Nutrition at home after critical illness

Sometimes after critical illness, a plate of food (such as you used to eat) can feel really overwhelming. So, to begin with, the best plan is to eat ‘little and often’, try to eat smaller portions more often by including snacks between meals and before bed so you eat every 2-3 hours (so eating 6 times a day). As you become used to eating again, you will gradually build up how much you are able to eat at each meal. 

Here are some high protein and energy snack ideas:

If you are only eating small amounts of food and you need to put on more weight, choose full fat foods instead of “light” or “diet” versions, as these are not right for you at the moment if you need to have more energy. If you have diabetes or high blood cholesterol, please ask your doctor or dietitian for advice on foods high in energy or protein that are suitable for you to eat.

You can also fortify your foods and drinks to get more energy and protein without  having to eat more food. Fortifying means adding something to it, to give it more energy or protein. The following section gives you some tips on how to do this.

There are many ways to add extra energy and protein to your food, for example:

Milk can be fortified by adding 2oz (4 tablespoons) of milk powder (such as Marvel or supermarket own brand) to 1 pint of full cream milk. Adding milk powder gives extra protein and more energy. This fortified milk can then be used in the usual way in drinks, on cereals, in sauces and puddings.

Savoury foods can be fortified, for example:

• add beans, pulses or ground nuts (like almonds), seeds, soy protein powder, pea protein powder, chick pea flour, or gram flour to soups and casseroles
• add nut butters (like peanut butter, almond butter, or cashew butter) to soups, casseroles or sauces over meals
• add cheese, milk, milk powder, butter, margarine or olive oil into mashed potato
• add 2 tablespoons of milk powder to a portion of white or cheese sauce
• add butter, full-fat margarine, cheese or white sauce on vegetables
• add cheese/cream/milk or crème fraîche to soup
• add cream/sour cream/crème fraîche or coconut milk to casseroles and curries
• add mayonnaise/salad cream or pesto to sandwiches or have two fillings, such as: egg mayonnaise and bacon or cheese and ham.

Fortify sweet foods, for example:

• add 2 tablespoons of milk powder to a portion of porridge, milk puddings and custard
• add nut butters (like peanut butter,  or almond butter, or cashew butter) to puddings
• add cream, custard, condensed milk, evaporated milk, fortified milk, or ice cream to pies, sponge or fruit
• add extra sugar, honey or syrup to desserts and cereals make jelly with fortified milk, instead of water
• add cream, yoghurt, sugar, honey, condensed/evaporated milk or dried fruit to breakfast cereals.

If you have diabetes or high blood cholesterol, please ask your doctor or dietitian for advice on foods high in energy or protein that are suitable for you to eat.

The long-term after effects of critical illness often include a loss of muscle protein and difficulty in regaining some muscle mass and strength. Eating enough protein along with doing physical activity will help this.

Your body uses protein to build and repair tissues. Protein is an important building block of bones, muscles, cartilage, skin, hair, nails and blood. Both energy and protein are important building blocks which help our bodies recover, repair and regain our strength.

This section gives tips about how to eat more protein.

You should try to have high protein foods at each meal, and have a milky dessert between your meals.  If you have a kidney disease, please ask your doctor or dietitian for advice on protein intake.

The following foods are good sources of protein:

• Meat: eating meat or poultry (such as chicken) and slightly larger portions (if you are able to) is an easy way to increase your protein intake. Try to choose cuts of meat without too much fat on them. If you find it difficult to chew and swallow meat, try cutting it into small pieces, or having it with gravy or sauce so it’s not too dry.
• Pulses: (for example lentils or beans) are high in fibre and a source of iron, as well as being affordable. If you buy tinned pulses, check the label and choose ones that have no added salt or sugar. They are easy add-ins to sauces, soups and stews, even if they’re not used in the original recipe.
• Soya: are high in good quality protein, low in fat and contain fibre and iron. Examples are a glass of soya milk, a pot of soya yoghurt or tofu.
• Quinoa: is a good protein food and an easy substitute for rice and pasta. 
• Nuts: provide protein and are packed with fibre. Although they are high in fat (and so are high in energy), most of this fat is heart-healthy unsaturated fats. Choose nuts which have not had salt added to them.
• Seeds: (such as sunflower or pumpkin seeds) contain healthy unsaturated fats and protein. They can be easily added to salads and pasta, or you can eat them plain as a simple snack.
• Cereal and grains: wholegrain (called wholemeal or brown) breads, rice and pasta have more protein, fibre and iron than white versions.
• Quorn/Mycoprotein & other Textured vegetable protein alternatives: these have a meat-like texture and are low in saturated fat. They are sold in a range of forms from mince, pieces, nuggets, sausages and fillets, so they can easily be swapped with meat.
• Milk & Dairy products: milk, yoghurt and cheese are great sources of protein and also contain calcium to keep our bones healthy. Dairy alternatives are much lower in protein but fortified versions are still a very good sources of calcium.
• Eggs:  are low in saturated fat and good sources of vitamin B12 and vitamin D. Generally there is no limit to how many eggs you can eat, but there are some medical conditions (such as familial hypercholesterolemia) which means you may need to not eat too many, so ask your doctor or dietitian for advice.
• Fish & Seafood: white fish is a low-fat protein source. Oily fish, such as sardines, mackerel or salmon, are a little higher in fat but contain omega-3 fatty acids, which are heart healthy and contain vitamins A&D. Seafood includes prawns, crab, lobster, mussels, oysters, scallops and clams. These can be brought fresh, frozen and  in tins.

The table below gives you an idea of the approximate amount of protein per serving size. Even if you do not need to work out how much protein you have, it may be a helpful guide to help you have more protein.

You can choose to have drinks that can give you extra nutrition. For example:

• Hot drinks: hot chocolate, Ovaltine/malted drinks, milky coffee, latte, cappuccino, instant soups made with fortified milk
• Cold drinks: milkshakes with added ice cream/cream, fruit smoothie (blended fruit with milk), ice cream/yoghurt with honey/malt, ice cream soda (ice cream added to a fizzy drink), fruit juice.

You can also have special drinks that are high calorie and protein drinks (also called nutritional supplement drinks). You may have had these recommended from your hospital stay and advised to continue them until you reach a better weight, or you are eating full meals. If you are uncertain about how to take them, or how long for, please contact your doctor or dietitian for advice.  

Nutritional supplement drinks come in a wide range of different types and flavours for example:

• Nourishing powdered drinks: Complan and Meritene are common brands. These are available from most chemists/supermarkets and are often advised as the first type to try before moving onto the ready-made ones below. They can also be added to foods to increase their nutrient content
• Nutritional supplement drinks: come in milkshake, juice or jelly styles. They also come in a variety of sizes, for example, there are compact types that give the same nutrition but in a smaller volume. You may have had these in hospital, and may have been told to continue them. They can be provided on prescription from your GP, but may have a different name (be a different brand) than those in hospital. Check with your pharmacist that they are similar (for example in protein content). If you are unsure about having these drinks, or you are not having them, but think they may help you while you are struggling with your eating or weight, speak to your dietitian or your doctor for advice.

A balanced diet is about having the right types and amount of foods that are good for you. One way to do this is to use the Eatwell Guide from Public Health England (see the link in the More information section). This explains the different food groups that should be part of a healthy balanced diet, including fruit and vegetables, protein, carbohydrates and dairy (or dairy alternatives). You need to try and eat some of these foods most days, and the picture gives an idea of how much to eat. You do not have to get this balance in every meal but roughly over a week.

It is helpful to make every meal as balanced as possible, and the Harvard Healthy Eating Plate picture (below) gives you an idea on how to do this. The Harvard Eatwell plate is a good visual guide for portion sizes on a plate. The advice to limit milk and dairy is not advice supported by the British Dietetic Association Try to make sure that half of your plate is filled with vegetables, salad, fruit or a mixture of them. The other half can be equally divided between starchy foods (such as pasta and bread), and foods high in protein (such as meats, dairy, eggs and nuts). It is particularly important to have enough healthy choices of protein during recovery as our bodies use this to help with healing and building muscle, so make sure you try to have a quarter of the plate as protein.

Fruit and Vegetables

Fruit and vegetables should make up just over a third of the food eaten.

Aim to consume at least 5 portions of a variety of fruit and vegetables every day, having different colours and types. These do not have to be just fresh,  so you can also include frozen, tinned, dried and unsweetened juices and smoothies. Try to avoid adding foods high in sugar or fat to fruit and vegetables, such as butter or syrups. To help eat more fruit and vegetables, you could add them to meals such as soups, casseroles, pasta, curries and salads.

Examples of vegetables and fruits are:

Potatoes, bread, rice, pasta and other carbohydrates

Potatoes, bread, rice, pasta and other similar foods are known as carbohydrates.  They are an important part of a healthy diet, and should make up just over a third of the food which you eat. Aim to include one food from this group at each meal. Try to choose wholegrain foods (brown rice or wholemeal pasta for example) if you can, as these contain more fibre, vitamins and minerals than white or refined starchy foods (such as white bread, rice or pasta). Wholegrains are also digested slower than white food, and so they give you more energy for longer, and you can feel full up for longer after eating them. Wholegrain carbohydrates include:

Dairy and dairy alternatives

Dairy foods are rich in protein and vitamins. They are good sources of calcium as our bodies can take the nutrition from it easily. Calcium is important for strong bones and teeth.  To get the calcium you need, try to have three portions per day. Some dairy foods can be high in fat and saturated fat, therefore try to choose reduced fat, lower sugar and unsweetened versions where you can. If you are having food that is calcium rich but is not dairy, try to have ones that have calcium added, which are called Calcium enriched milk alternatives.

Examples of dairy and dairy alternatives are:

Protein

Protein is in meat, fish and meat alternatives (such as Tofu or Quorn). Some types of meat are high in saturated fat, which is not heart friendly, so try to choose cuts of meat that are lower fat. You can also remove skin and visible fat from meat and poultry, and try not to have too much processed meat. Examples of processed meats include sausages, bacon, cured meats and reformed meat products. You can also keep meat low fat by the way you cook it. Try to avoid frying in fat and opt for grilling meat and fish or poaching/boiling eggs. Fish is also a good protein source, and it is recommended that you have at least two portions of sustainably sourced fish per week, including a portion of oily fish. Beans, peas and lentils are also a good option because they are low in fat and high in protein, fibre, vitamins and minerals.

Examples of meat, fish and alternatives include:

Oils and spreads

It is important to have some fat in your diet, but most people have too much, in particular saturated fat. Eating too much saturated fat can make you at a higher risk of heart disease. Examples of saturated fat include butter, lard, ghee, suet, palm oil, coconut oil, processed meats, fatty meat, fried foods, takeaways, cakes, pastries and biscuits.

If you are worried about having too much fat, possibly because of having a high cholesterol or if you have been advised to lose weight, then try to include more foods which contain fats that are healthy for your heart. These are called unsaturated fats and they provide essential fatty acids and fat-soluble vitamins. Examples of these are:

Keeping an eye on your portion sizes will help you to not eat too much at a meal or snack. Below is a guide to what a portion size is for different food types.

As you feel stronger and are able to do more and exercise, you may find that you want to eat more.  This might mean that you put on more weight than you want to. If you have been advised that losing weight will be better for your health, here are some tips that might help you:

The best way to lose weight is to make sure you are eating a variety of healthy foods, from all the different food groups and making sure you are eating the right amount of food (so having sensible portions). A weight loss of 1 to 2 pounds (½ to 1kg) a week is a safe achievable target for most people

• cut down on sugary and fatty foods e.g. pies, pastries, cakes, biscuits, chocolate, and crisps
• plan ahead to help ensure you have the right foods available when you are feeling hungry (so you are not tempted to snack on high fat and high sugar foods)
• start the day with a healthy breakfast, such as fruit, yogurt, cereal, or egg on toast
• eat three meals, spread out throughout the day (and have low calorie snacks if you feel hungry between meals)
• shop with a list, so you are not tempted to buy foods you don’t need
• read food labels and check the fat, sugar and salt content
• aim to have 5 portions of fruit and vegetables a day
• half fill your plate with vegetables/salad and divide the other half between meat/fish/eggs/beans and a carbohydrate e.g. potatoes, bread, rice or pasta
• choose low fat spreads, salad dressings, sauces and dips and use small amounts of oils (olive, sunflower or rapeseed oil for example) in cooking if you drink alcohol, don’t drink too much, as alcohol is high in energy
• when you are eating away from home, make sure you don’t eat too much (as portion sizes can often be larger than you need)
• avoid eating at the same time as doing something else for example watching TV, that way you can concentrate on what and how much you eat
• eat slowly. It takes time for your brain to know your stomach is full so wait at least 5-10 minutes before having more
• ensure that you drink enough.  Aim to drink 1.5-2 litres a day (3-4 pints). Try and drink plenty of water but you can also have some tea, coffee and low calorie soft drinks.

If you feel that you have lost muscle, it can help to still have a good amount of protein in your meals and drinks. Please see page 9 for tips about how to do this.

More information:

One You for how to get healthier and feel better:

Change for Life - Easy ways to eat well and move mor.

British Dietetic Association Food Fact Sheets have a variety of diet advice leaflets.

Websites  with healthy and nutritious meal ideas: (remember to look at the serving sizes to work out the calorie, protein and fat content per portion).

• British Heart Foundation Recipe finder.
• Diabetes UK – Recipes.
• Change for Life  - Recipes.

Advice on to support you to start or continue to by physically activity:

• Chartered Society of Physiotherapy.
• Exercise on referral.  
• NHS 10 minute workouts.
• Also consider using Apps like Couch to 5k, 7 minute workout, Fitbit, 30 day ab challenge.  

See ICUsteps information for more information https://icusteps.org/information