1. Sunshine Care Training Sarah Yorwerth & Tara Hollinshead

4. Meat is a good source of protein, vitamins and minerals in your diet. However the Department of Health has advised that people who eat more than 90g should cut down to 70g. Red meat is a good source of iron. Iron aids the red blood cells, which carry oxygen around the body. Some meats are high in fat, especially saturated fat(increases plaque). This can raise cholesterol levels in the blood, which increases the risk of heard disease. It is advised to cut all the fat off and ask for a lean cut. 1.Grill meat rather than fry. 2.Roast meat on a metal rack. 3.Bacteria and Viruses can be found all the way through meat. So It is important to cook thoroughly. Especially: Poultry and game, Pork, Offal, Burgers and Sausages, Kebabs. Liver and Liver Pate are excellent sources of iron and Vitamin A. Vitamin A strengthens immunity and improves eyesight.

5. Many of us eat too much salt. Salt can raise blood pressure, which puts us at risk of heart disease and stroke. Do not add salt, 75% of our food already contains a high %. High blood pressure normally has no symptoms. High salt is 1.5g per 100g Low salt is 0.3g per 100g. High- salt food: Anchovies Bacon Cheese Gravy Ham Olives Pickles Prawns and salt fish, Nuts Crisps Ready meals Soup sauces Adults should eat no more than 6g a day! Salt is also sometimes called ‘Sodium Chloride’ on nutrition labels: Salt= sodium x 2.5

6. Milk and Dairy, such as Cheese and Yoghurt, are great sources of calcium and protein. Our bodies need protein to work properly and grow or repair themselves. Calcium helps keep our bones strong. The Calcium in dairy foods are absorbed more easily. The Fat in dairy products varies, but it provides essential vitamins such as B2 and B12. Although it is saturated fat so it should be limited if you have high cholesterol (opt for Semi-Skimmed) Cheese can be high in fat and salt, so it needs to be proportionate. Brie, Stilton, Cheddar, Lancashire and Double Gloucester- contain between 20g to 40g of fat per 100g. Which means they are high in fat,  Butter is very high in fat, choose a low fat spread.  Cream is also high in fat.  Yoghurts contain protein, calcium, B vitamins and magnesium.

7. Lactose intolerance is where people cannot digest the sugar found in milk (lactose), it can cause bloating and diarrhoea, but its not severe. One type is IgE-mediated milk allergy which can cause reactions within a few minutes of having cow’s milk. Symptoms include- rashes(hives), swollen lips, diarrhoea and vomiting and difficult breathing. Rarely, but It can cause anaphylaxis. Non-IgE-mediated milk allergy is an allergy to the protein in cows milk. Symptoms include- rashes, eczema, vomiting and diarrhoea, but take longer to occur, even a few days.

9. Plenty of foods rich in starch and fibre  Fibre-rich foods include wholegrain or brown types of starchy foods such as bread, rice, pasta and breakfast cereals. Other good sources of fibre are potatoes, oats, beans, peas, lentils, fruit and vegetables.  Eating foods containing fibre could be good for your digestion. Constipation tends to become more of a nuisance as you get older, but fibre-rich foods can prevent constipation and other digestive problems.  Don't buy raw bran and sprinkle it on your food to increase your fibre as this may prevent your body absorbing some important minerals.  Fibre can help prevent heart disease, diabetes, weight gain and some cancers.  You should aim for at least 18g of fibre a day Soluble fibreInsoluble fibre Soluble fibre can be digestedInsoluble fibre cannot be digested. Helps reduce the amount of cholesterol in your bloodIt passes through the gut without being broken down and helps other foods move through more easily. Helps soften stools.Helps keep bowels healthy, limit the amount if you have diarrhoea Good sources are: Oats, barley and Rye Wholemeal bread Bananas, apples, carrots and potatoes Bran and cereals Nuts and seeds.

10. Vitamin A Retinol Vitamin KVitamin C Ascorbic Acid Vitamin DVitamin E

11. Thiamine B1Riboflavin B2Niacin B3Pantothenic Acid B6

12. CalciumIodineIron

13. Vitamin D has several important functions. For example, it helps regulate the amount of calcium and phosphate in the body. These nutrients are needed to keep bones and teeth healthy. A lack of vitamin D can lead to bone deformities such as rickets in children's, bone pain and tenderness as a result of a condition called osteomalacia in adults. Good Sources of Vitamin D:  Sunlight on skin (which is made by our body under the skin, in reactions to summer sunlight)  Oily fish (salmon, sardines and mackerel)  Eggs  Fortified fat spreads and breakfast cereals  Powdered milk. People at risk of not getting enough Vitamin D:  All pregnant and breastfeeding women  Babies and young children under the age of 5  Older people ages 65+  People who do not have enough sunlight.  It is recommended by Department of Health for the Elderly to take 0.01mg of Vitamin D

14. Water makes up about 2/3 of our body weight. Most of the chemical reactions that happen in our cells need water in order to take place. Water also carries nutrients around the body and gets rid of the waste. How much? It is important to replace the fluid we loose when we breathe, sweat or urinate. Some fluid comes from the food we eat. Food Safety Authorities recommended women should drink 1.6 litres of fluid and men drink about 2.0 litres a day. All drinks count! Including tea, coffee, milk and fruit juices. Signs of Dehydration When our bodies don’t have enough water, we are said to be dehydrated. One of the first signs of dehydration is feeling thirsty.  Dark urine and not passing much urine when you go to the toilet  Headaches or feeling light headed  Lack of energy  Dry lips and tongue  Sunken eyes, Brittle hair  Confusion or delirious behaviour

15. It is universally recognised that dehydration in the elderly can easily be prevented or treated, by ensuring they have enough to drink, unless there is swallowing difficulties. Preventable dehydration has long been associated with neglect and is an indication or poor quality care. CQC recently reported that staff had to, in one hospital, actually prescribe drinking water on medication charts to ensure patients received adequate fluid intake! Complications such as UTI’s, Pressure Ulcers, Kidney Stones, Renal Failure, Cardiac diseases are commonly associated with dehydration. UTI’s costs the NHS £124m each year, with 798,000 addition bed days and Pressure Ulcers account for 4% of the NHS Budget (£1.4bn)

16. Increasing factors affecting older people’s risk of dehydration include:  Reduced sensation of thirst  Reduced renal function  Female gender  Physical weakness  Communication problems  Onset Dementia.  Fear of incontinence  Medication-diuretics. CQC have requested a list of prompts to encourage adequate care of hydration: 1.Referral to appropriate services 2.Identified at risk patients- fluid intake is monitored 3.How the risks (as above) will be managed. 4.Enable independence 5.Patients are in an appropriate position to drink safely. 6.Supportive equipment or aids to assist.

17. A project to raise awareness of malnutrition among elderly people is being launched with government backing. Nearly a million over-65’s in England suffer from untreated malnutrition, says Age UK- almost all of whom are in the community. Disease related malnutrition costs in excess 13 billion per annum  More than 1.3 people recently admitted to care homes  1/3 adults on admission to hospital People at highest risk are:  Chronic Disease- COPD, cancer, inflammatory bowel disease, gastrointestinal disease, renal or live disease  Chronic progressive disease- Dementia, Neurological (Parkinson’s, MND)  Where food is not being consumed for more than 5 days  Frailty, immobility, old age, depression, recent discharge from hospital  Poor support, housebound, inability to cook and shop, poverty.

18. Malnutrition simply means poor nutrition. It can occur when a person’s diet lacks essential nutrients. The consequences of Malnutrition include:  Increased risk of illness and infection  Slower wound healing  Increased risk of falls  Difficulty keeping warm  Low mood  Reduced energy levels  Reduced muscle strength. All of which may result in a hospital admission. Malnutrition can affect anyone; however it is particularly common amongst older people and those who are socially isolated as a result of poor mobility, poor physical health or mental health problems. It can occur over a long period of time which sometimes makes it difficult to spot. Does this apply to any of your clients?

19. The common indicators of malnutrition:  Weight loss- which can cause clothes, dentures, belts or jewellery to become loose.  Tiredness and lethargy.  Alteration in mood  Loss of appetite  Disinterests in food or fluids.  General ‘slowing up’, for example, taking a long time to understand and answer questions. A balanced diet is essential for health and well-being. Try to implement the follow.  Eat 2-3 portions of high protein foods every day (e.g. meat, fish, eggs, nuts, beans, pulses, soya, quorn)  Eat/drink 2-3 portions of dairy foods every day (e.g. cheese, milk and yoghurt)  Eat a serving of starchy foot at each meal (e.g. bread, cereals, potatoes, pasta or rice)  Eat some fruit and vegetables every day and if possible try for 5 portions.  Drink at least 6-8 glasses/ mugs of fluid every day. High calorie drinks where possible.  Typically, it is advised to limit foods high in fat/sugar. However, when someone has a poor appetite, fat and sugar can help improve energy intake without adding volume. So therefore, should be routinely added to foods.

20. Overcoming Malnutrition:  Eat ‘little and often’- try a small snack between meals and a dessert after meals.  Drink plenty of fluids can help prevent fatigue, have drinks with and between meals. Choose milky drinks such as Horlicks, full fat milk and hot chocolate, Ovaltine and fruity milk shakes, hot drinks keep you warm!  Avoid low/diet versions of foods and fluids (skimmed or semi-skimmed, low fat yoghurt, diet drinks etc.).  Choose meals that you enjoy, are easy to prepare and eat, and are high in calories. Ready meals that are high in calories will have a red symbol next to the number of calories on the label, Other high calorie foods:  Biscuits  Cheese and Crackers  Thick and Creamy yoghurts  Ice Cream  Crisps  Nuts and seeds  Peanut Butter  Bombay Mix  Chips  Chocolate *NOTE* Be aware of any other health concerns such as diabetes or high cholesterol.

21. Add sugar, jam, Honey etc. Add butter, margarine, oils or mayonnaise etc. Add cream etc.Add cheese etc.Add skimmed milk powder. Cereal or Porridge, Puddings Mashed potatoesSauces Milk Hot DrinksToast/BreadMashed potatoesPasta Dishes/PizzaPorridge Milkshakes/ Smoothies SaucesSoups Mashed Potato PuddingsScrambled Egg/Omelette Sauces Pastry and CakesMashed PotatoesCustard Cereal or Porridge Beans on ToastMilk Puddings Milkshakes/ Smoothies Creamy Soups Milkshakes

22. Enriched Milk Add up to 4 tablespoons of dried milk powder to 1 pint of full cream milk. This can be used wherever milk is being used and is useful when someone is not able to eat or drink a larger amount. Swallowing difficulties If you notice any of the following when eating or drinking you should seek advice from a health care professional such as a GP or Nurse, who can make a referral to speech and language therapist:  Difficulty swallowing  Choking or coughing  Bringing food back up, sometimes through the nose  Sensation that food is stuck in throat or chest  Neurological disorders (Dementia)

23. Some people who have problems with eating or drinking could be due to underlying medication condition, such as cancer. This can lead to other digestive problems or difficulty when eating.  Sickness  Bowel problems  A lot of pain  Difficulty breathing  Fatigue (tiredness) Loss of Appetite (Anorexia)  Doctors call loss of appetite ‘anorexia’. This is very different to the psychiatric condition anorexia nervosa- it is not the same.  Anorexia is common in people with cancer. It can happen in the early stages of your disease or much later if the cancer grows and spreads to other parts of your body. As many as 1 in 4 people diagnosed with cancer have loss of appetite. 90% of people with advanced cancer lose their appetite. People sometimes just cannot be bothered to eat.

24. Weight Loss This is a very common symptom in people with cancer. Losing weight is often associated with loss of appetite. But this is not the only cause. Your client may be eating normally but still losing weight.  The body may not be absorbing all the fat, protein and carbohydrate from the food you eat. Or your body may be burning up calories faster than normal.  Continuous weight loss can be very upsetting and worrying. It can be a constant reminder of the illness and affect how the client feels about themselves. How much weight depends on the type on cancer. About 60% of people with lung cancer and 80% of people with stomach, pancreatic or oesophageal cancer have lost a significant amount of weight by he time they are diagnosed. People with breast cancer or prostate, don’t tend to have lost weight at diagnosis. If there is a weight loss of more than 5% of normal weight in 1 month, or 10% in 6 months (without dieting) the GP will want to find out a cause and needs investigating.

25. Cachexia (wasting syndrome) Also known as ‘wasting syndrome’ or ‘anorexia cachexia syndrome’. Up to 60% of people with advanced cancer develop some degree of Cachexia. Cachexia is Greek for ‘bad condition’. Anorexia means loss of appetite. It is a very complex problem involving changes in the way the body normally uses protein, carbohydrates and fats. It leads to many problems including muscle wastage. It is also common in other illnesses such as Heart Disease, HIV and Kidney Disease. Symptoms include:  Severe loss of weight, including loss of fat and muscle mass  Loss of appetite  Feeling sick (nausea)  Feeling full after eating small amounts.  Anaemia (low red blood cells)  Weakness and fatigue. Scientists think that the cancer releases chemicals into blood that contribute to the loss of fat and muscle. These chemicals may make metabolism speed up and burn calories fast.

26. Loss of appetite  Try to eat small amounts of high protein and calorie foots every 2-3 hours instead of 3 large meals a day.  High protein foods such a meat, fish, eggs, dairy, beans and pulses.  Eat puddings and desserts- foods with fat or sugar are good sources of calories.  Small amounts of favourite alcoholic drink can help boost appetite.  Add extra calories and protein to any food (butter, milk, honey and cheese)  Appeasing foods.  Eat cold or slightly warm food  Pre prepare snack foods available to hand.  High calorie ‘meals in a drink’

27. Diarrhoea Diarrhoea is a common side effect of some cancer treatments. It often disappears after a few days, but it may go on for some weeks after treatment. Its not only unpleasant, but can also make your client feel week and tired. It is easy to become dehydrated if your client has bad diarrhoea, so drink plenty of fluids. Tablets can help reduce the diarrhoea.  Eat smaller meals and more snacks.  Avoid high fibre foods during this time.  Try low fibre, starchy foods.  Drink plenty of fluids. Constipation Some drugs, especially painkillers can cause constipation. Constipation can make your client feel full and not want to eat. Mild laxative can be given during treatments. It is important to inform GP if your client is constipated for more than days. Drink plenty of fluids, and eat fresh fruit and vegetables where possible.  Drink 8 to 10 cups of fluid each day- water, prune juice and orange juice.  Eat high fibre foods such as fruit, vegetables, lentil, beans and wholegrain.  Exercise if possible

28. Make your own! It is easy to make own energy filled drinks by liquidising combinations of milk, fresh fruit, yoghurt, honey or sugar and ice cream, as a smoothie or milkshake. Smoothie can contain by blending fresh apple, strawberries, banana or other soft fruit with fortified milk, fruit juice or yoghurt in a liquidiser. To make nutritious milkshake, mix fortified milk with either pureed fruit, or yoghurt. Make a chocolate and banana milkshake with a chocolate flavour milk and whizz in a blender with a banana. Better than a meal! Ready made drinks (Liquid Supplements) High calorie meals in a drink or energy drinks are also called ‘liquid food supplements’ or ‘sip feeds’. They can be useful short term if your client’s appetite is poor and cant manage to take in enough nourishments. Some can be found on the market, and but them from the chemist, but also bought on prescription. There are many different flavours, both sweet and savoury.  Balanced Supplements- These come as a powder over the counter such as Build up and Complan.  Complete meal supplements- These contain the nutrients to replace a meal. They are available on prescription. Ensure Plus, Fresubin Energy, Fortisip, Resource shake, Ensure, Fortifresh, Clinutren, Fortijuice, Clinutren Fruit, Provide Xtra. It is advisable to drink these between meals around 2/3 a day and they contain additional vitamins

29. High Blood Pressure, or hypertension is very common in the UK- 1 in 4 adults has it. As we get older, we get the risks or high blood pressure because the blood vessels don’t stretch as well. But we cannot stop this, but we can adjust our lifestyle to suit. If left untreated, hypertensions increases the risk of heart attacks and stroke, as well as kidney and eye damage.  Cut down on salt.  Reduce the amount of processed foods (ready meals!)  Less that 0.25g salt per 100g is recommended.  Aim for less than 6g (tsp) of salt a day.  Reduce Alcohol (3-4 units for men) (2-3 for women).  Losing weight.  Eat fruit and vegetables (fresh not tinned)  Low fat dairy foods- opt for semi skimmed milk.  Exercise (recommended at least 30 minutes a day)  Caffeine in excess can raise blood pressure.  Stress can lead to high blood pressure.

30. Stroke is the leading cause of dysphagia, which is paralysis of the throat muscles. This can disrupt the swallowing process and make eating, drinking, taking medicines and breathing difficult.  More than 70% of stroke survivors experience dysphagia at some point. Swallowing is one of the most complicated processes of the central nervous system. It involves multiple muscular contractions and use of the brain. Dysphagia can be mild to severe, but the most common are coughing, choking or feeling like food is sticking in the back of the throat. Symptoms include:  Difficulty initiating the swallow  Choking  Coughing  Liquid coming out of the nose (nasal regurgitation)  Food getting caught in the lungs

31. Treatment can lead to improvement. 30% of stroke survivors will face issues furthermore. Swallow Therapy is electric stimulation that can help improve the swallowing. Speech and Language Therapists can teach special exercises to stimulate nerves involves in swallowing. E.g. Tucking in the chin or rotating the head. Medication, usually muscle relaxers can help open the throat. Management. Dietary Modifications should be customised by a professional for each individual. For example, modifying food texture by chopping, mincing or pureeing foods. Thin fluids are harder to swallowing, adding thickeners can be helpful e.g. Thick n Easy. Food should always be prepared and consumed correctly to avoid aspiration.

32. ConsistencyDescription PureedThick, consistent textures e.g. Pudding Ground/MincedEasy-to-chew foods, no coarse textures, raw fruit or veg. e.g. mashed bananas SoftSoft foods without use of blender Modified generalSoft textures prepared without grinding or chopping Fluids ThinRegular fluids Nectar- likeFluids thin enough to slip through a straw but thick enough to fall off a tipped spoon e.g. buttermilk Honey-likeThick fluids eaten with a spoon, unable to hold their shape and too thick for a straw e.g. tomato sauce, honey, yoghurt Spoon-thickPudding-like fluids that must be eating with a spoon and hold their shape on a spoon. E.g. thickened apple sauce.

33. People with Dementia often experience problems with eating and drinking. It is important to maintain a healthy diet. People with Dementia may become dehydrated as they may not be able to communicate or recognise they are thirsty, and forget to drink. This can cause increased confusion, urinary tract infections and worsen the symptoms. Later stage dementia, the priority should be making sure the person with dementia takes on nutrition, and a higher calorie diet. Weight loss is also common in people with Dementia. Which could be due to lack of appetite, difficulties cooking, problems with communication or recognising hunger, and difficulties with chewing and swallowing. Poor appetite could be due to Depression, Communication (they may communicate through behaviour), Pain, Tiredness, Medication, Physical Activity (lethargy or restlessness) and Constipation.

34. Have you faced these problems? I have already eaten Does your client hold food in their mouth and forget to chew? Does not recognise that it is food? Trying to eat non-food items? Struggles to co-ordinate utensils to mouth? Become aggressive or anti-social around meal times? Become distracted?

35. Tips for Carers!  Regular snacks or small meals- instead of set routines.  Make it interesting! Colours, smells and tastes.  Look for opportunities. Maybe a midnight snack if they are awake?  Know the likes and dislikes. Do not overload the plate! (think about the ration times)  Milkshakes and smoothies. Encourage participation  Food taste may change- stronger flavours, or sweet foods.  Do not withhold desserts- if they haven’t eaten the savoury, they may prefer the dessert!  Serve half portions  Try soft foods (scrambled eggs or stewed apple) easier to chew.  Get involved with the meal preparation  Sit with your client and eat! Mirror image.  Soft music, friendly atmosphere. Not a busy canteen like environment.  Use eating and drinking as a social stimulating activity.  The ability to recognise food may diminish- try using familiar food, or use picture cards.  Concentration may diminish also. They may become disinterested in their meal after time. Allow for finger foods to eat as they go along.

36. Problem with Co-ordination People with Dementia may struggle to hand cutlery or pick up a glass. They may also have trouble getting the food to mouth. They may not open their mouth wide enough as food approaches.  Chop up the food and use a spoon instead  Prompt or guide the person to use the spoon.  Try finger foods such as: Sandwiches, vegetables, sausages, cheese and quiche.  Eat where they feel comfortable  Speak to an OT for non-spill cups and adapted cutlery. Chewing and Swallowing People with Dementia may forget to chew or hold food in their mouth (e.g. Biscuits) These should be avoided for these reasons, it could be poor oral hygiene which is the cause. Try alternatives which area easier to chew and swallow. As Dementia progresses, dysphagia is more common. The person will need to be referred to a Speech and Language Therapist.

37. Fluid Intake. The sensation of thirst changes as people get older, which can sometimes mean the person isn’t aware that they are thirsty. A person with dementia may also have similar problems. They may be less able to provide drinks for themselves. The person should be encouraged to drink throughout the day. Recommendations of at least 1.6 litres a day.  Have a drink on hand whenever the person is eating  Use a clear glass, and a bright coloured straw for attention  Offer the person the cup or put it in their sight.  Describe what the drink is  Offer various types- both hot and cold  Make sure it is suitable (not too heavy)

38. Eating Behaviours A Person with Dementia may refuse to eat food or spit it out. This is because they dislike the food, or try to communicate something to you such as, the food is too hot or they are unsure what to do with the food.  The person with Dementia may become angry or agitated or exhibit more challenging behaviour during mealtimes.  Think about the Environment, is it too noisy? is there a lot to take in? how many other people are there or distractions?  They may not want you to help, or may think you’re a stranger.  It can be a big challenge to determine what the problem is, but remember, its not a deliberate attempt to be difficult, or a personal attack. Try not to rush them, eat with them, avoid patterns on plates, table cloths etc. As Dementia progresses they may put non-food items into their mouths e.g. Napkins or soap. It could be that 1.The Person no longer understands what that item is for. Remove it from their view. 2.The Person may be hungry, offer an alternative or finger foods!

39. Finger Foods.  Buttered toast or bread fingers  Small bread rolls with butter  Sandwiches  Buttered crumpets  Crackers with cheese  Biscuits  Scones, malt loaf, teacakes.  Fruit cake or ginger bread  Waffles  Cereal bars  Fish fingers  Quiche or Pizza  Cheese Cubes  Sliced Fruits (bananas, apples, pears, melons, strawberries etc)

40. For Adults that need to gain weight.  Eat with them- no one likes to eat alone, think back to their adulthood days, mealtimes were normally a social experience.  Increase the calories.  Make high calories drinks- adding bananas, peanut putter, milk etc.  Adding powdered milk to cereals or hot drinks.  Don’t rush.  Making big pots of stew or soup and divide them in to portions- freeze them for future use.

41. Breakfast ideas:  Vanilla Yoghurt  Wholegrain toast with peanut butter, jam or marmalade.  Low fat mini quiche  Simple Smoothie’s  Warm oatmeal/Porridge/Weetabix with nuts, fruit or banana.  Banana bread and milk.  Eggs- poached, scrambled or boiled.  Scrambled eggs with ham Snacks:  Nuts- without added sugar or low salt  Finger fruits- grape, bananas, apple slides, orange segments in a bowl  Cheese sticks- cut into long strips  Vegetables with dip- cucumber, tomato, carrots, peppers.  Whole grain pitta bread with dips