OESOPHAGEAL PATIENTS ASSOCIATION

Difficulty in swallowing may be experienced for a number of reasons; for example, a growth may be being treated by chemotherapy prior to surgery or after surgery if considered helpful; a stricture may need dilatation (stretching); a tube (stent) may have been inserted within the oesophagus (gullet) to make a passageway through an obstruction; or during radiotherapy or laser treatment the ability to swallow may be affected. Whatever the reason, some thought may be needed as to what can be eaten, the nature of the food and its consistency. A diet of soft food often becomes variations on a theme of soup, jelly and ice-cream which can be very boring. This booklet aims to show that it need not be.

IF YOU HAVE A TUBE (STENT) FITTED (Back to top)

Modern stents are made of a wire mesh, generally covered with a thin material. They are easy to insert being encased in a pencil-thin sheath before release opposite the constriction. They usually cannot be taken out again. They come in different internal diameters (usually 9-12 mm) and lengths to suit individual needs. Generally they are held in place by the constriction they are opening up.

Looking after the stent: (Back to top)

• Don’t rush eating.

• Have soft food in small mouthfuls and chew it well.

• Drink a little during and after meals - fizzy drinks are helpful.

• Sit up straight when eating.

• Don’t tackle large lumps of food - cut them up small and chew well.

• Spit out anything not chewed.

• Mix food supplements such as Complan very thoroughly - dry powder will block the stent.

• If you feel the stent is blocked stop eating, drink a little and walk around a bit.

• If the blockage persists for more than 3 hours ring your GP or contact the hospital where you were treated.

• Clean the stent after eating with a drink of soda water or lemonade or use this mixture:

4oz sugar

2oz cream of tartar

2oz sodium bicarbonate

Use one teaspoon of the mixture in a half tumbler of water.

• Keep teeth and dentures in good order so that chewing is effective.

Foods to avoid: (Back to top)

• Green salads and raw vegetables

• Fried egg white and hard boiled egg

• Fruit skins and pith of grapefruit and orange

• Tough meat and gristle

• Fish with bones

• White bread, crusty bread and toast

• Shredded Wheat and Puffed Wheat

• Hard chips and crisps

• Nuts and dried fruits

IF YOU ARE HAVING RADIOTHERAPY (Back to top)

Radiotherapy for oesophageal problems can affect taste, make the throat feel tender and very dry, and sometimes nausea and tiredness can add to your difficulties and make you a little depressed. All these matters improve when the treatment stops, but taking the best nourishment you can while it lasts will help recovery. Use the suggestions in this leaflet and ask the hospital dietitian for help if needed. Medicine can be given to reduce nausea.

Generally hot, spicy foods should be avoided and ask about alcohol if you normally enjoy a drink. Fizzy drinks, fruit drinks and even beer may sting as may very hot drinks, but nevertheless try to take plenty of fluids including milk.

IF YOU ARE HAVING CHEMOTHERAPY (Back to top)

Chemotherapy can also affect taste and appetite and cause nausea and vomiting for a day or two after being given. Cold food and drinks may be more acceptable at this time as they avoid cooking smells, and tart and salty flavours (eg lemon, crackers) may help. Cut down on fat and keep up the fluid intake as some dehydration can occur. Milk is good if you can tolerate it and fruit juice/Ribena to supply vitamin C, glucose drinks such as Lucozade, fizzy drinks, spring water and herbal teas (if your taste for tea and coffee has changed) are all useful. Fresh pineapple is good for keeping your mouth fresh and moist.

Make use of marinades, strongly flavoured sauces such as sweet and sour, pasta or curry, herbs, spices and seasoning as long as you have not got a sore mouth or mouth ulcers. If you get any cravings go along with them.

Take energy supplements (see page 9) and for the section on feeling sick see page 7. It may help to suck a boiled sweet or a mint while the chemotherapy is being given. The second and subsequent doses of chemotherapy may be better tolerated but taste may be more affected particularly if fungal infections occur.

A BALANCED DIET (Back to top)

To get everything you need from your food you should eat at least two foods from each of the following groups every day.

Group 1: Bread, cereals and porridge, rice, pasta, potatoes.

Group 2: Meat, poultry, fish, eggs, milk, cheese, yoghurt, nuts, peas, beans and lentils.

Group 3 Vegetables, salads, fruit, fruit and vegetable juice. Try to include a glass of fruit juice every day.

The body needs to be well nourished in order to be able to fight infection. Normally it has stores of some nutrients, such as iron, which will cover your needs for a short time if you are not eating properly, but will eventually run out.

If you eat less food than you need your body can use up its fat stores first, but eventually the muscles will weaken and this will make you feel tired. Also your body tissue will be damaged more easily than normal and it will not heal as well. This is especially important if you have surgery and/or radiotherapy/chemotherapy. The dietitian at your hospital will be pleased to advise you if you need more information about diet.

Each of the following sections must be read in conjunction with the general advice appropriate to your treatment, eg fizzy drinks may not suit during radiotherapy, and fatty foods during chemotherapy. Milk intolerance may be experienced following oesophagectomy and gastrectomy.

If you need more energy: (Back to top)

• Add extra sugar or glucose to drinks, cereals, desserts and fruit.

• Use high energy drinks like Ribena and fruit syrups mixed with water or milk or straight from the bottle on ice-cream. Fizzy drinks are good but not the low calorie kinds.

• Put melted butter on vegetables, meat and fish and in sauces and milk puddings. Spread plenty on bread, toast and scones. etc.

• Grate cheese into sauces, mashed potatoes and soup.

• Spread jam, honey or marmalade on toast. Stir honey into yoghurt or stewed fruit and have honey or golden syrup on porridge.

• Have mayonnaise on salads and in sandwiches, cream in soups, sauces and desserts, and cream cheese on bread or biscuits.

• Keep snacks by you so that you can eat whenever you feel like it, eg fruit, cheese, biscuits, chocolate, sweets.

• Keep ice-cream, ice blues, full fat yoghurt and other desserts in the fridge for times when you fancy something cold.

• Use special energy supplements from the chemist, flavoured drinks or flavourless powders which are added to foods and drinks (see section on food supplements).

If you need more protein, eg after surgery: (Back to top)

• Add milk powder to porridge, soups, sauces and scrambled eggs. Use evaporated milk on cereals and desserts.

• Keep grated cheese in a plastic container in the fridge, ready to put on vegetables, potatoes, soups, sauces, pasta and fish.

• Put minced meat or flaked fish into soups.

• Mix four tablespoons of milk powder into a pint of milk and use this for all your drinks and cooking. Use it instead of water when making condensed or packet soup (see section on food supplements).

If you need more vitamins and minerals: (Back to top)

• These are only needed in very small amounts and you are unlikely to be short of anything if you are eating a reasonable quantity and variety of foods.

• Dairy produce (milk, butter, cheese, eggs, yoghurt) and cod liver oil are rich in vitamins A and D; bread, biscuits, nuts, wheatgerm, malt extract and Marmite are good for vitamin B; most vegetables and fruit contain vitamin C, especially citrus fruits and blackcurrants.

• Balanced food supplements like Build-up and Complan contain a wide range of vitamins and minerals.

• Multi-vitamin and mineral tablets are readily available from chemists. If you are not eating meat because your taste is impaired see your GP for a blood test as you may be anaemic and need extra iron. Other sources of iron are beans, pulses, eggs and green vegetables, best eaten together with some form of vitamin C (such as a glass of orange juice) which helps absorption of the iron.

Alternative diets: (Back to top)

Diets based on such things as carrot juice and large doses of vitamins have been advocated by some people in recent years for cancer sufferers but there is not much evidence that they are successful though some people may find them enjoyable. A well-balanced diet is generally recommended.

EATING PROBLEMS (Back to top)

If the ability to swallow is reasonable it may only be necessary to cut food up small or to process or liquidise those items which present problems, such as meat. However, if food needs to be of a softer consistency it may be simpler to blend the whole meal. Processing sufficient for several meals and freezing it in plastic tubs will save time.

A microwave oven is useful for reheating food that has gone cold, as may occur if you are eating slowly.

Not hungry: (Back to top)

• A drink of sherry before meals helps to increase the appetite, but check with your doctor first if you are on medication.

• Eat little and often.

• Make meals as attractive as possible with garnishes, eg parsley or other fresh herbs, tomato, lemon, ete, as appropriate.

• Nourishing drinks can be used to replace some meals - examples on page 19.

• Make foods such as soup, mashed potato, sauces and milk puddings more nourishing by mixing in milk powder, cream, evaporated milk, grated cheese or butter/margarine as appropriate.

Too tired to eat: (Back to top)

• Let others do the cooking.

• If you are on your own you may be able to have Meals on Wheels for a while.

• Use convenience foods; prepare food to freeze when you are feeling well to use when you are tired.

• You may feel more like eating after a rest or nap.

• Have food that is nutritious but easy to eat.

• Eat small meals with snacks in between.

Indigestion and heartburn: (Back to top)

• Have small regular meals.

• Drink an hour or so after meals. not with them.

• Chew your food well.

• Sit upright when you eat and stay like that for a little while afterwards to help the food to go down.

• Peppermint sweets may help.

• Avoid fatty or fried foods.

• Don’t eat within one hour of going to bed.

• Drinking milk or eating yoghurt may help.

Feeling too full: (Back to top)

• Eat little and often.

• Have snacks between meals.

• Chew slowly.

• Drink after, not with, meals.

• Medication (metoclopramide or domperidone) taken 30 minutes before meals may assist stomach emptying.

Feeling sick: (Back to top)

• Try to eat little but often.

• Have something dry like a biscuit first thing in the morning.

• Don’t eat fatty or highly spiced foods.

• Keep meals fairly dry and drink an hour or so after eating.

• Try cold foods and drinks - there’s no smell to upset you. Acid flavours like chilled tinned grapefruit are easier to take, or have ice lollies or fizzy drinks such as lemonade, cola or Lucozade or fruit juice mixed with soda water or lemonade.

• Drink plenty of fluids.

• Try salty foods. Ginger flavoured foods can also help.

• Drink through a straw.

• Keep away from the smell of cooking.

• Wear loose clothing.

• Have plenty of fresh air in your room.

• Try to go for a walk before meals.

Diarrhoea: (Back to top)

• Eat light, easily digested foods such as chicken, fish and milk puddings.

• Drink plenty but not with meals; don’t become dehydrated.

• No fatty foods.

• Keep off high fibre foods for a while, eg bran, peas, beans.

• Don’t have very hot or cold foods and drinks.

• Eat little and often.

• If it persists seek medical advice.

FOOD SUPPLEMENTS (Back to top)

These can be helpful if you need extra nourishment. There are many different ones to give you extra energy, protein, vitamins and minerals. They come as powders or liquids, to be taken as drinks or added to food and drinks or used in cooking. Some are readily available at chemists but more concentrated ones can be prescribed for certain conditions; a selection of these is listed below. The dietitian at your hospital is the best person to advise on the product most suitable for you and if you have a prescribed supplement it is important that the dietitian should monitor your progress. Ideas for using supplements are given in the recipe section and manufacturers also supply recipe leaflets for their products. If you are having supplements prescribed ask your GP to write “Variety of flavours” on the prescription form - the pharmacy can order a mixture of items for you to try.

Complete Food Supplements: (Back to top)

These are high in protein and calories and are nutritionally complete, including vitamins and minerals. They can be taken as drinks between meals or in place of a meal if you cannot manage food and can also be used in cooking. Cartons of sweet and fruit based supplements can be frozen and eaten as ice-cream or sorbets.

Powders: (Back to top)

• Build up and Complan - on sale at chemists - in a range of flavours, sweet and savoury.

Liquids: (Back to top)

• Clinutren 1.5/1.5 Fibre/Fruit/ISO – sweet/fruit flavours

• Enrich and Enrich Plus – sweet/fruit flavours

• Ensure and Ensure Plus – sweet/fruit/savoury flavours and yoghurt

style

• Fortifresh and Fortimel – sweet/fruit flavours

• Fortisip Bottle/Protein – sweet/fruit flavours

• Fortisip Multifibre – includes some savoury flavours

• Fresubin Original/Energy/Energy Fibre/Protein Energy Drink –

sweet/fruit flavours

• Nutriplus.

• Resource Shake/Protein Extra – sweet/fruit flavours

Puddings: (Back to top)

• Clinutren Dessert – caramel/chocolate/peach/vanilla

.• Formance – vanilla/butterscotch

.• Forticreme – vanilla/chocolate/coffee/banana/forest fruit

.• Resource Energy Dessert – caramel/chocolate/vanilla

ENERGY SUPPLEMENTS (Back to top)

In liquid or powder form these are an easy way to get extra energy but they are not nutritionally complete. They may be obtained on prescription.

Liquids (various flavours): (Back to top)

• Calogen – sweet/fruit flavours

• Maxijul – fruit flavours

• Polycal – orange/neutral

• Enlive Plus, Fortijuice, Provide Xtra and Resource Fruit Flavour Drink – fruit juice based and fat free. They maybe preferred to milk based supplements but provide fewer calories.

Powders: (Back to top)

• Resource Benefiber - can help with both constipation and diarrhoea.

• Maxijul

• Polycal

• Calshake, Enshake and Scandishake - flavoured - mix with fresh milk

Fortified Milk: (Back to top)

A useful supplement easily made at home, used like ordinary milk but giving more protein and energy. Mix 4 tablespoons of milk powder with a pint of milk (easiest to do in a blender).

SOFT NUTRITIOUS FOODS AND SOME WAYS TO TAKE THEM (Back to top)

w Milk puddings Shepherd’s pie

w Soufflés Pasta dishes (liquidise, if necessary, after cooking)

w Porridge Braised meat

w Pancakes Lentils

w Egg custard Grated cheese

w Mousses Cottage cheese

w Full fat yoghurt Cream cheese

w Milk jelly Dahl

w Creme caramel Taramasalata

w Fromage frais Moussaka

w Milk shakes Peanut butter

w Omelettes Avocado

w Scrambled eggs Hummus

w Ice cream

w Fruit mashed or blended - stewed apple, banana, strawberries, melon, ripe pears etc

w Cartons of fresh stock can be bought in supermarkets - more nutritious than stock cubes.

w Angel Delight made with fortified milk and served with fruit, eg butterscotch flavour with stewed apple or chocolate with mashed banana.

w Use milk, cream, fruit juice, sauces, stock or gravy as appropriate to soften the consistency of foods.

w Many soup recipes are suitable as long as a processor/blender is used.

w There are many varieties of prepared sauces, in tins, jars or packets. Soups, especially if condensed, also make good sauces.

w Poached or flaked fish in sauce.

w Grilled bacon or ham, processed, in scrambled eggs or omelettes.

w Instant mashed potato, enriched with butter or cheese, for when the family is having chips or roast potatoes.

w Fish pates - salmon, tuna, smoked mackerel, made softer with milk, cream, mayonnaise or stock.

w Herbs to add flavour - eg thyme, basil, oregano, parsley, mint, chives.

w Cranberry sauce, red currant jelly and chutney to add piquancy to meat dishes

w Pasta is very good - liquidise, if necessary, after cooking

RECIPES

Recipes using Food Supplements (Back to top)

Complan Soup

I tin or packet of soup

3 heaped dessertspoons natural flavour Complan

Heat enough soup for one serving, following the instructions on the tin or packet. Mix Complan with a little cold water to make a smooth paste. Remove soup from heat and slowly stir in the Complan.

Complan Angel Delight

I packet Angel Delight

3 heaped dessertspoons natural flavour Complan

½ pint cold water

Mix Complan with a little water to make a thin cream, then add the remaining water. Sprinkle in the dessert powder arid whisk briskly.

Complan Jelly Cream

1 pint packet jelly

4 heaped dessertspoons Complan (a flavour that blends with the jelly)

Make the jelly in the usual way and leave until cold but not set. Mix Complan with a little cold jelly to make a smooth cream. Blend mixture into jelly, stirring slowly all the time. Pour into four individual moulds or dishes and leave to set.

Build-Up Milk Jelly

1 sachet strawberry Build-Up

1 packet strawberry jelly

½ pint milk or fortified milk or vanilla Ensure

Dissolve jelly in a little boiling water and make up to V pint with cold water. Mix Build Up with the milk. When jelly is cold but not set, stir it slowly into the Build-Up. Pour into individual dishes or moulds and leave to set.

Alternative flavours. Vanilla Build-Up with various jelly flavours, or chocolate

Build-Up Yoghurt

½. sachet Build-Up

5oz carton natural full-fat yoghurt:

You may find Build-Up too sweet: mixing it with plain yoghurt gives it a much sharper flavour.

Ensure instant Soup

1 can Ensure

1 packet instant soup mix (eg Cup-A-Soup)

Heat Ensure but do not boil, add soup mix, stir well, blend and serve.

Ensure Banana Shake

1 banana

1 can chilled Ensure

Peel and slice the banana. Place in blender, add Ensure and blend until smooth.

Chocolate Diablo

1 tablespoon drinking chocolate

1 teaspoon instant coffee

1 can Ensure

Pinch cinnamon

Mix chocolate, coffee and cinnamon, add 2oz Ensure and stir until smoothly mixed. Stir in the rest of the Ensure and heat to required temperature, stirring all the time. Do not boil.

Alternatively, use chilled Ensure, mix as before and blend (with a scoop of ice cream if liked).

Soups (Back to top)

Stilton Cheese Soup

2oz butter

1 onion, finely chopped

2 sticks celery, finely chopped

1 ½oz flour

5 tablespoons white wine

1 pints chicken stock

½ pint milk

4oz blue Stilton cheese, crumbled

2oz Cheddar cheese, grated

Salt and freshly ground pepper

4 tablespoons double cream

Melt butter in a saucepan, add vegetables and fry gently for 5 minutes. Stir in flour and cook for 1 minute. Remove from heat and stir in the wine and stock; return to heat and bring to boil; simmer for 30 minutes. Add milk and cheese, stirring constantly. Season, stir in cream, liquidise, reheat but do not boil.

Smoked Fish Chowder

1lb smoked haddock fillet

8oz potatoes, finely chopped

2 medium onions, finely chopped

6oz carrots, finely chopped

2oz butter

2 level table spoons flour

¼ pint single cream

Salt and freshly ground pepper

Simmer the fish in 2 pints water for 10 minutes until tender; drain and flake coarsely, discarding the skin and bones. Sauté onion in the butter until soft then stir in the flour; gradually add the strained fish stock and bring to the boil, stirring. Add potatoes and carrots, simmer for about 10 minutes until tender, stir in flaked fish and cream, season well; liquidise and sieve if necessary; reheat but do not boil.

Chicken and Vegetable Soup

2 onions

½lb carrots

2 turnips

¼lb mushrooms

a few frozen peas and any other vegetables in season

2oz butter

1½ pints chicken stock

Salt and freshly ground pepper

Mixed herbs

Finely chop vegetables; melt butter in saucepan and sauté onions until soft; add the other vegetables and chicken stock; bring to the boil and simmer until vegetables are soft; season, liquidise, sieve and reheat.

Cream of Mushroom Soup

½lb mushrooms, sliced

¾ pint chicken stock

1 small onion, chopped

1oz butter

1oz flour

¾ pint milk

2 tablespoons cream

Salt and freshly ground pepper

Place the mushrooms in a pan with the onion and stock, bring to the boil and simmer for 20 minutes until tender; liquidise. Melt butter in a pan, add the flour and cook for 1 minute; gradually blend in the milk and then the prepared mushroom purée and season to taste; bring to the boil and simmer for 5-10 minutes. Just before serving stir in the cream.

Main Dishes (Back to top)

Cheese Pudding Serves 4

½ pint milk

Knob butter or margarine

3oz fresh breadcrumbs

4oz grated cheese

3 eggs

Salt and pepper

Pinch dry mustard

Grease a 2 pint baking dish. Put breadcrumbs into a bowl. Heat the milk and butter until just boiling and pour over the breadcrumbs; leave to cool for a few minutes. Separate the eggs; mix the yolks with the cheese and seasoning, and stir into the breadcrumbs. Whisk the egg whites until stiff and fold into the cheese mixture. Pour into the baking dish and bake at 375°F (190°C, Reg 5) until risen and brown (30-40 minutes). Serve at once.

Cheesy Tuna Casserole Serves 4

7oz tin tuna

1 tablespoon chopped onion

2 eggs

8oz cottage cheese

2oz fresh breadcrumbs

Salt and pepper

Drain and flake the tuna; mix with cottage cheese, onion, breadcrumbs and seasoning. Beat the eggs and mix well with the fish mixture. Turn into a greased 1 pint casserole dish and bake at 350°F (180°C, Reg 4) until set (30-40 minutes).

Fish Mousse Serves 2

4oz tinned salmon, tuna or kipper fillets

3 fluid oz whipping cream

2 tablespoons mayonnaise

A little lemon juice

Salt and pepper

2 teaspoons gelatine

Dissolve the gelatine in a little hot water. Flake the fish, removing any bones or skin; blend if necessary. Mix well with the mayonnaise and lemon juice and season to taste. Stir in the gelatine. Whip the cream until it forms peaks, and fold into the fish mixture. Pour into a serving dish and place in a fridge until set.

Ham Custard Serves 2

4oz cooked ham, minced or chopped

½ pint milk

2 eggs

Salt and pepper

Grease a 1 pint baking dish and place the ham in it. Beat eggs, milk and seasoning and pour over the ham. Stand the dish in a shallow pan of hot water and bake at 325°F (170°C, Reg 3) until set (40-50 minutes).

Variations; you can replace the ham with cooked chicken, grated cheese, or flaked cooked fish, and cooked vegetables may also be added.

Macaroni Cheese Serves 2

4oz macaroni (or cut spaghetti or other small pasta)

½ pint cheese sauce (see Sauces)

1oz grated cheese

Cook the macaroni in lightly salted boiling water until just tender; drain and tip into a baking dish. Pour the cheese sauce over and sprinkle with grated cheese. Bake at 375°F (190°C, Reg 5) until brown (20-30 minutes).

Variations; minced ham or chicken can be added, or vegetables such as sweetcorn or peas.

Chicken Supreme Serves I

About 3oz cooked minced chicken

Tinned condensed mushroom soup

Mix together and heat gently in a saucepan. Serve with rice.

Variations; chopped cooked vegetables can be added or other kinds of meat or fish can be combined with different varieties of condensed soup.

Puddings (Back to top)

French Rice Pudding Serves 3-4

2oz ground rice

2oz sugar

1 pint fort milk or milk and vanilla Ensure