lacto-ovo- vegetarian As others
                    AND eggs, milk, cheese, yoghurts
                    and honey

Vegetarians and vegans do not need any special dietary products, but it is important
to ensure they have as wide a variety of foods from both within and between the 4
main food groups as possible (As identified in the ‘Eating Well for Healthy Adults
with a Good Appetite and Healthy Weight in Care Home Settings‟ document).
This will ensure they have a diet adequate in protein, iron, calcium and other
vitamins and minerals. The following tips are a useful starting point for these diets:-

   Try to ensure that the diet is not made up predominately of cheese and eggs for
    those residents who eat these foods as they are high in fat. Try to include nuts,
    quorn, tofu and pulses as alternative sources of protein in their diets.

   When menu planning, if a vegetarian option is offered every day, it will ensure
    vegetarian residents are catered for and different meal choices can be offered for
    all residents. For example, meat eaters may like to eat a vegetarian dish
    sometimes and they can choose this option from the menu.

1.2 Ethnic Diets

There are many different cultures and religions in the UK today. Eating patterns that
are followed may be influenced by a variety of factors, including:-

   Religious beliefs / principles
   Cultural background and ethnic origin
   Availability of traditional foods

It is important to ask individuals their dietary preferences and not make assumptions.
For example, it should not be assumed all Hindus are vegetarians or that all Asians
follow the traditional practices. As many people with different religious backgrounds
have been born and brought up in the UK, they will most probably eat western food
also. This is why it is very important to discuss dietary preferences with each

Table 3: Summary of Food-Related Customs

                 Jewish       Hindu*        Sikh*      Muslim      Buddhist   Rastafarian**

Eggs             No blood     Some          Yes        Yes         Some       Some

Milk / Yoghurt   Not with     Yes           Yes        Yes         Yes        Some

Cheese           Not with     Some          Some       Possibly    Yes        Some

Chicken          Kosher       Some          Some       Halal       No         Some

Mutton /Lamb     Kosher       Some          Yes        Halal       No         Some

Beef and Beef Kosher          No            No         Halal       No         Some

Pork and Pork No              No            Rarely     No          No         No

Fish             With fins    With fins     Some       Some        Some       Yes
                 and scales   and scales

Shellfish        No           Some          Some       Some        No         No

Butter / ghee    Kosher       Some          Some       Some        No         Some

Lard             No           No            No         No          No         No

Cereal foods     Yes          Yes           Yes        Yes         Yes        Yes

Nuts / pulses    Yes          Yes           Yes        Yes         Yes        Yes

Fruit / Veg      Yes          Yes           Yes        Yes         Yes        Yes

Fasting***       Yes          Yes           Yes        Yes         Yes        Yes

*Strict Hindus and Sikhs will not eggs, meat, fish and some fats

** Some Rastafarians are vegan

*** Fasting is unlikely to apply to the elderly and infirm

1.2.1 Asian diets

There are three main religions of Asians living in the UK, Hinduism, Islam and
Sikhism. Each have different dietary restrictions as detailed below:-

1.2.1a Hinduism

1. Most Hindus will not meat or fish of any kind. Less strict Hindus may eat lamb,
    chicken or white fish.
2. Very strict Hindus may not eat eggs since they are a potential source of life.
3. Fats such as dripping or lard are not acceptable. Ghee (clarified butter) or
    vegetable oil is used in cooking.
4. Strict Hindus may refuse to eat food unless they are certain that the utensils used
    in preparing and cooking have not been in contact with meat or fish.

There are three festivals in the Hindu calendar which are observed as fasting days:-

1. Mahashivrati – in March.
2. Ram Naumi – in April.
3. Jan Mash Tami – late August.

1.2.1b Islam

   All foods eaten should be „lawful‟ or Halal1.
   Non-lawful foods include:-
       o Foods and food products from the pig. Manufactured foods which contain
           animal fat or gelatine may not be eaten.
       o All meat which has not been ritually slaughtered (Kosher meat – see
           section on Jewish diets - is acceptable).
       o Alcohol including that used in cooking.
       o All carnivores and birds of prey.

  Islam has laws regarding which foods can and cannot be eaten and also on the proper method of
slaughtering an animal for consumption.

Muslims are required to fast from dawn to dusk during the month of Ramadan, which
is the ninth month of the Muslim calendar. Older people, people with diabetes and
children are exempt from fasting.

1.2.1c Sikhism

   Food restriction is a matter of personal preference. Sikhs are not as strict as
    Hindus or Muslims, but for each Sikh, their own self-imposed restrictions are

   Many Sikhs are vegetarian but many will eat chicken, lamb and fish. They are
    unlikely to eat beef and less likely to eat pork. Alcohol is forbidden.

   Some devout Sikhs may fast once or twice a week.

1.2.2 African- Caribbean diets

The amount of traditional food eaten by African Caribbean people will depend on the
availability of food in the UK and how much the Western diet has influenced the
traditional diet. Therefore, individuals will vary in the amount of traditional foods they
eat. The table below is a guide for foods that are commonly consumed by African

Table 2: Types of food consumed by African Caribbean people

Food Group               Types of food consumed

Grains and cereals       Rice, corn, cornmeal, oats
                         Pasta, cakes, bread
                         Cassava, Yam, sweet potato, dasheen, coco yam
Meat, fish and           Fish: Mackerel, sardines, pilchards, snapper, red bream, red
alternatives             mullet
                         Peas, beans (stews, one-pot meals, accompaniment to meals)
                         Cashew nuts, almonds, coconut
Fruit and vegetables     Pineapple, banana, guava, breadfruit, plantain
                         Spinach, kale, carrots, peppers, okra, sweetcorn, cabbage,
                         tomato, pumpkin
Dairy products           Usually preferred is evaporated or condensed milk
Fats and sugars          Butter, margarine, palm oil, coconut cream
                         Sugary snacks and sugar or honey added to foods

   Many of the dishes cooked in the African Caribbean diet are highly seasoned,
    with lots of salt and spices. Sugary snacks are preferred.

   There are three main religions within the African Caribbean culture; Christian,
    Rastafarian and Seventh Day Adventist. Table 3 (page 7) outlines food-related
    customs and shows the different diets for these religions.

1.2.3 Diets for Jewish Residents

There are regulations in the code of dietary laws, relating to the slaughter of animals
used for food and the kinds of dishes served at special holidays, festivals and the
Sabbath. These are underpinned by the maintenance of health and food hygiene.

   Pork and all products from the pig are forbidden.

   Meat must not be cooked with milk or milk derivatives or be served at the same

   Utensils for milk and dairy products must not be used for cooking meat.

   Meat and fish eaten must be Kosher2.

  „Kosher‟ refers to the selling or serving of food prepared in accordance with traditional Jewish dietary
laws. For example Kosher meat relates to meat obtained from animals that chew the cud and have
cloven hooves, including cattle, sheep, goats and deer (although the hindquarters must not be eaten).
Kosher fish refers to fish with scales and fins only (excluding shellfish for example). Additionally, the
animals must be slaughtered according to ritual, without stunning, before it can be considered Kosher.

1.3 Diets for Overweight and Obese Residents

Being overweight brings with it many health issues. They include diabetes, high
blood pressure, high cholesterol, stroke, heart problems, some types of cancer,
arthritis of the back and legs, gallstones, menstrual problems, incontinence of urine,
breathing problems and depression. Losing a moderate amount of weight will help to
reduce the risk of these health and other related problems (for example reducing
joint pain, increasing self-esteem / confidence, improving mental health and
wellbeing etc).

 Intervention and support is often justified for overweight individuals to
. prevent further weight gain and reduce the risk of obesity developing. In
 addition to this, certain motivated individuals may even be able to achieve a
 healthy weight through appropriate intervention.

A person puts on weight if the amount of energy in the foods and drinks that they eat
is greater than the amount of energy that they use in activities of daily living and in
other physical activity. Energy from foods and drinks that is not used is converted
into fat and stored in the body.

Weight loss should therefore be achieved by a mixture of dietary restriction and
physical activity (for more detail on recommendations for physical activity, refer to
the „Physical Activity in Care Homes‟ guidelines). However, for many people with
mobility problems, exercise and other forms of physical activity may be limited. This
may be influencing a person‟s weight gain. If this is the case, modifying what a
person eats is the easiest way of helping them to reduce their weight.

It is important to note, however, that if a person is overweight, but their weight is
stable and their health and mobility are not affected by their weight (especially if they
are active or aged over 65 years), weight loss may offer limited health benefits for an
individual. Caution should be taken in supporting weight loss for such individuals
unless they wish to lose weight and there is a clear benefit associated with weight
loss for that individual.

1.3.1 Diets for Overweight Residents (BMI 25-29.9)

The aim is to achieve an average weight loss of between 1-2 lbs or 0.5-1kg per
week. More rapid weight loss increases the risk of muscle wastage and malnutrition
(as the diet may not contain enough nutrients from the key food groups). The „Eating
Well for healthy adults with a good appetite and healthy weight in care settings‟
guidelines for this award have been designed specifically to encourage a lower
intake of sugar and fat (which contribute additional and non-essential calories to the
diet) and to encourage a moderate intake of fibre (which helps to make the diet more
filling). In addition to these, it is recommended that residents:-

   Aim for 3 regular meals every day.
   Use “diet” or sugar-free / low calorie drinks.
   Switch to semi-skimmed or skimmed milk.
   Switch to low fat spreads instead of butter of margarine.
   Avoid seconds (or offer extra vegetables and fruit if need be).
   Try to avoid too many pastries, pies, fried food and rich puddings (instead of the
    latter, offer fruit, sugar free jelly or diet yogurts for the majority of their puddings).
   Try to avoid using particular foods and fluids as treats or to acknowledge
    achievements. Instead, involve the resident and/or their family in discussion and
    agreement on acceptable alternatives that can be used.
   Keep a record of their food intake to help identify where changes can be made.
   If the above strategies do not achieve the required level of weight loss, then aim
    to reduce energy consumed at mealtimes by gradually reducing portion sizes for
    all foods with the exception of vegetables until the intended weight loss is
    achieved. This could be achieved by using smaller plates at mealtimes.

Alternatively, given that many NHS patients are being referred to the commercial
weight loss sector (for more information on those being commissioned locally by the
NHS, contact the PCT in your locality; contact details are provided in „Useful
Contacts‟ at the end of this section), there is no reason to prevent residents using
such clubs as these have been evaluated to be effective and safe. However, there
will be a cost associated with these.

Residents will need lots of support to successfully lose weight and, where possible,
extra physical activity opportunities will need to be built into their daily routine to
support weight loss (for more information on this, refer to the „Physical Activity in
Care Homes Guidelines‟). However, it is also worth looking at whether reduction in
activity may have caused weight gain

1.3.2 Diets for Obese Residents (BMI 30 and above)

The first line of action for obese residents is to refer them directly to the local Dietetic
Service (in full consultation with their GP) for weight loss support, if the resident is
motivated and consents to this. Whatever action plans are recommended should be
communicated in individual care plans and followed until they are discharged from
care. At that point, if the individual has reached a BMI under 30, they can follow a
healthy eating plan as outlined above for overweight residents (unless they are
following a particular diet that is working for them and they wish to continue with

1.4 Food Allergies and Intolerances

Symptoms caused by food allergies and intolerances can range from mild to acutely
life-threatening. It is therefore essential that home managers are aware of any
residents suffering with either a food allergy or food intolerance and their individual
requirements. While many people believe they may be sensitive to certain foods, a
medical diagnosis of an allergy or intolerance will ensure the correct diet can be
provided and will prevent unnecessary dietary restriction.

Food allergy

A food allergy is a condition in which a reaction occurs after contact with a particular
food to which an individual has been previously exposed (or sensitised). The body
recognises the food as a foreign substance and mounts an immunological attack on
the proteins within the food that has been consumed. This triggers an allergic
response, resulting in mild to severe symptoms, which can include:-

 Swelling of the tongue and / or face and / or throat.
 A rash, which resembles a „nettle rash‟, known as „hives‟.
 Breathing problems, swollen throat, runny nose and eyes.
 Abdominal pain, bowel disturbances, nausea and vomiting.
 Life-threatening collapse (anaphylaxis).

Foods that can cause severe reactions include peanuts, nuts, shellfish, cow‟s milk,
eggs, fish, citrus fruits, wheat and other cereals. This is not a complete list and
further information can be made available to care home managers on request.

Food intolerance (non-allergic food hypersensitivity)

A food intolerance is a condition in which the body is unable to fully break down or
digest certain foods. This can result in the following symptoms, which can occur
hours or possibly up to a few days after ingestion of the offending food:

 Migraines
 Nausea
 Bloating
 Abdominal pain
 Diarrhoea
 Joint aches and pains
 Fatigue

Foods commonly associated with food intolerances include cow's milk (and foods
containing cow's milk), wheat (and other grain products that contain wheat). Some
people have adverse reactions to chemical preservatives and additives in food and
drinks, such as sulphites, benzoates, salicylates, monosodium glutamate, caffeine,
aspartame and tartrazine. This is not a complete list and further information can be
made available to home managers on request.

1.4.1 How to deal with food allergy and intolerance in a care home setting

 The home must have measures in place to clearly record in care plans those
  residents with food allergies or intolerances before they move or during the course
  of the resident‟s stay (depending when they are diagnosed).
 All staff caring for and catering for a resident with a food allergy or intolerance
  must be advised of the resident‟s condition, the measures they need to put in
  place to avoid a reaction and any treatment a person may require if they are
  exposed to the food causing the allergy or intolerance (this information should be
  detailed in the resident‟s care plan).
 In the case of potential anaphylactic reactions to food, care home managers must
  ensure they receive appropriate medication from the G.P and store this
 Staff must have identified and appropriately trained personnel who can administer
  medication as and when required and are able to make contact with emergency
  services if the need arises.
 The primary management of both food allergy and intolerance is to exclude
  offending food(s) from the diet. In some cases (for example milk intolerance or
  allergy), there are alternative foods items that can be provided. In other cases,
  where the offending food is an essential nutrient in the diet (in one of the key food
  groups), a suitable alternative must be found to ensure a nutritionally balanced
  and varied diet is offered.
 Complete avoidance of the offending food is often difficult due to the presence of
  very small quantities in commercially manufactured foods. The key is for catering
  staff to use food-labelling techniques to avoid contamination of an offending food
  component and to ensure that cross contamination of food does not occur.

The next sections details common food allergies and intolerances. Further
information can be made available to care home managers on request.

1.4.2 Gluten-free diet

Coeliac disease is a common bowel condition, which can occur at any age, caused
by intolerance to a protein found in wheat (gluten). Individuals may display the
following signs if they have Coeliac disease and eat gluten-containing foods:-

      Breathlessness
      Fatigue
      Diarrhoea
      Abdominal fullness (bloating)
      Discomfort
      Abdominal pain
      Vomiting
      Weight loss
      Iron deficiency

Gluten intolerance may also cause a condition known as „Dermatitis Herpetiformis',
which results in an itchy rash (with blisters and raised spots), often affecting the
elbows, knees, buttocks and scalp.

If a resident is diagnosed with Coeliac disease or Dermatitis Herpetiformis (DH), a
gluten-free diet is the cornerstone of their treatment and failure to comply in full with
the diet will, in time, result in a reoccurrence of symptoms / the individual becoming
unwell (in other words, a gluten-free diet is required permanently). Gluten is found in
wheat, rye and barley and these foods must be eliminated from the diet completely.
Oats may need to be avoided, but if they are, this will be evident in the individual‟s
dietary regime.

There are two main sources of gluten in the diet; the obvious and less obvious. The
obvious foods are those made from wheat, such as bread, cakes, biscuits, pastries
and pies. The less obvious are manufactured or processed foods. Table 4 below
illustrates foods that are free from gluten and can be include in a gluten-free diet.

Table 4: Gluten-containing and key gluten-free foods.

Food Group     Gluten-free foods                        Gluten-containing foods

Cereals and    Arrowroot                                Wheat, wholemeal, whole
flours         Buckwheat                                wheat and wholemeal
               Corn or maize                            flours
               Cornflour                                Bran
               Maize flour                              Barley
               Gluten free flour                        Rye
               Potato flour                             Pasta (all types)
               Rice and rice flour                      Semolina
               Sago                                     Spelt
               Tapioca                                  Kamut
               Soya                                     (any mixture containing
               Oats – if permitted                      these grains)
Prepared       Made from corn or rice (e.g.             Cereals made from wheat,
cereals        Cornflakes or Rice Krispies)             barley or rye (e.g. muesli,
                                                        Shredded wheat,
                                                        Weetabix, Sugar Puffs)

Baked Goods    Gluten free products:                    All ordinary baked goods,
               Bread                                    made from wheat, barley,
               Biscuits                                 rye flour, suet, semolina.
               Savory biscuits                          Ice cream wafers and
               Pasta                                    cones
               Bread mix
               (some local bakers and butchers may
               produce gluten-free products e.g.
               bread, sausages etc).
Milk           All types of milk                        Artificial cream containing
               Most brands of yoghurt                   flour
               Fresh or tinned cream                    Yoghurt containing muesli
Cheese         All cheese                               Cheese spreads
               Check cheese spreads                     containing flour

Eggs           Prepared without flour or breadcrumbs Any dishes containing egg
                                                     and flour or breadcrumbs
                                                     (e.g. Scotch eggs)

Food Group      Gluten-free foods                       Gluten-containing foods

Fats and Oils   Butter , margarine, oil                 Suet

Meat and fish   All varieties prepared and cooked       Savoury pies and puddings
                without breadcrumbs and flour           containing flour,
                                                        breadcrumbs, stuffing, and
                                                        suet. Sausages and
                                                        burgers containing
                                                        breadcrumbs. Battered or
                                                        crumbed fish, fish fingers
                                                        and fish cakes.
Vegetables      Fresh, canned, frozen, dried, cooked    Vegetables canned in
                Some brands of baked beans              sauces
Potatoes        Any fresh cooked potatoes               Breaded potatoes and
                                                        processed potatoes (e.g.
Fruit           Fresh, cooked, canned, frozen, dried    Fruit pies or crumbles
Nuts                                                    Certain brands of dry
                                                        roasted nuts
Puddings and    Jelly, milk puddings made from          Puddings and desserts
desserts        permitted cereals not semolina.         containing flour,
                Certain brands of ice cream, certain    breadcrumbs and suet. Ice
                brands of instant desserts              cream cones and wafers
Soups,          Soup, sauce and gravy if thickened      Soup, sauce and gravy
sauces and      with appropriate cereal (e.g. corn      thickened with or containing
gravies         flour)                                  wheat, barley, rye or pasta
Drinks and      Tea, pure instant or fresh ground       Barley – based instant
beverages       coffee, squashes and cordials, fresh    coffee, barley flavoured fruit
                fruit juice                             drinks. Malted drinks (e.g.

Seasonings    Salt, fresh ground pepper, herbs, pure    Ready mixed seasoning,
              spices, vinegar. Certain brands of        spices and curry powders
              ready made mustard, certain brands        containing flour as a „filler‟
              of curry powders and mixed spice
              seasoning. Monosodium glutamate
Miscellaneous Bicarbonate of soda, cream of tartar,     Medication containing
              tartaric acid, certain brands of baking   gluten
              powder, fresh and dried yeast,            Soy sauce
              colourings and essences and gelatine.

If a resident has been diagnosed with Coeliac disease, they are eligible for gluten-
free products on prescription. These can include, bread, rolls, pasta and biscuits
(both sweet and savoury). There is now a wide selection of gluten-free products
available in most supermarkets. It is worth being aware that many food
manufacturers selling specialist gluten-free food products offer free starter packs of
gluten-free food, which can be very useful when an individual is first diagnosed with
gluten intolerance.

It is also important, however, to note that certain ingredients on food labels may
indicate that a food contains gluten. To make shopping easier, „Coeliac UK‟ (see
„Useful Contacts‟ at the end of this document) has produced a „Food and Drink
Directory‟, which is updated monthly and lists products that are currently safe to
purchase for a gluten-free diet. It is worth noting, however, that food and drink
manufacturers can and do change ingredients used in their products. Therefore, it is
essential to maintain monthly updates of this publication to be sure that products
being purchased are currently gluten-free.

Another means of establishing if a food is suitable for a gluten-free diet is to refer to
other information provided on a food label, including the „crossed grain‟ sign (see
Figure 1 below) and the following claims, which can only be made under EU
legislation directives3:-

          „Gluten-free‟
          „Very low gluten‟
          „Suitable for Coeliacs‟

    Manufacturers have until January 2012 to comply with this legislation.

Figure 1: The ‘Crossed Grain’ Sign

It is also worth being aware that the following statements on food labels indicate that
the manufacturer has decided that there is a risk that the product contains gluten.
Products containing such statements on their labels are therefore best avoided on a
gluten-free diet:-

   „May contain traces of gluten‟
   „Made on a line handling wheat‟
   „Made in factory also handling wheat‟

Tips for cooking a gluten-free diet include:-

   Avoid cross contamination. Use a separate toaster when toasting gluten-free
    bread, as even breadcrumbs will irritate a Coeliac.

   Prepare bread on a clean surface to prevent cross contamination.

   Wash hands and surfaces before preparing gluten free foods.

   If deep frying foods, make sure the oil and basket are clean. Again, cross
    contamination is possible from breaded products.

   Store gluten free products on separate shelves.

   Use separate jams and margarines as these may be contaminated.

   Use clean utensils when preparing foods.

   Check the labels of products to ensure the product is gluten free.

   Cook and serve gluten free meals in separate dishes.

A useful source of more information is the Coeliac Society and the Food Standards
Agency (contact details are provided at the end of this document).

1.4.3 Lactose-free diet / Milk-free diet

Lactose is the name given to a type of sugar found naturally in milk. Some people
can‟t digest lactose properly, which results in dairy products making them feel sick or
giving them stomach pains and diarrhoea. The amount of lactose people can tolerate
differs from person to person. Some may be able to tolerate small amounts and
others, none at all. A milk-free diet involves the complete avoidance of cows‟ milk,
goats‟ milk, sheep‟s milk and all associated milk products such as butter, cheese,
cream, yoghurt and milk derivatives such as casein, whey, skimmed milk, non fat
milk solids and hydrolysed whey.

People with lactose intolerance can use soya, rice or oat drinks instead of milk. Try
to buy the products with added calcium to prevent osteoporosis (brittle bone
disease). Some examples of milk-free alternatives are given in the table below:-

Table 5: Products suitable for a milk-free diet

   Foods containing milk or milk                        Milk free alternatives

All milk – fresh, dried, evaporated,       Soya milks

Butter, all types of cheese, fresh and     Milk free margarines: - Telma, Vitaquel
tinned cream

Margarines and spreads containing          Low fat spreads – Suma, Outline

                                           Vegetable oil, lard, suet

Yoghurts, yoghurt drinks, ice cream,       Soya yoghurt, soya desserts, soya ice
dairy desserts, mousse                     cream

Breakfast cereals containing milk e.g.     Cornflakes, rice krispies
Special K, Coco Pops, some brands of

Instant desserts, instant porridge, milk   Oats, semolina, tapioca and rice

Soups or sauces and salad cream            Home made soups and sauces with milk-
containing milk products                   free ingredients

Monosodium glutamate with a lactose

Low calorie sweeteners containing          Canderel spoonful, table sugar
lactose e.g. „Sweet n Low‟ Canderel

Checking ingredients lists for ingredients containing milk or lactose is important for
individuals aiming to avoid these in their diets. The following list provides examples
of ingredients containing milk and lactose:-

       Milk (any fat level), full fat and skimmed milk powder, curdled milk,
        condensed or evaporated milk, milk solids, non-fat milk solids
       Cream (all types)
       Butter
       Kefir
       Cheese
       Whey powder, sweet whey powder, whey and whey proteins, demineralised
        whey, whey protein concentrate, whey solids
       Milk proteins
       Milk sugar or lactose
       Casein / Caseinate / calcium casein / sodium caseinate
       Albumin, lactalbumin

It is worth noting that individuals with lactose intolerance can tolerate different levels
of lactose in their diets. This means that some individuals can tolerate small amounts
of lactose in their diets without any adverse effects. As a rule of thumb, the higher
the fat content of milk and yoghurts, the lower the lactose content will be (although
some commercial yoghurts contain additional milk solids which increase the lactose
content). Fermentation (stronger varieties) and fat content (higher fat versions) are
generally more likely to make cheese varieties lower in lactose.

1.4.4 Nut-free diet

For individuals who are advised to avoid nuts in foods, careful checking of food
labels will be required, as even tiny amounts of nuts in food can cause a severe
reaction. It is worth noting the following:-

 „Nut free‟ claims on labels are only made by manufacturers who have
   implemented rigorous controls to ensure that the food has not had contact with
   any nuts or nut products.

 Labels with „may contain nuts‟ are used when a manufacturer cannot guarantee
   that the product does not accidentally contain them. Individuals suffering with nut
   allergies should not consume the food.

 Contamination from other foods needs to be considered. Foods for a nut-free diet
   need to be prepared separately in a safe environment.
The following table contains information on how to avoid nuts and nut-containing
products in foods.

Table 6: Products suitable for a nut-free diet

   Foods / ingredients containing nuts                     Nut-free alternatives

Peanuts, hazelnuts, walnuts, pecans, brazil
nuts, coconuts, almonds, macadamia nuts, pine
nuts, cashew nuts, ground nuts, earth nuts,
monkey nuts, mixed nuts.
Blended Oils, Unrefined / Gourmet Peanut,        Sunflower Oil, Olive Oil, Safflower Oil
Arachis, walnut, coconut, almond and
Groundnut oils. Peanut and hazelnut oils may /
may not cause an allergy.
All Biscuits, Almonds, Coconut biscuits,         Home made biscuits made with known
Macaroons.                                       source of oil.
Peanut Butter, Chestnut Puree, Chocolate and     Jam, Marmalade, Honey
Hazel Spread, Praline Spread, Sweet
Christmas Cake, Fruit Cake, Stollen, Marzipan    Home made cakes containing known
containing cakes, Carrot Cake, Passion Cake,     ingredients. Cakes guaranteed to be Nut
Cakes bought in Delicatessen, Cakes containing   free by manufacturers.
vegetable oil.
Crunchy Nut Cornflakes, Fruit & Fibre, Muesli,   Weetabix, Shredded Wheat, Cornflakes,
Shreddies, Fruitful, etc.,                       Rice, Krispies Etc. Check labels.
Dips & Sauces
Pesto Sauce, Waldorf Salad.                      Home made versions made with known
                                                 source of oil.

   Foods / ingredients containing nuts                         Nut-free alternatives

Vegetarian Food
Nut Loaf, Vegeburgers, Sausages. (Some               Home made versions made with known
products may be nut-free - Check Labels).            source of oil and no added nuts.
Nut Yoghurt, Nut Ice-creams, Puddings                Home made versions made with known
containing nuts.                                     source of oil and no added nuts, fruit and
                                                     plain yoghurts, vanilla and fruit ice
Nougat, Nut Brittle, Halva, Snickers, Topic, Fruit   Boiled sweets or fruit chews
& Nut, Bounty, Toblerone, Liquorice Allsorts,
Pralines, Florentines. Always Check Labels as
many contain nuts.
Eating out
Some Chinese, Thai and Indonesian Foods e.g.         When eating out, ask staff which foods
Satay.                                               contain nuts and the risk of contamination
                                                     of other foods. If possible, speak to the
                                                     Avoid eating foods at buffets or from
                                                     delicatessens or bakeries where it is easy
                                                     for food to be contaminated by touching
                                                     other foods containing nuts.

Strictly speaking, peanuts aren't actually 'nuts', they're 'legumes' (as are peas, beans
and lentils), but many people who are allergic to peanuts can also develop an allergy
to one or more tree nuts. So, even if someone is only allergic to one type of nut it still
might be better to avoid products containing any nut or peanut ingredient.

1.4.5 Egg-free diet

An egg-free diet involves the complete avoidance of eggs and foods containing eggs
or egg products. The following table helps to identify foods to avoid and include in an
egg-free diet:-

Table 7: Products / foods containing eggs and suitable alternatives for an egg-
free diet

        Foods / ingredients containing eggs                         Egg-free alternatives


   Hen, Duck, goose and quails eggs, egg powder,
    scotch egg.

Egg ingredients (see food labels)

   Egg powder, dried egg, frozen egg, pasteurised              Egg substitute (whole egg or egg
    egg                                                          white replacer) products are
   Egg proteins (Albumin, ovalbumin, globulin,                  available and most are on
    ovoglobulin, livetin, ovomucin, vitellin, ovovitellin)       prescription
   Egg white, egg yolk                                         Some „egg-free‟ products are
   Egg lecithin (E322)                                          commercially available (such as
                                                                 omelette mixes, cake and muffin
                                                                 mixes etc).
Breads, rice, cereals and other baked products

  Any commercial bread or bread product made with
   egg products or brushed with egg for glazing                 Plain bread, or buns (without egg
 Pancakes, Yorkshire Puddings, batter, choux                    products or brushing with egg for
   pastry, waffles, doughnuts, and muffins, pretzels             glazing)
 Egg noodles, egg-based pasta or egg-fried rice                Most cereals and grains, such as
 Baking mixes, batter-fried foods, French toast,                rice
   Fried rice containing eggs, soufflés, quiche
 Sponge and sponge fingers and trifle
Fruit and vegetables
                                                                Any vegetables prepared in a
   All fresh, frozen, dried, or tinned fruit and                sauce containing eggs in any
    vegetables and fruit juices                                  form (such as hollandaise sauce,
                                                                 vegetable soufflé or batter-fried
                                                                Any fruit served with a sauce
                                                                 containing egg such as custard
                                                                 sauce or with a sponge.

        Foods / ingredients containing eggs                      Egg-free alternatives

Meat, Meat Substitutes

  Commercially breaded meats, fish, or poultry             Any fresh meat, fish or organ
  Meatballs, meat loaf, some sausages, pate, other          meats
   processed meat, fish and chicken products
 Quorn products (some other vegetarian products
   and vegetarian burgers may need checking)
Milk & Milk Products

   Malted beverages, custard, Ovaltine, protein            Whole, low-fat or skim milk,
    drinks containing egg / egg products / egg protein       buttermilk
   Ice cream                                               Cheese and yoghurt

   Any stock cleared with egg (consommé, broth,            Soup or broth prepared with
    bouillon), any soup with egg noodles                     allowed ingredients

Desserts & Sweets

  Cakes, biscuits, cream-filled pies, meringues,           Gelatin, fruit ice lollies
   whips, custard, egg custard, ice cream, sherbet ,        Homemade cakes and desserts
   fresh mousses                                             prepared with allowed
 Chocolate made with cream or fondant fillings              ingredients
   (including crème caramels), marshmallow sweets,
   nougat, fudge, chewits,
 Fondant icing, marzipan, chocolate sauce
 Dessert powders
 Pie crust or jelly beans brushed with egg whites
Fats & Oils

   Commercial salad dressings and mayonnaise               Butter, margarine, vegetable oil,
    (unless egg free)                                        shortening, oil & vinegar
   Tartar sauce                                             dressing

   Root beer, wine, or coffee if clarified with egg        Water, fruit juice, fruit drinks
                                                            Tea
                                                            Carbonated beverages
Condiments & Miscellaneous

   Cream sauces made with eggs                             Sugar, honey, jam, jelly
   Hollandaise sauce, tartar sauce, marshmallow            Salt, spices
   Baking powder containing egg white or egg
   Lemon curd
   Some gravy granules

1.5 High Fibre Diet

A menu providing foods that are high in fibre should be encouraged for all healthy
residents and is considered within the „Eating Well for healthy adults with a good
appetite and healthy weight in care settings‟ guidelines. Eating higher fibre foods
keeps the digestive system healthy, preventing bowel problems such as
constipation, diverticular disease (bulges or pockets in the large bowel) as well as
reducing the risk of bowel cancer and reducing cholesterol in the blood. A high fibre
diet is also recommended for people with constipation, high blood pressure and
raised cholesterol levels. They also help to fill people up which is important if people
are trying to loose weight or maintain a healthy weight. Fibre-rich foods are low in fat
and high in vitamins and minerals.

The fibre in take in the UK is 12g a day, yet the recommended intake in 18g a day.
Foods which have 6g of fibre per 100g can be labelled high fibre foods. To achieve
this intake, a diet rich in oats, fruits and vegetables, pulses (peas, beans and lentils),
wholegrain cereals, wholemeal rice, wholegrain pasta and wholemeal bread is
recommended. The more that fibre intake needs to be increased, the greater will be
the need for substitution of processed cereals and grains for good dietary sources of
fibre (see the table below).

It is worth noting that, where an increased fibre intake is being recommended for
constipation, fluid intake should also be increased as wholegrain cereals and
wholemeal bread absorb water in the gut and work more effectively as bulking
agents when more water is available to the gut.

If a resident has a specific need for a high fibre diet due to a medical condition such
as diverticulitis, inflammatory bowel disease or Crohn‟s disease, further dietary
advice and information should be sought through referral to the local dietetic
department (in full consultation with GP and with resident‟s consent. This should also
be documented in the resident‟s care plan.

Table 8: Good, Moderate and Poor sources of fibre in the diet

Good Sources of fibre                        Peas, beans, Brussels sprouts, parsnips,
                                             spring greens Jacket potatoes
(more than 4g per portion)
                                             Wholemeal, rye and granary bread,
                                             wholemeal pasta

                                             All Bran, Bran flakes Muesli

Moderate sources of fibre                    Most fruits, vegetables and nuts

(1-4g per portion)                           Other bread, brown rice, other pasta

                                             Wholemeal and fruit cake

                                             Weetabix and porridge

Poor sources of fibre                        Lettuce, marrow, grapes, mandarin oranges

(less than 1g per portion)                   White rice, sago, cornflour, tapioca, plain
                                             cakes and biscuits

                                             Cornflakes, Rice Krispies

1.6 Diabetic Diets

Diabetes is a condition in which the body struggles to or cannot regulate the amount
of blood glucose (sugar in the blood) within a normal range, which is between 4 and
8 millimoles per litre. There are two main types of diabetes, and the approach to
dietary changes may be different in relation to the type of diabetes and the treatment
given. The aim for management of the condition is to maintain the best possible
blood glucose levels, maintain a healthy weight, normal blood pressure and
cholesterol levels.

1.6.1 Type 1 diabetes

The body does not produce any insulin and therefore has to be given insulin.
Currently, this is given through injections (or through a pump system). If a resident
has this type of diabetes, it is likely that they are following a healthy eating regimen,

which may involve a regular and consistent eating pattern with regular snacks,
including one before bedtime.

1.6.2 Type 2 diabetes

With this condition, the body cannot make enough insulin or the insulin produced
does not work properly. Treatment includes a healthy eating regimen, which involves
eating regularly and including starchy carbohydrate as a basis of all meals and
possibly also medication, tablets or insulin.

To maintain good blood glucose control for both forms of diabetes, the following tips
should be followed. They are based on healthy eating advice to help maintain a
healthy weight and, blood glucose control and cholesterol levels and only differ from
healthy eating advice in relation to the following:-

       To achieve a high carbohydrate intake, all meals should be based on starchy
        foods (bread, cereals, pasta, rice, potatoes, yam, chapattis, noodles) and
        preferably also higher fibre varieties where possible. Additional carbohydrates
        can also be provided by fruit and vegetables (as part of the recommended 5
        or more portions of fruit and vegetables per day), pulses (peas, beans and
        lentils) and milk and dairy products (see next bullet point below). Diabetes
        care multi-disciplinary teams overseeing individuals on insulin regimens may
        suggest that the individual matches the amount of drugs required to daily
        carbohydrate intake. In this case, the total amount of carbohydrate consumed
        needs to be calculated from meal to meal and day to day and the resident‟s
        drug levels need to be adjusted according to their carbohydrate intake 4. If this
        regimen is being followed, information should be available from the resident‟s
        diet sheets and / or their diabetes care multi-disciplinary team.

 This is called „carbohydrate counting‟. More information on this system can be obtained from
Diabetes UK (2009). About carbohydrate counting: For people with Type 1 diabetes
Available from:
Type-1-diabetes/About-carbohydrate/Carbohydrate-counting/ [Accessed 16.02.10].
      Dairy products provide a source of carbohydrate to people with diabetes.
       However, as they can also provide significant amounts of fat in the diet,
       reduced fat milks and other reduced fat and sugar dairy products (such as diet
       yoghurts) are recommended, rather than higher fat varieties.

      Ensure three meals a day are eaten at regular time intervals. Residents may
       also require additional snacks according to their medication regimen.

      Avoid sugary drinks and limit sugar consumed in snacks and added sugar
       used in cooking. Artificial sweeteners can be used in drinks and some can be
       used in cooking. However, some added sugar in recipes can be also be
       reduced by substitution with fruit. Below are some examples of suitable
       snacks to use:-

          o Plain biscuits e.g. digestives, rich tea, Garibaldi

          o Tea cakes, hot cross buns

          o Crumpets

          o Malt loaf

          o Wholemeal scones

      Offer at least 2 portions of oily fish per week on the menu (and up to 4
       portions in total).

      Limit alcohol intake to recommended levels as advised in the „Drinking Well‟
       guidelines for this award. Drinking more than this on one occasion can risk
       hypoglycaemia (low blood sugar levels); details of which are provided below.

      Foods labelled and sold as „Diabetic‟ such as chocolates, cakes and sweets
       have no benefit and are often expensive. They are normally high in fat and
       calories and can sometimes cause diarrhoea due to the sweeteners they

1.6.3 Hypoglycaemia

1. It is important to note that insulin and certain tablets taken by people with
   diabetes can put them at risk of hypoglycaemia (low blood sugar levels),
   especially if too much medication is taken, a meal or snack is unduly delayed,
   insufficient carbohydrates have been consumed or a person has been involved in
   strenuous exercise.

2. Hypoglycaemia means blood glucose levels below 4 millimoles per litre.
   Symptoms include shakiness, sweating, tingling lips, pale complexion, pounding
   heart and irritability in milder cases, which can develop into unconsciousness and
   can be life-threatening in extreme cases.

3. Advice should be sought from the diabetes care team about resident‟s medication
   and their risk of hypoglycaemia.

4. If hypoglycaemia cannot be avoided, treatment should involve a resident taking a
   sugary drink or glucose tablets followed as quickly as possible by a starchy
   carbohydrate snack or a meal (if this is due). In extreme cases, people with
   diabetes on insulin regimens should have stocks of glucagon to inject if they fall
   unconscious as a result of a hypoglycaemic event.

1.6.4 Hyperglycaemia

Whilst some people with diabetes may experience hypoglycaemia, many with poor
control or during periods of illness or stress, may experience raised or high blood
glucose levels (hyperglycaemia). Although this may not seem appropriate, at these
times, it is very important to continue a normal medication regimen as the
consequences of hyperglycaemia could be potentially very serious. If the person with
diabetes cannot eat properly or is suffering from nausea and / or vomiting, refer them
to their medical team immediately, who will be able to offer additional advice on
maintaining blood glucose levels through other means (which may include using oral
nutritional supplements).

 Regular blood glucose monitoring is generally recommended, especially if
 an individual has a history of sub-optimal blood glucose control or is
 suffering from an illness. Review is recommended by the diabetes specialist
 nurse / Dietitian if blood glucose levels frequently stray beyond
 recommended limits (see the table below).

Table 9: Targets for blood glucose levels for self-monitoring purposes

Diabetes Type                          Fasting / Pre-meal              Targets 2 hours after
                                        Targets (mmol/L)                 meals (mmol / L)
Type 15                                          4-7                         Less than 9
Type 26                                          4-7                        Less than 8.5

It is also recommended that if any of the following conditions are experienced, urgent
medical review should be sought:-

   High temperature
   Stomach pain
   A fruity smell on the breath, which smells like pear drops / nail varnish.

1.7 Modified consistency diets

A modified consistency diet is one in which the texture of the food offered has to be
altered in order to help an individual swallow safely without choking and in some
cases, to limit pain associated with swallowing. Some may require the individual to
be able to chew before swallowing and some may not.

1.7.1 What types of modified consistency diets exist?

There are two types of modified consistency diet; a modified food and a modified
fluid textured diet. It is very common for individuals requiring a modified consistency
to require modification of both food and fluids. It is important to note, however, that

 NICE (2004); update (2009). Guidelines for the diagnosis and management of Type 1 diabetes in
children, young people and adults. Guideline Number 15. NICE: London Available from: [Accessed 16.01.10].
 NICE (2008). Type 2 diabetes: the management of Type 2 diabetes. Clinical guideline 66. NICE:
London. Available from: [Accessed

these diets can often be much lower in energy than traditional diets and need to be
adequately fortified (see the sub-section entitled „Tips on fortifying food‟ for more
information on how to do this).

1.7.2 When would a modified consistency diet be required?

The most common reason individuals require a modified consistency diet is when
they are suffering from a condition known as dysphagia (this term covers all
problems associated with the swallowing process). Causes could include:-

    A weakness in tongue or cheek muscles that support chewing by moving food
     around the mouth.
    Signals from the brain are affected and the swallowing reflex cannot start.
    Weakness in the muscles in the throat present difficulties in moving food down
     into the stomach.
    Infection or irritation can cause narrowing of the tube that carries food from the
     throat to the stomach.
    Physical abnormalities in the mouth and throat.

Any of the above problems can result in food and / or fluids falling or being drawn
into the windpipe, which can cause choking and also chest infections if coughing or
throat clearing cannot adequately remove them.

It is usual for individuals requiring a modified consistency diet to have diagnosis of
dysphagia made by a Speech and Language Therapist (referral is made via the GP).
Recommended food and fluid consistencies are then made by Speech and
Language Therapists in conjunction with Dietitians. Dietitians will also support
supplementation of the diet to prevent malnutrition.

However, there may be cases where dysphagia can occur spontaneously in an
individual who may never have had previous problems with chewing or swallowing.
Warning signs are frequent coughing or choking when eating or drinking. If care
home residents display such symptoms, an urgent request to the resident‟s GP to
recommend immediate referral to a Speech and Language Therapist is advised.

Failure to do so could result in serious, if not fatal consequences. Some residents
may also suffer regular and persistent chest infections. In this case, the resident
should receive an urgent detailed multi-disciplinary clinical review to eliminate
dysphagia as a potential cause.

Once a diagnosis has been made and appropriate consistencies recommended,
diets that are recommended should be followed until clinical reviews indicate that the
diet is further modified or dietary restriction is removed. Once a normal diet is
recommended, provision of a modified consistency should cease according to the
clinical recommendations given.

Care home cooks must therefore be trained in order to ensure that the various
consistencies recommended are repeatedly produced to a high standard and are of
a sufficient nutritional quality (such training is included within this award programme).
A simple guide to the textures that are clinically recommended7 is as follows (for
more information, refer to guidance provided by your local Speech and Language
Therapy / Dietetic team):-

 British Dietetic Association (2009). National Descriptors for Texture Modification. Available from: Accessed 28.10.09

Table 10: Guidelines for Modified Fluid Textures

Texture            Description of fluid texture                      Examples

Thin Fluid         Still Water                                          Water,        tea,
                                                                         coffee without
                                                                        Diluted squash,
                                                                         spirits, wine
Naturally    Thick Product leaves a coating on an empty glass           Full cream milk,
Fluid                                                                    cream liqueurs.
                                                                        Complan, Build
                                                                         Up (made to
                                                                        Nutriment.
                                                                        Commercial sip
Thickened Fluid    Fluid to which a commercial thickener has
                   been added to thicken consistency.

                       Can be drunk through a straw.
Stage 1 =              Can be drunk from a cup if advised or
                       Leaves a thin coat on the back of a spoon.

                       Cannot be drunk through a straw.
Stage 2 =              Can be drunk from a cup.
                       Leaves a thick coat on the back of a

                       Cannot be drunk through a straw.
                       Cannot be drunk from a cup.
Stage 3 =
                       Needs to be taken with a spoon.

Table 11: Guidelines for Modified Food Textures

Texture            Description of food texture                      Food examples

A        (Smooth      A smooth, pouring, uniform consistency.         Tinned tomato
pouring               A food that has been pureed and sieved to         soup
consistency            remove particles.                               Thin custard
pureed)               A thickener may be added to maintain
                      Cannot be eaten with a fork.
                      This is similar in texture to Stage 3
                       thickened fluid texture.
B        (Smooth       A smooth, uniform consistency.                  Soft    whipped
dropping               A food that has been pureed and sieved to        cream.
consistency             remove particles.                               Thick custard
pureed)                A thickener may be added to maintain
                       Cannot be eaten with a fork.
                       Drops rather than pours from a spoon but
                        cannot be piped and layered.
                       Thicker than A.
C (Smooth thick        A thick, smooth, uniform consistency            Mousse
consistency            A food that has been pureed and sieved to  Smooth
pureed)                 remove particles                                 fromage frais
                       A thickener may be added to maintain
                       Can be eaten with a fork or spoon
                       Will hold its own shape on a plate, and can
                        be moulded, layered and piped
                       No chewing required
D (Fork minced)        Food that is moist, with some variation in  Flaked fish in
                        texture.                                         thick     sauce
                       Has not been pureed or sieved.                   stewed    apple
                       These foods may be served or coated with         and thick
                        a thick gravy or sauce.                         Custard
                       Foods that are sufficiently soft to be easily
                        mashed with a fork.
                       Meat should be prepared as per „C‟ above.
                       Requires very little chewing.
E (Soft)               Dishes consisting of soft, moist food.          Tender     meat
                       Foods can be broken into pieces with a           casseroles
                        fork.                                            (approx 1.5cm
                       Dishes can be made up of solids and thick        diced pieces).
                        sauces or gravies.                              Sponge      and
                       Avoid foods which cause a choking hazard         custard.
                        (see list of High Risk Foods)

1.7.3 Foods which are not recommended for modified consistency diets

   Stringy, fibrous texture e.g. pineapple, runner beans, celery and lettuce.
   Vegetable and fruit skins including beans e.g. broad, baked, soya, black-eye,
    peas, sweetcorn and grapes.
   Mixed consistency foods e.g. cereals which do not blend with milk, e.g. muesli,
    mince with thin gravy, soup with lumps.
   Crunchy foods e.g. toast, flaky pastry, dry biscuits and crisps.
   Crumbly items e.g. bread crusts, pie crusts, crumble and dry biscuits.
   Hard foods e.g. boiled and chewy sweets and toffees, nuts and seeds.
   Husks e.g. sweetcorn and granary bread.

1.7.4 Tips for successfully pureeing food

The first rule is to use equipment suited to the amount of food that is being pureed. A
food processor or liquidiser is recommended for larger quantities. However, when
single portions are being liquidised, it is advisable that a hand blender is used as
larger equipment may not uniformly puree smaller portions. Ideally, each component
of the meal should be pureed individually and served attractively to increase its
sensory appeal to residents. Un-damaged sieves should be used to remove even the
smallest lumps which could cause a choking episode. Make sure that the
temperature of food is the same when it is served as it was before it was pureed, as
hot food can cool or cool food can warm significantly when it is pureed and sieved.

The following are food types that work well for pureed consistency diets:-

Table 12: Foods that puree easily

Hot food options                          Cold food options

Meat, poultry and fish cooked in Cottage cheese
gravies and sauces

Scrambled eggs and cheese                 Pureed fresh soft fruit (with skin and
                                          seeds removed)

Baby cereals,      Ready   Break    and

Thinned cooked cereals (e.g. rice, Plain, smooth and drinking yoghurts
pasta, couscous and noodles).

Pancakes                                  Smooth      puddings,   mousses    and

Mashed and boiled potato                  Sugar, syrup, honey and jelly

Fruit and vegetables (excluding those Cream and non-dairy creamers
with skins that cannot be removed; see
list of foods not recommended)

Soups                                     Margarine

Gravies and stocks                        Mayonnaise, ketchup and mustard

Sauces, including cheese, white,
creamed, barbeque and tomato.

Custard and sweet white sauces

Plain steamed sponge puddings

Rice, sago and tapioca puddings

Once the food is pureed down, it may need loosening to get an appropriate texture.
Fluids to use to thin down the food should be nutrient-dense, such as milk, gravy and
sauces. Water is not recommended as it has no calories. A thickening agent should
be added to ensure the food is the correct consistency. There are 2 main commercial
thickeners, and are available on prescription for an individual if they require
thickened fluids and pureed meals:-.

   1. „Thick and Easy‟ produced by Fresenius KABI.

   2. „Nutilis‟ produced by Nutricia Clinical Care.

Both companies have representatives willing to provide training and education to
care homes. Contact details for these companies are provided in the „Useful
Contacts‟ section at the end of this document.

1.7.5 Tips for encouraging residents to eat pureed meals

It is more important than ever with pureed foods to ensure that flavour is optimised
as it is very easy to overlook the sensory appeal of such foods. Use of herbs,
spices, condiments and lemon juice can all help to enhance flavour.

Another important consideration with thick pureed foods is that they should be
presented creatively. Ideally, individual components should be served separately on
a plate and colours mixed. For example, foods that are light in colour should be
served with foods that have bright colours. Use of coloured garnishes can also
significantly improve the visual appeal of pureed meals, so long as they are not

Pureed foods can be served using food moulds which can make them look more like
real food. Moulds are available from commercial companies as stated above.

1.7.6 Soaking solution

Certain foods can be soaked in fluid and thickener to make them suitable for
individuals requiring a pureed diet. A soaking solution is made up using a fluid and
a commercial thickener in measured quantities. Foods such as bread and biscuits
can be „soaked‟ and they hold their shape and still look like normal foods.

It is worth noting that due to the different starches used in the manufacture of
thickening agents, only certain commercial thickeners can be used for this purpose;
It is therefore important to check information available from the company that is
used for a resident‟s standard thickening agent to check if it can be used for this
purpose and for guidance on how to do this. If an additional agent needs to be
prescribed for this purpose, advice should be sought from a Speech and Language
Therapist or Dietitian.

Table 13: Examples of foods which can be prepared using soaking solution

Food                                        Fluid used for soaking solution

Plain biscuits                              Fruit juice or milk

Plain sponge cake / Madera cake             Fruit juice or milk

Sandwiches                                  Vegetable stock
Bread ( no seeds)                           Water
Fillings:- seedless jam
            Meat paste
            Fish paste
The filling has to be smooth
Crackers                                    Vegetable stock

Cereal e.g. malted wheat, Weetabix          Milk or fruit juice

1.7.7 Eating safely with dysphagia

The following are tips to help prevent choking when eating and drinking with

   Seek advice on suitable aids which can be used, e.g. cutlery, plates (heated
    and/or adapted to avoid slipping), plate warmers, cups and straws etc.
   Maintain an upright position when eating or drinking.
   Eat and drink small amounts at a time and do not rush meals and drinks.
   Avoid distractions whilst eating and drinking including talking and maintain a
    relaxed atmosphere.
   If there is a weakness in one side of the mouth, place food in the stronger side.
    Once a meal has been finished, check inside the mouth for any leftover food
    which may have collected.

   Positioning the head downwards with the chin against the chest whilst
    swallowing can help to support safe swallowing.
   Avoid mixing foods and fluids in the same mouthful by „washing foods down‟
    unless this has been medically recommended.
   Maintain, wherever possible, an upright position for 30-40 minutes after each
    meal, in case any stomach contents come back up into the gullet or mouth and
    are re-swallowed.

1.7.8 Administering medication to individuals requiring modified consistency

Individuals requiring modified consistency diets also require modified consistency
medication (which could include the medication itself and the water used to wash it
down). Ensuring that a pharmacist has been consulted first (to check that such
actions do not have a negative impact on the action of medication taken), it is worth
considering that:-

   Tablets can be crushed and mixed into small amounts of thickened water.
   Liquid medicines may be need to be thickened or thinned before they are

1.8 Fortification of Food and Fluids

The main situations in which fortification of food and fluids is advised include:-

   Where energy and protein needs of the body are increased and are unlikely to be
    met through a normal diet without increasing the volume needing to be consumed
    significantly (such as in situations where the body has been subjected to trauma
    or injury; which includes pressure sores) and / or

   Where requirements are the same as normal but appetite is reduced and a
    person is struggling to eat enough food to meet their needs.

Several examples of situations in which food fortification is recommended have been
outlined in the „Meeting the Wide Range of Nutritional Needs of Residents in Care
Homes‟ section, although it is worth noting that they are by no means exhaustive.

The key to food and fluid fortification is therefore increasing the calorie and protein
content of food and fluids (and where possible also vitamin and mineral content)
without increasing the volume that needs to be consumed.

1.8.1 Eating a high energy diet

The „Eating Well for healthy adults with a good appetite and healthy weight in care
settings‟ guidelines should not be applied as they limit potential energy consumption.
In fact, the opposite guidance is appropriate in the case of fat and sugar intake,
where the following are recommended:-

High calorie, high fat, high sugar foods should be encouraged on the menu and as
snacks, including:-

   Full fat milk

   Cream (which can be provided on tables as well as in food served).

   Ordinary and creamy cheeses

   Thick and creamy yoghurts (not low fat or diet varieties).

   Ordinary butter / margarine (not reduced fat varieties or low fat spreads).

   Cakes (including those with butter icing and cream fillings).

   Biscuits (higher calorie options include those with cream fillings or chocolate

   Sweets and confectionery.

   Crisps (not reduced fat varieties).

   Mayonnaise or salad cream (not reduced fat varieties).

   Nuts
   Pastry (sweet and savoury).

   Fried foods (including fried breakfasts, fried fish, chips, sautéed potatoes, roast
    potatoes etc).

   Creamy soups and sauces.

   Meat with its fat left on it for cooking, poultry served with its skin or minces that
    are not drained during cooking.

   Offer additional snacks throughout the day – aim to encourage up to 3 small
    meals and up to 3 high energy snacks daily if possible.

   Increase activity levels to increase hunger.

   Discourage excessive consumption of soft drinks and high sugar drinks between
    meals or offering drinks just before meal times as this can make residents feel full
    and discourage them from eating well at mealtimes.

   Offer milky drinks throughout the day and before bedtime.

1.8.3 Tips on fortifying food

When offering a high energy diet, it is also worth actively fortifying food. Whilst this
helps to increase the fat content of food offered, it also helps to increase the protein,
vitamin and mineral content also. Everyday foods can be fortified by the following
cooking methods (see table below for the Calorie and protein content). For example:-

   Add cheese to sauces and potatoes and plenty on top of potato-topped pies.

   Add skimmed milk powder to drinks made with milk and to savoury white sauces
    and custard and use full-cream milk to make coffee, hot chocolate, porridge,
    custard, milk jellies, etc.

   Add plenty of margarine to mashed potato and vegetables (avoid using low fat

   Use plenty of oil in cooking (such as when frying onions, chunks of meat, mince

   Add extra jam, cream or honey into puddings.

However, it is not appropriate to fortify all the meals that are offered in a care home if
several residents also require a healthy diet. Individual portions can be fortified at the
table or just before service by the simple techniques shown below:-

   Sauces can be divided up into servings appropriate for those requiring a healthy
    diet and those on a fortified diet just before serving. If the sauce that requires
    fortifying is left in a saucepan and has additional milk powder dissolved in a
    minimal amount of milk added to it, the sauce can be heated through and then
    served alongside the healthier sauce.

   Extra butter, cream and cheese can be added to mashed potatoes just before
    they are served. Again, dividing up healthier portions and portions needing
    fortification just before serving is an ideal way to do this.

   If meals are cooked in more than one oven dish, one or more of these could be
    fortified before being put in the oven (e.g. additional oil can be added to meat in
    sauce if this is the base of a dish just before it is spooned into an oven dish and a
    fortified potato mash or pastry topping can be used for higher energy version
    meals whilst healthy eating techniques have been used in the cooking process
    until that point).

   Those sandwiches required for fortified diets can be made with extra margarine,
    mayonnaise or salad cream.

   Extra sugar can be sprinkled on cereals and in hot drinks.

   Add full fat milk, milk powder, cheese or cream to soups just before serving. This
    allows lower fat versions to be available for other residents.

Table 14: Energy (Calorie) and protein content of foods which can be used to
fortify meals

     Food                     Quantity                 Calorie / protein
     Butter                   1 Pat                    70 kcal
     Double Cream             50ml                     225 kcal
     Olive Oil                1tblsp                   99 kcal
     Mayonnaise               1tblsp                   128 kcal
     Sugar                    1tblsp                   80 kcal
     Jam                      1tblsp                   40 kcal
     Skimmed milk powder      1tblsp                   22g protein / 118kcal
     Cheese                   25g                      6g protein
                                                       104 kcal

Section 2 - Dietary Supplementation

Vitamin and mineral supplementation and nutritional supplementation (using fortified
powders, drinks and other liquids) is covered in this section. Guidelines are provided
for appropriate use of these and for alternative approaches that care homes can take
to reduce reliance on these where possible.

2.1 Vitamin D and Calcium Supplementation

Loss of bone density and muscle mass, which happens as people age, can lead to
an increased risk of falls and bone fractures, especially for individuals with lower
than recommended vitamin D levels in their body.

Vitamin D is essential for the absorption of calcium in the body. Without sufficient
vitamin D, bones can become thin, brittle and misshapen. The main source of this
vitamin is from sunlight; exposure of the skin to sufficient sunlight promotes
manufacture of the vitamin within the body. For housebound residents in care
homes, exposure to sunlight can be particularly limited. For older residents, residents
who wear a high factor sun cream outdoors or cover most of their bodies when they
are outside or residents with darker skin colouring, the problem can be made worse
as the ability to produce vitamin D in the body is reduced.

Certain foods are naturally rich sources of vitamin D and some are fortified with it by
law to ensure the public consume enough vitamin D. Foods high in vitamin D are:

      Herring and kippers
      Tined salmon
      Tinned sardines
      Margarine and low fat spreads (fortified)
      Cornflakes (fortified)
      Evaporated milk
      Skimmed milk powder

Calcium is also important for bone health. Good sources of calcium in the diet
include the following foods:

      Spinach
      Sardines
      Cheese
      Tofu
      Milk (all types)
      Yoghurt
      Pilchards

A diet rich in calcium is recommended for older people with known bone problems
associated with low bone density (such as osteoporosis [„brittle bone disease‟]) and
for all post-menopausal women.

Obtaining enough vitamin D for older people from the diet on its own is very difficult,
so recommendations are that people in care homes who are not exposed to
sufficient sunlight are recommended to take vitamin D as a supplement. However, to
facilitate absorption, vitamin D and calcium should ideally be prescribed together.
This award recommends that medical advice is sought for younger individuals with
limited sun exposure to be medically reviewed with a view to considering vitamin D

  Care homes offering care to older people (over 65 years), individuals from
  a Black and Minority Ethnic background or individuals who cannot go
  outside should ideally refer such residents to their GP with a view to
  considering prescription of a vitamin D supplement daily (preferably as a
  calcium and vitamin D supplement) in addition to a healthy, balanced diet,
  unless alternative supplements are advised.

2.2. Iron Supplementation

Iron is an essential part of the pigment in red blood cells called haemoglobin, which
carries oxygen around the body. There are 2 forms of iron:

   Haem iron, found in meat and fish, which is easily absorbed into the body.
   Non-haem iron, found in fruit and vegetables and cereal foods, which is not so
    easily absorbed into the body.

Good sources of iron in the diet include:-

 Haem                                        Non-haem
 Beef                                        Fortified breakfast cereals
 Lamb                                        Bread - especially wholemeal
 Liver                                       Pulses (peas, beans and lentils)
 Kidney                                      Green leafy vegetables
 Oily fish                                   Dried fruit
 Chicken legs                                Quorn

If the diet contains insufficient iron-rich foods, iron stores in the body may become
compromised and blood haemoglobin levels may fall (otherwise known as anaemia).
People with anaemia may have a pale complexion, tire easily, have shortness of
breath on minimal exertion and may be less resistant to infections. Anaemia is
common in malnourished people, especially older people.

To increase iron intake in the diet, it is recommended that iron-rich foods (from both
haem and non-haem sources) are encouraged as part of the daily diet. As non-haem
iron is less well absorbed by the body, vitamin C in foods and drinks like diluted fruit
juice, broccoli and potatoes taken with non-haem foods helps the body to absorb this
nutrient. Protein from meat or fish also helps. Therefore, iron absorption from good
non-haem sources of iron can be boosted by consuming lower iron-containing meat
or fish dishes as well (such as white fish or chicken or turkey breast meat).

Tea and coffee reduce the absorption of iron in the body. It is therefore
recommended that care homes aim to offer drinks other than tea and coffee with
meals and aim to offer a glass of fruit juice to help the absorption of iron for residents
whose main iron source at mealtimes is non-haem based.

Iron supplementation should only be recommended by a medical practitioner.
Complications of iron supplementation include constipation and black stools. Care
should be taken when residents are prescribed iron supplements that adequate fluid
and dietary fibre is consumed to manage iron-related constipation, together with
adequate physical activity (where possible).

2.3 Multivitamin (and Mineral) Supplementation

Some residents may need a multivitamin and in some cases also a multi-mineral
supplement if their dietary intake is limited, their eating habits are poor or they have
increased needs (such as for wound healing / pressure sores). These should be
prescribed by a medical practitioner and should consider medical needs and other
supplements that are being taken by the individual to avoid overdosing.

Overdoses of certain vitamins and minerals can be very dangerous. It is therefore
recommended that care home staff note all dietary supplements used by individuals
in their care (including both prescribed and over-the-counter varieties) and check
with medical practitioners if they suspect that more than one form of the same
vitamin or mineral is being taken (e.g. through taking individual vitamin or mineral
supplements and multi-vitamin supplements or through taking a mixture of vitamin
and / or mineral supplements and oral nutritional supplements, especially meal
replacement supplements).

 Vitamin and minerals supplements should only be taken if prescribed by a
 medical practitioner. In certain cases (e.g. where residents are on a long-
 term pureed diet or are being treated for pressure sores), medical advice
 should be sought to determine whether multivitamin and multi-mineral
 supplements or other nutritional supplements should be prescribed.

 If a person’s diet is varied, residents should not need a vitamin and mineral50
 supplement, as high doses of certain vitamins can have toxic effects.
2.4 Oral Nutritional Supplements

These can be brought over-the-counter or prescribed.

Two examples of products which can be brought over-the-counter from
supermarkets or pharmacies are Complan and Build Up. They contain energy and
other nutrients. They come in powder form and milk or water needs to be added
according to manufactures‟ guidelines. It is worth noting that certain forms (soups)
may contain less energy than the drinks and may not contain enough energy on their
own to replace the energy needs of a resident at a mealtime who is consuming
nothing else.

There are also prescribable alternatives to Complan and Build Up, which are also
available on prescription. 4 major companies provide these products:-

       Abbott
       Nutricia
       Nestle
       Fresenius Kabi

A range of supplements are available on prescription8 and can be used instead of or
in conjunction to Complan and Build Up to:-

       Offer a greater chance for an individual with a poor appetite or increased
        nutritional needs to meet their energy and nutrient requirements.
       Provide a greater choice to account for individual preferences and to support
        better compliance.

The forms they come in include:

   Prescribed vs. Non – prescribed

 Note: There may be a local prescribing formulary in place for oral nutritional supplements – A
pharmacist and/or the local dietetic team can provide advice on this.

    Ones which can be freshly made up with milk vs. premade UHT versions
    Savoury versions vs. Sweet versions
    Milk- vs. Juice- vs. Yoghurt-based versions
    Carbohydrate vs. fat vs. protein-only sources
    No fibre vs. High Fibre versions

2.4.1 Handy tips when using oral nutritional supplements

    Supplements may be incorporated into food. A variety of recipes are available
     from manufacturers, using both powdered and liquid supplements to make and
     fortify puddings, drinks and snacks. However, it is worth also remembering that
     ordinary foods can also be used to supplement meals too (as described in the
     „Fortification of Food and Fluids‟ subsection of this document).

    Presentation is also important. Consider decanting the supplement into a glass
     or cup and serve either cold or warmed through, according to the type used and
     the resident‟s preferences (do not boil as this will destroy some of the nutrients in
     the supplement).

2.4.2 Caution when using oral nutritional supplements

It is not common for individuals to be mostly or totally reliant on either over-the-
counter or prescription supplements. They are normally used as an addition to food
to boost the calorie and nutrient content of someone‟s diet where they are struggling
to eat enough to meet their needs. They are not the „easy option‟ alternative way to
feed people with poorer appetites. Whatever needs cannot be met from energy-rich
foods and drinks can then be met through supplementation, where this is deemed

If a resident is prescribed oral nutritional supplements, they should be reviewed at
regular intervals (as part of the nutrition assessment and screening review process)
to assess if supplements are still required. They are not intended for long term use.

    If a resident consistently receives more than 2 oral nutritional supplements
    daily, it is recommended that a Dietitian reviews this or medical advice is
    sought where a Dietitian is not involved in resident’s care to consider the
    best long term plan to meet the resident’s needs.
If supplements have been prescribed for a certain resident, do not give their
supplements to any other resident. They are only to be used for the named person
on the prescription.

2.5 Enteral Tube Feeding

Some residents will not be able to meet any or all of their energy and nutrient
requirements orally. Reasons for this include:-

       Inadequate intake (e.g. increased requirements and / or poor intake, despite
        the use of a fortified diet and oral nutritional supplements) and / or
       Unsafe oral intake (e.g. lack of consciousness / dysphagia etc.).

In such cases, enteral tube feeding regimens may be recommended, so long as a
resident has a functioning gastrointestinal tract (gut). Residents or their families
would be expected to provide consent for enteral tube feeding. In the absence of
such consent, a doctor would be consulted to decide upon the care that is deemed to
be in the resident‟s best interests.

Tube feeding usually occurs through the following routes:-

       Nasogastric (or through the nose into the stomach)
       Gastrostomy (directly into the stomach through the abdominal wall)
       Nasoduodenal or Nasojejunal (through the nose into the upper small
       Jejunostomy (directly into the small intestine through the abdominal wall)

The first 2 routes of feeding are more commonly used and are used when the upper
gastrointestinal tract is functional and accessible. The latter 2 routes are used where
there is a problem with accessibility or function in the upper gastrointestinal tract.
The effectiveness of feeding through the nasogastric and gastrostomy routes is fairly
similar. For certain individuals, however, the gastrostomy route may be favoured
above the nasogastric route, as nasogastric tubes can often dislodge themselves
and may cause irritation or discomfort and in some cases, problems swallowing
safely. However, there are potentially severe and life threatening risks of insertion of
a gastrostomy tube that need to be weighed carefully against the benefits of this
method of feeding for each individual.

Enteral tube feeds can be used to supplement oral nutritional intake or to totally
replace oral intake.

There are different ways in which enteral tube feeds can be given. These include:-

       Continuous feeds (these are set up to run for 24 hours a day). This is the
        most common method used for enteral tube feeding and strongly
        recommended for individuals with diabetes to support better blood glucose
        control. These feeds are delivered continuously by a pump system.
       Night only feeds (for individuals who are mobile in the daytime or eating a
        reasonable amount which needs „topping up‟ at night rather than during the
        day when it may affect their appetite). These feeds are also delivered by a
        pump system.
       Cyclical or intermittent feeds (for example 16-18 hours with 2-4 hour
        breaks or 4-6 hourly with 2 hours rest respectively). These are delivered by a
        pump system and can be used by mobile individuals, but require regular
        „hooking‟ up to the pump system and could therefore limit mobility.
       Bolus feeds (usually given 3-6 hourly, containing between 250-500ml of
        feed). These can be administered via a pump system, but can also be given
        through a wide bore syringe (these are allowed to run naturally out of the
        nozzle of the syringe; they are not forcibly syringed out).

Usually, the method of feeding used is decided by accounting for the individual‟s
preferences, convenience and for the medication that they require.

The types of feeds are usually determined by a Dietitian and those which are usually
administered include:-

       Standard enteral feeds: These contain all the energy and nutrients and in
        some cases, fibre required by an individual in a given quantity of feed.
       “Pre-digested" feeds: These are specifically designed to provide nutrients
        that are in their more basic „building block‟ forms. The aim of these feeds is
        to improve nutrient absorption.

2.5.1 Care of residents receiving enteral tube feeds and prevention of

The following list includes the most common complications of enteral tube feeding
regimens and recommended care to be provided to residents to prevent them

       Nasogastric tubes can becomes dislodged / can fall out or be pulled
        out. Tubes which are pulled out should be replaced by healthcare
        professionals with the relevant skills and training. It is also necessary to
        check the position of these tubes before each feed is administered. Failure to
        do so could result in the feed being administer into the lung by mistake. The
        National Patient Safety Agency9 has provided advice on what needs to be
        done when tubes are misplaced to reduce the harm caused by this and care
        homes should seek appropriate training for staff involved in checking
        placement of nasogastric tubes before feeds are administered.
       Reflux occurs (acid from the stomach leaks upwards into the oesophagus or
        gullet). In this case, placement of nasogastric tubes should be checked.
        Reflux can also occur due to incorrect placement of the individual receiving a
        feed. Propping a resident up by 30-45o angle during and up to 30 minutes
        after feeding is recommended to help to prevent this. If a resident has no
        option other than to lie flat when receiving a feed, it may be worth informing
        the clinical team in charge of the resident as feeding into the upper small
        intestine may be considered a viable feeding option to prevent this.

  National Patient Safety Agency (2005). Reducing harm caused by the misplacement of nasogastric
feeding tubes. Available from: [Accessed

       Adverse gastrointestinal effects may occur (e.g. nausea, bloating, pain
        and diarrhoea). In such cases, symptoms experienced may respond to
        reduced feed administration rates, continuous rather than bolus feeding or
        alternative feed preparation. Dietitians can advise on alternative methods of
        feed administration if such problems occur.
       Adverse effects of re-feeding may occur (in individuals with extremely
        limited / no oral intake prior to enteral tube feeding). Re-feeding can
        cause relatively minor symptoms (such as vomiting and diarrhoea) through to
        life-threatening conditions. To prevent this, feeds should be started slowly
        (both the rate and amount administered) in accordance with dietetic advice
        and the resident should (if they are not hospitalised at this point) be
        monitored regularly by a doctor / other healthcare professional taking and
        analysing blood samples to check the resident‟s electrolytes (phosphate,
        potassium and magnesium levels).
       Gastro-intestinal bleeding / inflammation. Flexible fine-bore nasogastric
        tubes help to prevent may nasal and gastro-intestinal complications
        associated with this type of feeding.
       Infections. These can occur through bacterial contamination of feed or
        feeding equipment and/or tubes used. Risks can be minimised by flushing
        feeding tubes with water before and after use (warm water can help to
        remove blockages) and through discarding administration sets and feed
        containers every 24 hours. Feed should never be decanted and equipment
        used without sterile gloves.

2.5.2 Re-establishing better oral intake in enteral tube-fed residents (where this
is possible)

There may be cases where the use of enteral tube feeding is a semi-permanent
solution for an individual and where oral food and fluid intake will need to be
regularly monitored to establish if oral intake is sufficient to meet a resident‟s
nutritional needs. Regular monitoring of oral intake through food diaries (see
Appendix 5) and fluid record charts (see Appendix 2) would also be recommended

for residents receiving supplementary enteral tube feeds to establish the correct
amount of feed to provide a resident with.

Section 3 - Conditions where Special Dietary
Considerations Apply

This section relates to complex conditions the care home residents commonly
present with (such as dementia, learning disability and palliative care to name but a
few), which impact on a resident‟s nutritional requirements and intake and on the
many different approaches that care home staff may need to take to support them.

For the following conditions, establishing nutritional needs is a fairly complex
process. In such cases, care homes may need to carefully assess needs through
screening and assessment processes but also through monitoring residents‟ habits
in the care home to produce an appropriate person-centred care plan.

3.1 Dementia

It is estimated that at over half of the residents in non specialised care homes have
some degree of dementia10.                  The most common forms of dementia include
Alzheimer‟s disease, vascular dementia and mixed dementia. People with dementia
have difficulties in reasoning power and memory and have varying degrees of
neurological, mood and behaviour changes.

The effects of dementia have a serious impact on a person‟s eating habits, as
detailed below (note that each individual may experience the following to greater or
lesser degrees):-.

  Dening, T., and Bains, J. (2004). Mental Health Services for Residents of Care Homes. Age and Ageing
[Editorial]. British Geriatrics Society. 33; 1-2. Available from: [Accessed 03.11.09].

Practical and physical changes

    Unable to use cutlery as they have forgotten what it is, or they can‟t physically
      hold the cutlery.

    Tremors or lack of co-ordination when transferring food to their mouth.

    Inability to unwrap or peel items of food.

    Unable to sit at a table for a meal.

    Slower eating.

Physiological changes

    Loss of sense of taste and smell.

    Loss of appetite.

    Difficulty swallowing.

    Difficulty chewing food.

    Mouth or tooth pain.

    Have a preference for sweet foods.

Emotional / cognitive changes

    Become distracted during eating.

    Forget to eat or forget having eaten.

    Find it difficult to make food choices as they can‟t remember what food looks
      or tastes like.

    Prefer to eat food with their hands.

    Are unable to communicate hunger and thirst.

    Refuse to eat.

    Become suspicious of food, thinking it may be poisoned.

Other common behaviours which could be potentially dangerous may

      Hoarding food in their mouth without swallowing it.

      Not chewing food before swallowing.

      Eating pieces of food which are too large, and bolting food down quickly.

      Spitting food out.

      Eating non food items.

These can be potentially harmful to the individual, so it is important to ensure one-to-
one supervision at mealtimes.

As with all residents, individual likes and dislikes and eating abilities should be
recorded and regularly monitored. However, it is very useful to record eating
behaviours and the amount and type of food consumed by people with dementia as
this will allow all staff to know what food and drink-related behaviours are and to help
them find ways of managing these.

3.1.1 Nutritional concerns with dementia

Many older people are malnourished, and those with dementia are more likely to be

3.1.1a Energy intake

There is no evidence to suggest that people require a higher energy diet as a result
of dementia; even for those with a tendency to „wander‟ around or rock a lot.11 Not
eating enough food is the most likely cause of weight loss amongst the majority of

  Caroline Walker Trust (1998). Eating Well for Older People with Dementia. A good practice guide
for residential and nursing homes and others involved in caring for people with dementia. Report of an
expert working group. Available from: [Accessed

people with dementia because they are simply not consuming enough food.
Therefore, fortification of foods is recommended for individuals who are underweight,
as well as the use of oral nutritional supplements as necessary.

3.1.1b Dehydration

People with dementia may not be able to communicate they are thirsty, forget to
drink or even refuse fluids, which increases their risk of dehydration significantly.
Encouragement of fluids is important to prevent dehydration and the related effects
(see the „Drinking Well‟ guidelines).

3.1.2 Medication

Many drugs taken for dementia have side effects which could affect a person‟s
nutritional intake, such as:-

     Dry mouth.

     Loss of taste and smell sensations.

     Drowsiness making them feel too tired to eat.

     Constipation.

     Disinterest in food.

     Metallic taste in the mouth.

     Promoting weight loss.

     Nausea.

3.1.3 Practical tips for achieving a balanced diet for people with dementia

   Provide familiar foods and eating patterns. These should be discussed and
    recorded on admission.

   Make meals as colourful as possible, and serve in separate sections on the plate.
    A colourful plate may distract from the food, so try to use plain plates and bowls.

   Have different colour tablecloths to plates, so people with dementia can
    distinguish between them.

   If meals are of a modified texture, serve each component separately on the plate.

   Serve one course at a time to help them focus on the main meal in front of them.

   Too large a serving may be overwhelming and off-putting. Serve smaller portions
    which are higher in calories (and fortified if necessary; see „fortification of foods‟

   Offer frequent high calorie snacks.

   Allow adequate time and staffing levels for meals.

   Try to maintain independence as much as possible. Use appropriate cutlery or
    serve finger foods so that residents can pick them up themselves (see „Finger
    food‟ examples below).

   When feeding people, think about positioning, utensils being used and timing
    between mouthfuls.

   Food related activities may help to trigger memories of food. Use picture cards of
    food to remind people of what food looks like.

   Staff training is imperative to support good feeding techniques, thickening of
    fluids and understanding problems associated with eating and dementia. This will
    be provided as part of the award training.

   Offering verbal encouragement during eating, such as „now open your mouth‟ or
    „chew‟ are helpful whilst feeding a person with advanced dementia.

   Touching food against a persons lip may stimulate them to open their mouth.

   The same member of staff should be with the same resident for the duration of a

   Assist but never force the food into the mouth.

   Staff should give residents their full attention, avoid talking to others whilst
    feeding someone and should aim to maintain eye contact with the person they
    are feeding.

   A quiet eating environment provides fewer distractions for people with dementia.
    Sitting small numbers of residents with dementia at a table also helps.

   Plate guards are useful to help encourage independence. Contact the local
    Occupational Therapy department for details of appropriate modified cutlery and
    eating aids. For details on where to source these, see the „Assistive Technology‟

   Preparing residents for mealtimes will help to remind them that food is being
    served. Remind them when lunch is being served imminently and show them the
    menu of the day to help stimulate their appetite (pictorial menus may be better

3.1.4 Finger Foods

Offering finger foods can help to maintain independence with eating and help to
preserve eating skills for people with dementia. They can be served at room
temperature, thus reducing safety issues with hot food. It can help to trigger people‟s
attention back to the food on the plate and encourage them to eat more.

To make the food look more interesting, shaped cutters such as those used for
baking can be used to change the shape of the food (such as using a tree-shaped
cutter to cut out a sandwich).

Table 15: Examples of Finger foods

Food group         Example finger food

Bread,          Buttered toast cut into fingers
cereals and Sandwiches
potatoes        Buttered muffins, crumpets cut into fingers
                Fruit bun
                Fruit loaf / malt loaf with butter
                Crackers with butter and cream cheese
                Chips / roast potatoes – cooled to room temperature
Vegetables      Carrot, or celery sticks
                Broccoli spears
                Sliced cucumber
                Cooked brussel sprouts
                Cooked green beans
Fruit           Bananas
                Handful of grapes
                Orange segments (peeled)
                Slices of apple
                Dried fruit
Meat,     fish, Cut sliced meat into fingers
cheese and Sausages
meat            Meatballs
alternatives    Chicken fingers cut from the breast
                Fish fingers
                Crab sticks
                Pork pie
                Hard boiled eggs
                Cheese on toast
                Cubes of cheese

These foods are of varying energy content, therefore the individual needs of
residents must be assessed to ensure that appropriate foods are offered.

Many people with dementia will have swallowing problems causes by dysphagia. If a
resident has been assessed by a Speech and Language Therapist and prescribed a
modified texture diet, this should be followed (refer to the earlier section on „modified
texture diets‟).
Other people will not have a medical reason for swallowing problems, yet they may
find chewing difficult and it may seem that they have a problem. If this is the case,
offer soft textured food and see if their food intake increases. It is not recommended
that a pureed diet is offered to those people who have not been assessed by a
Speech and Language Therapist.

3.2 Learning Disability

Learning disabilities are frequently associated with nutritional ill-health. There is also
evidence to suggest that people with learning disabilities have a 58% increased risk
of dying before the age of 50 than the general population have.12 Early death in this
population group is associated with greater incidence of respiratory disease and
pneumonia, heart disease, cerebral palsy, limited mobility and hospitalisation, some
of which can be lowered with dietary intervention.

However, their health needs appear to be less easily recognised by support staff and
care professionals than they appear to be in the general population. Common
causes of nutritional ill-health in individuals with learning disabilities include:-

    Overweight (which could be linked to normal or abnormal eating behaviour
     [including eating disorders] and altered appetite associated with conditions such
     as epilepsy).

    Underweight (which could also be linked to normal or abnormal eating behaviour
     [including eating disorders]).

    Chewing or swallowing difficulties (which could be intensified by poor posture
     and dental health problems).

    Reflux (backward flow of liquid from the stomach to the oesophagus).

  Caroline Walker Trust (2007). Eating Well: Children and Adults with Learning Disabilities. Nutritional and
Practical Guidelines. Available from: [Accessed 17.11.09].

   Diabetes

   Bowel disorders (including constipation).

   Poor oral health

Certain additional factors can also impact on the amount and quality of the food and
drink that is consumed by or the eating experience of individuals with learning
disabilities. These may be present to a greater or lesser extent, depending on the
severity of the learning disability, including:-

   Poor sight, hearing, taste or smell.

   Poor communication skills, which affect their ability to communicate food likes
    and dislikes effectively, the portion size they require or, for health and safety
    purposes, to determine the temperature of food they are eating.

   Poor social skills that may influence their enjoyment of mealtimes or behavioural
    problems that may make communal eating difficult in some cases.

   Side effects of medications that are taken.

   Fussy eating behaviour (usually associated with autistic conditions) where the
    individual may only consume food of a particular colour, taste, texture, smell or

   Insufficient support to maintain independence at snack and mealtimes or, where
    it is required insufficient assistance with meals and drinks.

Individuals with learning disabilities are also at the same risk of lifestyle-related high
blood pressure, stroke and coronary heart disease as the general population, which
means their wider health needs should also not be overlooked. This means that an
individual with a learning disability should primarily be considered for a healthy diet if
their weight is healthy and they have no other major health problems.

The following table has been produced to help care homes identify the correct plan
of action for common problems associated with learning disabilities (where special
diets have already been explained for such conditions earlier in this section (e.g.
diarrhoea and constipation), the advice for these will apply and they are not referred
to the information below :-

Table 13: Common problems associated with learning disabilities and
mechanisms for addressing them

Problem         How to address the problem
Underweight     Follow guidance on „fortification of food and fluids‟ unless the
                problem is related to a suspected or existing eating disorder, where
                medical review may be required and clinical guidance should be
                followed. If there are additional behavioural problems, refer to the
                guidance on „fussy eating‟ or „Dealing with food-related behavioural
                problems‟ later in this section of the document.
Overweight      Follow guidance on overweight and obesity earlier in these
                guidelines unless the problem is related to a suspected or existing
                binge eating disorder where medical review may be required and
                clinical guidance should be followed. If there are additional
                behavioural problems, refer to the guidance on „Dealing with food-
                related behavioural problems‟ later in this section of the document.
Reflux          There are several ways in which this can be improved, including:-
                   Weight loss if a resident is overweight.
                   Avoidance of smoking.
                   Trying to eat smaller, more frequent meals, and aim to eat an
                    evening meal 3-4 hours before bedtime.
                   Limit foods that have been associated with triggering reflux for
                    the individual, including alcohol, coffee, chocolate, tomatoes, or
                    fatty, spicy foods.
                   Raising the head of the bed.
                   Certain medications can improve the condition, but should be
                    medically recommended and account for other medications

Problem        How to address the problem
Fussy             Check that oral health, constipation, distress, agitation, pain,
eating             paranoia or swallowing problems do not underpin the fussy eating
                   behaviour observed. If so, the cause needs to be treated.
                  Pictures and photos can be used to make menus more appetising
                   and alley any fears residents may have about what they are
                  See if a person‟s preferences are recorded and considered; if they
                   are achievable, try to honour them (e.g. not allowing different food
                   items to touch each other on a plate). If this is not the case and
                   they limit a resident‟s ability to eat a balanced diet (such as a
                   resident only consuming pre-packaged snacks), try to agree ways
                   of introducing other foods.
                  A calm and comfortable eating environment with people eating
                   together, chatting and enjoying their food can help to encourage a
                   better food intake.
                  If residents continue refuse a significant amount of food, they
                   should be nutritionally screened and weighed weekly if possible
                   and referred for medical help as advised through the „Meeting the
                   Wide Range of Nutritional Needs of Residents in Care Homes‟
                   care plan flow chart.
Drooling or       Between 1-1.5 litres per day is normally produced and
dribbling          automatically swallowed daily. As well as causing embarrassment,
                   drooling or dribbling can lead to a sore or dry mouth, gum or
                   dental decay; see „oral health guidelines‟, eating difficulties (and in
                   some cases also swallowing difficulties; see „modified consistency
                   diets‟) and dehydration.
                  In order to reduce drooling or dribbling or its effects, the following
                   are important:-
                         o Good hydration; see the „drinking well‟ guidelines.
                         o Gently drying the mouth with an absorbent dry cloth.
                         o Positioning the head so that the back of the neck is
                         o Using special clothing such as scarves.
                         o Certain drugs or travel bands can be used, although
                           their side effects need to be balanced against their
                           benefits; seek advice from the individual‟s GP.
Chewing /         Follow advice given on „modified consistency diets‟ earlier in this
swallowing         section.
difficulties      The National Patient Agency (contact details in the „Useful
                   Contacts‟ at the end of this document) provides tools that can be
                   used for assisting people with dysphagia and Learning Disabilities.

Problem        How to address the problem
Dealing with      Problems experienced by individuals follow 3 key themes:-
problematic              o Eating style / pattern disorders (including incorrect use
feeding                    of utensils, very slow or fast eating, drinking excessively
behaviour                  or eating non-food items).
                         o Resistive or disruptive behaviour (including playing with,
                           throwing, hiding or hoarding of food, distracted eating,
                           demonstrating impatient behaviour at mealtimes or
                           wandering around at mealtimes).
                         o Oral behaviour (involving inadequate / prolonged
                           chewing, holding food in the mouth, spitting out food or
                           not opening their mouth).
                  Solutions to these problems very much depend on the presenting
                   behaviour and may include using assistive technology, specific
                   verbal cues, offering smaller portions or presenting food in
                   different forms (such as finger foods), altering the meal
                   environment and so on. As a minimum, care homes should aim
                         o Respect individual‟s food and drink and mealtime
                         o Gain as much information             about   the   resident‟s
                           preferences and habits.
                         o Take care when trying to interpret cues from individuals
                           around their choices of food.
Using food        Some care homes may be keen to use food as a comfort or treat
as a comfort       as a reward for achieving something or perhaps to compensate for
or treat           negative feelings (such as pain or sadness). However, using
                   sweet and / or high fat treats can have negative consequences
                   both in terms of a resident‟s oral health, but also their body weight.
                  Other non-food treats are therefore recommended, including:-
                         o Offering praise
                         o Using stickers / badges / or a wall chart.
                         o Offering the opportunity to engage in favourite activities
                           or to have access to favourite films, CD‟s or talking

3.3 Feeding and Hydration for Residents Receiving Palliative Care

Palliative care is a very sensitive subject – especially when it comes to decisions
about feeding. For example, it can be argued that feeding could unnecessarily
prolong death and evoke feelings of fear and despair in people who are in a lot of
pain at that stage. If swallowing is a problem or they are tube fed, there may also be
a greater risk of regurgitation and resultant chest infections. However, there are also
many benefits, including:-

   Improved quality of life and sense of wellbeing.

   Maintaining a certain level of normality and routine for a resident.

   Reduced risk of infection and pressure sores.

   Reduced muscle wasting, therefore better mobility and strength.

   Increased energy levels.

It is also worth noting that eating / assistance with feeding is considered to be an
essential part of a person‟s basic care. As such, food should never be withdrawn
unless oral feeding becomes impossible. Hydration is essential for wellbeing and is
also an essential part of a person‟s basic care.

The issue in terms of feeding someone receiving palliative care therefore comes
down to the ethics of providing artificial hydration or nutritional support only and not
in circumstances where an individual can eat or drink (with or without appropriate
support; this includes high energy, fortified diets where food intake is limited).
Failure to feed or properly hydrate a resident (unless this has to be done artificially)
therefore can constitute the legal equivalence of withdrawal or withholding of care.

In the case of artificial nutritional support (which includes the use of oral nutritional
supplements, tube feeding or intravenous feeding), the concern may be that it is
better not to start care, rather than to start and then withdraw it at a later stage.
However, where a resident may be undergoing a trial of a particular therapy or
where there is an agreed period for review with agreed objectives set at that point,
there is no reason why intervention cannot be started and then reviewed. For
residents already receiving some form of artificial nutritional support at the point that
they undergo palliative care, withdrawal of treatment and the physical /
psychological impact of this also have to be carefully considered. Therefore,
decisions on the form of nutritional treatment to be offered need to be carefully
considered by the team of specialists that provide that individual‟s care, including
the individual and / or their carer (as appropriate).

The only situation when intervention may not be appropriate is in a resident‟s last
few days13. At this point, the focus on provision of food and fluids for pleasure and
comfort should form the major focus. The resident‟s wishes, anxieties and physical
symptoms also need to be carefully considered. The issue of artificial hydration at
this point is controversial.

  Gillon, R. (1994). Palliative Care Ethics: Non-provision of artificial nutrition and hydration to terminally ill and
sedated patients. Journal of Medical Ethics. 20; 131-132. Available from: [Accessed 17.11.09]

Section 4 - Useful Contacts

Allergy UK
3 White Oak Square
London Road,
Swanley, Kent
Tel: 01322 619898

Alzheimer’s Society
Alzheimer's Society,
Devon House
58 St Katharine's Way
London E1W 1JX
Tel: 020 7423 3500

Anaphylaxis Campaign
PO Box 275
GU14 6SX
Tel: 01252 542029

British Association for Parenteral and Enteral Nutrition
Secure Hold Business Centre,
Studley Road,
B98 7LG
Tel: 01527 457850
Fax: 01527 458718
E-mail: Contact by telephone to establish the direct e-mail required for your query.

Caroline Walker Trust
P.O. Box 17621
SW10 9WT
Tel: 0171 835 0513

Coelliac UK
3rd Floor, Apollo Centre
Desborough Road
High Wycombe
HP11 2QW
Tel: 01494 437 278

Diabetes UK
Macleod House,
10 Parkway, London NW1 7AA
Tel: 020 7424 1000

Food Standards Agency
Food Standards Agency,
Aviation House,
125 Kingsway,
London. WC2B 6NH
Tel: 020 7276 8829 (General enquiries)

Fresenius Kabi (producer of ‘Thick and Easy’ thickener)
Fresenius Kabi,
61346 Bad Homburg v.d.H.,
Tel: +49 (0) 6172 686 2627

123 Golden Lane
London EC1Y 0RT
Telephone: 020 7454 0454

National Patient Agency
National Reporting and Learning Service,
National Patient Safety Agency,
4-8 Maple Street.
London W1T 5HD.
Tel: 020 7927 9500
For learning disability and dysphagia resources, see:-

NHS North Staffordshire (Primary Care Trust)
NHS North Staffordshire
Moorlands House
Stockwell Street
Leek .
ST13 6HQ
Telephone: 0845 602 6772

Nutricia Clinical Care (producer of ‘Nutilis’ thickener)
Nutricia Ltd,
White Horse Business Park,
Newmarket Avenue
Trowbridge, Wiltshire, UK,
Tel: 01225 711688

Osteoporosis Society
National Osteoporosis Society
Tel: 01761 471771 / 0845 130 3076

South Staffordshire Primary Care Trust
Anglesey House,
Towers Business Park,
Staffordshire WS15 1UL
Tel: 01889 571700
(East locality office: 01283 507100 / West Locality Office: 01543 465100)

Vegan Society
Donald Watson House
7 Battle Road
St Leonard‟s on Sea
East Sussex
TN37 7AA
Tel: 01424 427393

Vegetarian Society
Dunham Road
WA14 4QG
Tel: 0161 928 0793

Section 5 – Bibliography

1. British Dietetic Association (2009). National Descriptors for Texture Modification.
   Available from:
   pdf [Accessed 28.10.09].

2. Caroline Walker Trust (1998). Eating Well for Older People with Dementia. A
   good practice guide for residential and nursing homes and others involved in
   caring for people with dementia. Report of an expert working group. Available
   from: [Accessed 04.11.09]

3. Caroline Walker Trust (2007). Eating Well: Children and Adults with Learning
   Disabilities.  Nutritional  and   Practical  Guidelines.  Available    from: [Accessed 17.11.09].

4. Caroline Walker Trust (2009). Eating Ewell: Supporting Adults with Learning
   Disabilities. Training Materials for People Working with Adults with Learning
   Disabilities. Available from:
   [Accessed 19.01.10].

5. Commission for Social Care Inspection (2006). CSCI Clinical Trigger: The
   Management of Nutritional Care for Older People in Care Homes. Available from:
   [Accessed 19.01.10].

6. Dening, T., and Bains, J. (2004). Mental Health Services for Residents of Care
   Homes. Age and Ageing [Editorial]. British Geriatrics Society. 33; 1-2. Available
   from: [Accessed

7. Department of Health (2003). Care Homes for Older People: National Minimum
   Standards and the Care Homes Regulations 2001. Available from:
   ments/digitalasset/dh_4135403.pdf [Accessed 19.01.10].
8. Department of Health (2003). Care Homes for Adults (18-65) and Supplementary
   Standards for Care Homes Accommodating Young People Aged 16 and 17:
   National          Minimum           Standards.           Available         from:
   minimumstandards.cfm [Accessed 19.01.10].

9. Department of Health (2007). Improving Nutritional Care: A joint Action Plan from
   the Department of Health and Nutrition Summit stakeholders. Available from:
   ments/digitalasset/dh_079932.pdf [Accessed 20.10.10].

10. Diabetes UK (2009). About carbohydrate counting: For people with Type 1
    diabetes.      Available      from:
    carbohydrate/Carbohydrate-counting/ [Accessed 16.02.10].

11. Gillon, R. (1994). Palliative Care Ethics: Non-provision of artificial nutrition and
    hydration to terminally ill and sedated patients. Journal of Medical Ethics. 20;
    131-132.                              Available                                 from:              [Accessed

12. National Institute for Health and Clinical Excellence National Institute for Health
    and Clinical Excellence (2004); update (2009). Guidelines for the diagnosis and
    management of Type 1 diabetes in children, young people and adults. Guideline
    Number            15.        NICE:          London         Available          from:
    [Accessed 16.01.10].

13. National Institute for Health and Clinical Excellence (2006). Nutrition Support in
    Adults: Oral Nutrition, Enteral Tube Feeding, and Parenteral Nutrition. Available
    from: [Accessed

14. National Institute for Health and Clinical Excellence (2008). Type 2 diabetes: the
    management of Type 2 diabetes. Clinical guideline 66. NICE: London. Available
    from: [Accessed

15. National Patient Safety Agency (2005). Reducing harm caused by the
    misplacement      of    nasogastric    feeding    tubes.   Available    from: [Accessed 16.02.10].

16. Thomas, B., Bishop, J. (2007). Manual of Dietetic Practice. 4th edition. Wiley-


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