Swallowing & Nutrition - when it's difficult

Introduction

Difficulty in swallowing is the most common symptom of oesophageal (gullet) cancer. There may be some pain in the form of a burning sensation when swallowing food or you may feel that your food is sticking in your throat or chest and you can’t swallow it. This is usually caused by a mass or swelling blocking the oesophagus (gullet). Along with this swallowing difficulty the treatment you receive is also likely to affect your food intake as you may have chemotherapy as well as radiotherapy, a tube (stent) may be inserted into the gullet (oesophagus) to make a passageway through an obstruction; a stricture may need stretching (dilatation). Whatever the treatment, some thought will be needed as to what can be eaten, the nature of the food and its consistency. A diet of soft food can often become based on a theme of soup, jelly and ice cream, which can be very boring. This information aims to show that it need not be and helps to support and advise what can be eaten throughout the different treatment pathways.

If you have a tube (Stent) fitted

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. The aim of the stent is to improve your swallowing and allow you to drink and/or eat better than you have been able to recently but you will need to make changes to your usual diet.

Looking after the stent:

  • Don’t rush eating.
  • Have soft foods in small mouthfuls and chew it well.
  • Drink a little during and after meals - fizzy drinks are helpful.
  • Always eat sitting upright and try to stay upright for at least half an hour after eating.
  • Don’t tackle large lumps of food - cut them up small and chew well.
  • Spit out anything not chewed.
  • If you feel the stent is blocked, stop eating, drink a warm or fizzy drink and walk around.
  • If the blockage persists for more than 3 hours ring your GP or contact the hospital where you were treated.
  • Keep teeth and dentures in good order so that chewing is effective.

Foods to avoid:

  • 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

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 dietician 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

Chemotherapy can affect taste, reduce appetite and cause nausea and vomiting. Cold food and drinks may be more acceptable at this time as they reduce cooking smells. Tart and salty flavours (eg lemon, crackers) may help and it is important to keep up the fluid intake as 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 7) 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

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. It is important to try to prevent weight loss whilst having chemotherapy/radiotherapy/pre and post surgery and gaining weight might help to improve energy levels and strength. 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, milk intolerance may be experienced following oesophagectomy and gastrectomy.

If you need more energy:

  • 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 cubes, 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, e.g. after surgery:

  • 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:

  • 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:

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

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 food 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:

  • 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 increase nutritional intake- 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:

  • 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:

  • Have small regular meals.
  • Drink 30 minutes 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 yogurt may help.

Feeling too full:

  • 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:

  • 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:

  • Drink plenty of fluids (sip drinks regularly) to prevent dehydration. Take at least 8 to 10 cups of fluid daily.
  • Limit or avoid alcohol, strong tea and strong coffee.
  • Limit or avoid spicy, greasy and fatty or fried foods.
  • Avoid very hot or very cold food and drinks.
  • Limit use of artificial sweeteners such as sorbitol and xylitol which are often found in chewing gum, sugar free mints and drinks. These can make diarrhoea worse.
  • Eating slowly and chewing food well is important.
  • It may help your symptoms if you avoid drinking fluids at the same time as eating.
  • Eat little and often.
  • If it persists seek medical advice.

Food Supplements

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 dietician 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.

Oral Nutritional Supplements:

These are high in protein and calories, 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. Some can be bought from the chemist whilst most you can get from your GP on prescription.

Liquids:

Milk based

Available in sweet/fruit based flavours e.g. vanilla, strawberry, forest fruit.

  • Ensure Plus Compact/Twocal/Fibre
  • Fortisip Compact/Protein/Savoury/Multifibre
  • Fresubin Original/Energy/Energy Fibre/Protein Energy
  • Resource energy/fibre

Juice Based

Available in sweet/fruit based flavours e.g forest fruit, apple, orange.

  • Fortijuice
  • Fresubin Juicy
  • Ensure Plus Juice
  • Resource Fruit

Puddings:

Available in sweet/fruit based e.g chocolate, banana, vanilla.

  • Ensure Plus Creme
  • Forticreme complete
  • Fresubin Creme/YO Creme
  • Prosource Jelly
  • Resource Dessert Energy

Liquid Shots:

Available in neutral and fruit based flavours e.g strawberry.

  • Calogen Extra
  • Polycal Liquid
  • Procal Shot
  • Prosource Liquid
  • Fresubin 5Kcal shot

Powders:

Available in neutral, savory, soup and sweet flavours. To be mixed with water and/or full fat milk or added to food.

  • Build up
  • Fresubin Powder Extra
  • Complan Shake
  • Shandishake
  • Calshake
  • Vitasavoury Soups - chicken/golden vegetable/leek and potato/mushroom
  • Pro-cal powder
  • Super soluble maxijul

Fortified Milk:

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

• Milk puddings • Shepherd’s pie
• Soufflés • Pasta dishes (liquidise, if necessary, after cooking)
• Porridge • Braised meat
• Pancakes • Lentils
• Egg custard • Grated cheese
• Mousses • Cottage cheese
• Full fat yoghurt • Cream cheese
• Milk jelly • Dahl
• Creme caramel • Taramasalata
• Fromage frais • Moussaka
• Milk shakes • Peanut butter
• Omelettes • Avocado
• Scrambled eggs • Hummus
• Ice cream
  • Fruit mashed or blended - stewed apple, banana, strawberries, melon, ripe pears etc.
  • Cartons of fresh stock can be bought in supermarkets - more nutritious than stock cubes.
  • Angel Delight made with fortified milk and served with fruit, eg butterscotch flavour with stewed apple or chocolate with mashed banana.
  • Use milk, cream, fruit juice, sauces, stock or gravy as appropriate to soften the consistency of foods.
  • Many soup recipes are suitable as long as a processor/blender is used.
  • There are many varieties of prepared sauces, in tins, jars or packets. Soups, especially if condensed, also make good sauces.
  • Poached or flaked fish in sauce.
  • Grilled bacon or ham, processed, in scrambled eggs or omelettes.
  • Instant mashed potato, enriched with butter or cheese, for when the family is having chips or roast potatoes.
  • Fish pates - salmon, tuna, smoked mackerel, made softer with milk, cream, mayonnaise or stock.
  • Herbs to add flavour - eg thyme, basil, oregano, parsley, mint, chives.
  • Cranberry sauce, red currant jelly and chutney to add piquancy to meat dishes
  • Pasta is very good - liquidise, if necessary, after cooking

 Please visit our Recipe page for more information.

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