With over 20 years’ experience in the catering sector and over 8 years in aged care, Niamh set up Dining with Dignity in 2019 to provide catering consultancy training in the healthcare sector, primarily in aged care. Niamh has collaborated globally with dietitians and speech & language therapists on how best to create safe food for those who struggle to swallow.She has also been asked to contribute to a book for UNESCO and a series of books for Breakthrough Cancer Research.FROM HOSPITALITY TO HEALTHCAREAt the age of 12, I started my cooking career in my Uncles Deli and little did I know it, but it was an introduction to the world of food that was going to have me hooked for life. I continued to work with food while I was in school and started working in hotels and bars, and from this went on to study Food Process Engineering in UCC.What did I do to put me through college? Well yes, I worked as a chef. Constantly learning from other chefs, I realised that engineering was not for me and went back to cooking. I have also worked designing kitchens. Who best to design a kitchen but a chef?
My previous role was catering contractor in a golf club where the hours were long and the events were exciting. From day-to-day catering to special events like gala dinners for the Presidents’ Prize, it was all very fast paced and constantly evolving. The requirements of a caterer in a golf club meant that I was working 80 hours a week and on call constantly. Yes, I had special requests like gluten free meals, vegan meals, low fat and some other allergen requests and we catered to everyone of them as best I could.
But it wasn’t until I was asked to work in an aged care facility that my world in terms of food changed. I started in a small 50 bed nursing home in West Cork 2014 and was convinced by the owner that the role would be a more relaxed environment than what I was previously used to, with less hours and a work life balance. So, was he right? Yes he was. But what he didn’t say was there were other obstacles that I needed to face.
Yes, cooking for 50 people seemed easy with 3 meals a day but then the Director of Nursing started speaking and informed me that there were other medical diets to cater for. Diabetics, low fat, high fat, renal diets and then texture modified diets.What in the name of God is a texture modified diet?? I could manage the rest as it was a manipulation of ingredients, but this was a whole other ball game!
A texture modified diet is required for people with ‘Dysphagia’ and there were different textures to suit a person’s individual needs. Dysphagia is a medical term for swallowing difficulties. It was then explained to me, that it also needed to look good. Bear in mind that all I had in my head was, throwing a roast dinner in the blender and making a smoothie.
I asked if I would get training and I was told that I would figure it out. Totally petrified to be responsible for feeding somebody with medical needs I decided that I would look it up online and figure it out like I was told. Sweet divine, I was now panicking as the internet was little or no help, so I began asking questions as often as I could.
Yes, initially I was blending the food altogether and serving it, as that was all I knew and also that was what was done before me. If I was to stay in this job, I needed to do better. Simply put, if I wouldn’t eat it then why in the name of God would I expect the residents to eat it. So, I decided that we would blend the foods separately and hope that the colours of the foods would entice people to eat.
A lot of these residents were losing weight and had little or no appetite as nothing seemed to whet their appetite. They were missing the actual taste of savoury foods. Yes, there were plenty of options when it came to sweet desserts, with mousses, custards and sweetened yogurts but very little in terms of savoury items.
From when I was working in the Hotel, to running my own catering company, I was always obsessed with the plates coming back into the kitchen. I wanted to see if people enjoyed their food. This attitude followed me into the nursing home and the staff thought that I was bonkers. The main food at the time that was not been eaten was the modified diets. Clearly, I understood why and couldn’t expect people to eat their meals like this anymore, so it made me look for another way.
We first opted for blending foods separately. I often sat and ate meals with the residents and asked if they enjoyed it. I witnessed a lady’s joy at the sight of 3 scoops of food on her plate and I thought that I cracked it. To hear her shout “yes Ice-cream” nearly broke my heart as she clearly didn’t realise that this was her dinner. She tasted it- it was hot, it was salty and NOT ice-cream, so she pushed the plate away and refused everything until she got ice-cream. The trouble here, was that this lady, because of her swallow could not eat ice-cream as the risk of choking or aspiration was too high.
Even though this was not right, we learned what foods our residents didn’t like and learned that they ate more when they could taste the food separately. We now knew why they were refusing a beef casserole blended, especially if they were like my grandmother and didn’t eat carrots. It was all starting to make sense.
We took it one step further and started to attempt to make the food look better by piping the hot fresh food into recognisable plates of food. There was so much to learn and very little training available. Then I sourced food moulds in Australia to make things a little easier for the catering staff when I wasn’t there as it was a lot to ask people to pipe hot food and burn their hands. With a combination of food moulds and piping, meals were now recognisable and eaten. “Nutrition only counts if it is consumed”.
Then in 2019 an International Standard was introduced in Ireland where we now had testing methods to ensure the foods were safe for each level within this standardisation. IDDSI (International Dysphagia Diet Standardisation Initiative) made things clearer for chefs to audit their techniques and gave a sense of reassurance. This led to me being extremely curious and I was finding it hard to get to speak to speech & language professionals and dietitians as they were extremely busy and only ever spoke to the clinical team. These people were handing documents to the clinical teams to refer residents to a special diets/food fortification or move within levels in the IDDSI framework. These documents were handed to the catering team with no discussion on how best to prepare the meals or even an explanation of the changes that were being made. I was on a mission to find someone to talk to and to get an understanding of whether what I was doing was right or needed more work.
Eventually I met a dietitian, Grainne Kent from Nutricia, who happened to be standing at the desk waiting for the clinical team… so what did I do? I pounced. I think I freaked her out because I had 100 questions fired at her within 2 mins and I barely came up for air. I pulled her away from the desk and brought her to the kitchen in case anybody distracted her. Thank God I did as she shared the same passion as I did.
From this meeting we always met to discuss the residents and how I could improve nutrition in pureed diets. So much so that she did a dysphagia challenge with me, and we consumed pureed food and thickened drinks for 3 days to learn what people face with dysphagia. The information that we got from doing this was huge. I also got her to plate her own food as I wanted to highlight that plating food is not as easy as it looks, especially for purees. I then plated mine and we compared. She still laughs at this and even posted it on her Instagram account!
Did I learn anything from this? Yes! Preparation and consumption of Food is a social activity and we need to include everyone. Food is not a luxury but a necessity for many and the whole experience should be shared.
The importance of collaboration makes it clear how important it is to work closely with speech & language, dietitians, doctors, nursing teams, care assistants, managers, chefs and relatives. It’s a big wheel that needs every cog working simultaneously.
I have been working as a consultant dysphagia chef with Nutricia since 2018, and they asked me to present at their symposium. I am a chef, and this really was out of my comfort zone, but I wanted to get across what it was like to have dysphagia! I asked the hotel for scones and biscuits.I introduced myself and said that before we start, I wanted to divide the room in 2. I offered the people on the left of the room scones with jam & cream and biscuits and the people on the right, I ignored them & left them sit there because why? Well, they had dysphagia. You should have seen the look on their faces! Observing the other side of the room eating their lovely treats, triggered a mix of emotions by the people left with nothing. This is the reality for someone with dysphagia!My focus now is providing the best possible mealtime experience for those who struggle to eat. I look at meals and wonder if it would be possible to recreate them in a pureed form. I try to make the foods look like what they should and enhance the taste of each individual flavour. This was something that I learned when I did the 3-day dysphagia challenge. As chefs we are taught texture and layers within meals but this is completely different when you have a pureed meal. The flavours tend to merge because the texture is the same for everything. Using strong flavour to enhance taste sensations on the tongue like ginger for heat and mint for cooling to name a few.Training chefs and recreating recipes with dietitians to provide safe foods for those who need it most, is now a role that I didn’t expect to be filling but one that I wouldn’t change.
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