IDDSI Level 7: Easy to Chew (ETC)

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If you’re having problems eating, chewing or swallowing food, you may find it helpful to change the texture of your food. Your Speech and Language Therapist (a person with specialist knowledge of swallowing problems) or Dietitian has advised you to eat easy to chew foods. Easy to chew food is easier to swallow when the muscles of the mouth and throat are too weak to bite, chew and swallow hard or crunchy foods. Easy to chew food may also be easier if you get tired after a lot of chewing. This leaflet contains ideas and practical advice on how to make easy to chew food correctly and to make sure your diet remains varied and enjoyable. If you have a small appetite or you have recently lost weight, you will also find some advice on how to enrich your meals to make them as nourishing as possible. If you need a special type of diet, for example, gluten-free, lactose-free, dairy-free, low sodium or low potassium, speak to your Dietitian about which foods are suitable for you.

What is an easy to chew diet?
Easy to chew options are normal everyday foods which are naturally soft and tender. If you enjoy a diet associated with a cultural background or religious belief (ethnic food), and after reading this booklet you’re not sure whether certain foods are suitable for a soft diet, ask your Speech and Language Therapist for more advice.

Why do I need easy to chew food?
Sometimes, the swallowing muscles in the mouth and throat can become weaker, slower or less coordinated. This can be due to being unwell or as a result of certain medical conditions. These changes might make it more difficult to eat, chew and swallow your foods and could lead to food getting stuck in the mouth or throat, choking or ‘aspiration’. ‘Aspiration’ is the term used to describe when food has entered the airway. Aspiration can lead to serious chest infections, or pneumonia. Eating easy to chew foods can help to reduce the risk of aspiration and choking.

What are the signs of aspiration?
● Coughing, choking or throat clearing before, during or after swallowing
● Shortness of breath before, during or after swallowing
● Wet, gurgly voice quality
● Changes in skin colour; e.g. face turning red and sweaty, or very pale
● Unplanned weight loss
● Recurrent chest infections: if you are worried that you have a chest infection, please speak to your GP.

If you are concerned that you have any new symptoms/ changes in your swallowing, please tell your Speech and Language Therapist and/or GP.

A note about drinks
Most people need to drink 6-8 glasses or mugs of fluid (around 2 litres) every day to keep hydrated. You may need more on a hot day. Drinks may include water, squash, tea, coffee, hot chocolate,
milk and milky drinks, fruit juice, fruit smoothies, enriched drinks and nutritional supplements. If you’re having problems swallowing drinks, your Speech and Language Therapist will tell you how to make sure you’re drinking safely. There is a separate booklet available for people who also have problems swallowing drinks – ask your Speech and Language Therapist for details.

What foods can I have?
You should be able to enjoy most of your favourite foods on an easy to chew diet. Where foods are too challenging (ie. if they are crispy/ crunchy/ hard/ fibrous etc), it is normally possible to modify these consistencies to make them softer, tender and easier to chew i.e. by adding extra sauces and gravies to moisten them or changing the way you cook them i.e. slow cooking meats.
If you are unable to modify foods to make them easier to chew, you may want to consider switching these for a softer option. Consider switching crunchy potato crisps for maize crisps, dry crumbly biscuits for dunked biscuits or soft cake bars, and pastry based pies for mashed potato topped pies.

Are there any foods I should avoid?

Crunchy and crumbly foods: e.g. dry biscuits, flaky pastry, dry toast, crisps, pie crust, crumble toppings, crackers, battered or
breaded foods etc.

Hard foods: e.g. boiled and chewy sweets, nuts and seeds etc.

Stringy, fibrous textures: e.g. green beans, runner beans, celery, lettuce and other salad leaves, pineapple etc.

Vegetables and fruit skins/husks: e.g. peas, grapes, oranges, baked beans, black-eye beans, tomatoes, sweetcorn etc.

Mixed Consistency foods:A mixed consistency is when there is food with a separate runny liquid. Sometimes foods may look like they are one consistency, but can “burst” or separate into solids and liquids in the mouth. These types of foods can be particularly difficult to control and may lead to signs of choking or aspiration. Your Speech and Language Therapist may advise you to avoid these foods, or you may decide you find these too difficult to manage. e.g. cereal with milk, soup with lumps, meals with a thin gravy, oranges, grapes, tomatoes etc.

Sample Menu
• Fruit juice or thick fruit smoothie
• Soft cereals moistened in milk – add sugar, honey, jam or syrup
• Soft white bread with scrambled, boiled, or poached eggs

Lunch and Evening Meals
• Thick or creamy soups (fresh, tinned or packet), cheese, fish or soft vegetable, omelette or quiche, moist sandwich with soft cheese, tuna or egg mayonnaise
• Fish in a thick creamy, cheese or tomato sauce;
• Fish pie
• Casseroled or stewed meat and vegetables cooked until tender in a thick gravy or tomato sauce
• Corned beef hash
• Soft pasta with soft meat or fish and a thick tomato, cheese or creamy sauce; lasagne, risotto, macaroni cheese
• Skinless jacket potato with cheese, beans, flaked fish
• Soft cooked or mashed potato or vegetables
• Lentil casserole

• Milky pudding e.g. rice , semolina , sago, Tapioca
• Trifle or mousse
• Yogurt or fromage frais
• Fresh, tinned or stewed fruit with cream, ice cream, etc
• Soft sponge cake with custard or pancakes with cream
• Blanc mange
• Fruit fool

Between meal snacks
• Nourishing drink made with enriched milk (See Page 5) e.g. milky tea or coffee, hot chocolate, Horlicks, Ovaltine, cup-a-soup, milkshake, yoghurt drink, Build Up or Complan
• Pudding choice as above.

Practical tips
Appearance: Don’t mix a whole meal together, unless it is a complete meal such as a stew. Prepare each individual element separately and serve them so you can see each portion of food on the plate. This retains the individual flavours of each food.
Variety in meals: It is important to keep variety in your meals to keep you interested in food and eating. You will need a healthy balanced diet to ensure you get all the nutrients you need.
Flavour: Season foods to taste. You could consider adding herbs, spices, or other sauces.
Environment: Eat in a quiet and relaxed atmosphere where there are no distractions and no rush to finish quickly. This will help you concentrate on eating safely.

What if I have a small appetite?
As you get older, it’s natural to start eating less because you tend to become less physically active. This means your body might need less food.
• If you can’t manage to eat three large meals per day, have smaller amounts more frequently with nutritious snacks between mealtimes, such as those on Pages 3 and 4.
• If you find it difficult to eat a full meal, have a milkshake, hot milky drink or cup-a-soup made with enriched milk after eating. Alternatively, enjoy a thick soup and a pudding instead.
• It’s important to eat regularly, at least three times a day. You might not always feel like cooking so you could choose to eat more tinned, chilled and frozen ready-prepared meals. It’s a good idea to make some soft foods in bulk and store them in the freezer. Divide them into portions using small storage containers or freezer bags. Always make sure you heat chilled and frozen food until it’s
piping hot all the way through.
• Use enriched drinks such as Complan or Meritene as a nutritious snack between your meals to give you the extra calories and nutrients your body needs. You can buy these from your chemists or
• Because drinks can make you feel full, you might not feel as hungry after drinking. Instead of drinking before you eat, drink after meals, or in between meals, so that you feel hungrier and can
eat more at mealtimes

How can I add extra nourishment to my drinks?

Use the following ideas to help you increase the calories in your drinks:

Use full fat milk instead of semi skimmed milk. Enrich your milk by adding 4 tablespoons of milk powder to 1 pint of full fat milk. Mix the milk powder into a smooth paste with a little of the milk. Then whisk in the rest of the pint with a fork or whisk. Try to use at least 1 pint of full fat milk in your food and drink every day.

Use enriched full fat milk instead of water to make hot or cold drinks, such as those below:
• Milky coffee made with enriched warm milk
• Hot chocolate and malted drinks e.g. Horlicks or Ovaltine made with enriched milk
• Cup-a-soup made with enriched warm milk
• Yoghurt or banana blended with enriched milk to make a thick drink- add honey, syrup or treacle
• Milk or Milkshake made with enriched milk and ice cream

How can I add extra nourishment to my food?
Use the following ideas to help you increase the calories in your food:
• Use enriched milk, cream or double cream, evaporated or condensed milk when making drinks, porridge, puddings (e.g. custard, rice pudding, Angel Delight), soups, mashed potatoes, white and
cheese sauces.
• Add 1-2 handfuls of grated cheese, or extra cream cheese, cream, butter, margarine, or mayonnaise to warm vegetables, potatoes, stews, soups and sauces.
• Add extra sugar, cream, syrup, jam, honey, treacle or chocolate spread into puddings, drinks and cereals. If you have diabetes, speak to your GP, Dietitian or Diabetic Nurse for more advice. You
may need to check your blood sugar levels more often, or you may need to change your medication.
• Use full fat dairy food instead of low fat options, e.g. whole milk, thick and creamy yoghurts, full fat cream, cheese and mayonnaise.

How can I tell in I am losing weight?
A modified diet should not result in any weight loss. If you have concerns that you are not meeting your nutritional needs or are losing weight, please contact your GP or dietitian for further advice.
Weigh yourself weekly to check if you are losing weight. If you cannot weight yourself, you may notice you are losing weight if your clothes or jewellery feel looser. If you have followed this advice but you are still losing weight, ask your Dietitian, GP, or Practice Nurse for more help.

Contact Details
If you have any questions or concerns, please contact your speech and language therapist.
Speech and Language Therapy Service
Milton Keynes University Hospital
Standing way
Milton Keynes
Tel: 01908 725292