Smoothies and Liquid Nutrition During Treatment

There is a point in treatment where chewing becomes the obstacle. The mouth is sore, the jaw is tired, swallowing is slow, or the sight of a loaded plate is enough on its own. A blender solves a surprising amount of that, because it separates the nutrition from the effort of eating.

It also has limits, and one of them is genuinely dangerous. That part is near the end of this page, and it is worth reading before you buy a blender.

More than smoothies. The NCI booklet Eating Hints groups full-liquid foods together: refined cereals such as Cream of Wheat and instant oatmeal, broth, milkshakes, smoothies, yogurt, ice cream, custard, pudding, and protein supplement drinks such as Ensure and Boost.

That list matters because variety is what keeps liquid nutrition going past day three. Nobody drinks the same shake for two weeks.

Guessing at what a shake is worth is how people end up drinking a lot and losing weight anyway. NCI publishes recipes with the counts included.

Banana milkshake. One sliced ripe banana, one cup of milk, and a few drops of vanilla extract, blended smooth. Made with whole milk, that is 255 calories and 9 grams of protein.

High-protein milkshake. One cup of whole milk, two tablespoons of chocolate or butterscotch sauce, half a cup of ice cream, half a teaspoon of vanilla, and a third of a cup of instant dry milk powder. That comes to 600 calories and 22 grams of protein.

The difference between those two is mostly the dry milk powder and the ice cream. That is the lesson: what you add matters more than what you start with.

Think of a shake as a base plus three jobs.

The base. Whole milk, lactose-free milk, soy milk, kefir, or a supplement drink. NCI suggests using whole milk or yogurt for milkshakes and smoothies specifically to raise the calories.

The protein. Instant dry milk powder is the strongest and blandest option, and Eating Hints suggests stirring it into soups, sauces, mashed potatoes, and puddings as well. Greek yogurt, silken tofu, peanut butter, and protein powder all work too. Eating Hints suggests adding protein powder to oatmeal, sauces, soups, and pancakes.

The calories. Eating Hints calls this power packing: peanut butter, nuts, seeds, avocado, honey, and jam. Ice cream and granola do the same job.

The flavor. Ripe banana, canned peaches, cocoa, maple syrup, cinnamon. Keep citrus and tomato out if your mouth is sore, because acid on broken tissue hurts.

Make it in the morning while you have energy, and keep it in the refrigerator in single glasses.

A smoothie is uncooked food, and cooking is what normally kills bacteria. When treatment has lowered the white blood cells that fight infection, that changes the math.

Eating Hints is specific about produce. Scrub all raw fruits and vegetables with a brush and water. Skip produce that is hard to wash properly, and it names berries and grapes. Raw sprouts are out entirely, as are raw nuts.

Beyond the produce:

• Use pasteurized milk, yogurt, and juice only. Unpasteurized versions are a known risk.
• Wash the blender jar, lid, blade, and gasket after every use. The gasket is the part everyone forgets.
• Do not leave a finished shake standing. Perishable food should not sit out more than 2 hours, or more than 1 hour above 90°F, because bacteria multiply fastest between 40°F and 140°F.
• Keep the refrigerator at 40°F or below.
• Thaw frozen fruit in the refrigerator, not on the counter.

• Mouth or throat sores. Cold, smooth, and bland. Strain out seeds and skins. No citrus, tomato, or vinegar.
• Metallic taste. Serve cold, and use a plastic spoon or straw rather than metal.
• Nausea. Cold food gives off less aroma. NCI also notes that foods containing ginger may help.
• Full after a few sips. Sip small amounts often rather than finishing a glass. NCI suggests resting upright for 30 minutes after eating.
• Dairy is a problem. Use lactose-free milk or a soy base. NCI advises avoiding milk and dairy while diarrhea is active.
• Diabetes. Shakes are concentrated sugar. Ask your team how to build one that fits your plan.

This is the part to take seriously. For some people, liquid is harder to swallow safely than soft solid food.

Trouble swallowing is called dysphagia. The American Cancer Society lists the warning signs as coughing or choking when you try to swallow, feeling like you cannot swallow, food seeming to stick on the way down, pain on swallowing, and unexplained weight loss. It is common after head and neck cancer, radiation or surgery to the mouth, throat, or esophagus, and when the esophagus has narrowed.

The risk is aspiration, which means food or liquid going into the lungs instead of the stomach. ACS notes this can lead to infection and breathing problems.

Thin liquids move fast and are the hardest to control. So the fix is often the opposite of what people assume. ACS suggests soft, smooth foods, thicker liquids, and sitting upright to eat and drink. It also notes that a speech pathologist, many of whom have special training in swallowing, may be brought in.

If you cough while drinking, stop improvising and ask for a swallowing assessment before you build a routine around shakes.

Supplement drinks are useful, and NCI suggests sipping them between meals rather than with them, so they add to your intake instead of replacing food.

If liquid nutrition still is not keeping weight on, say so early. NCI describes enteral nutrition, which delivers liquid feed through a tube into the stomach or small intestine and is preferred whenever the digestive system works, and parenteral nutrition, which goes into the bloodstream when the gut cannot be used. Raising this early is not surrender. It is easier to arrange before a crisis than during one.

• Call 911 or go to an emergency department if a drink goes down the wrong way and leaves you fighting for breath, or if a coughing fit after drinking is followed by chest pain, breathlessness or a fever. That combination can mean liquid has reached the lungs.
• Ring your oncology team without delay, whatever the hour, if the thermometer reads 100.4°F (38°C) or higher while you are having treatment. CDC calls a fever during chemotherapy a medical emergency, and it needs to be assessed within the hour rather than at the next clinic call. If they cannot be reached that fast, go to an emergency department and tell them you are on chemotherapy.
• Call your care team the same day if nothing has stayed down for a full 24 hours, or mouth pain now defeats even a cold, smooth drink.
• Call your care team within a day or two if you cough or splutter on thin liquids, your voice turns wet or gurgly after a swallow, or a drink feels stuck in the throat or chest. Ask for a swallowing assessment before you build a routine around shakes. Ring within the same window if more than 3 to 5 pounds have gone in one week, which NCI says to report right away.

• How many calories and how much protein should one shake give me?
• Can you look at my recipe and tell me what is missing?
• Should I be drinking these between meals or instead of meals?
• Do I need a swallowing assessment before relying on liquids?
• Which supplement drink suits my situation, and will insurance cover it?
• Which fresh ingredients are off-limits while my counts are low?

Read next: Getting Enough Nourishment When You Can Only Eat a Little, Eating When Swallowing Is Hard, Managing a Dry Mouth During Cancer Treatment, Feeding Tube Basics During Cancer Treatment, and High-Protein Snacks During Cancer Treatment.

• https://www.cancer.gov/publications/patient-education/eatinghints.pdf
• https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss
• https://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-pdq
• https://www.cancer.gov/about-cancer/treatment/side-effects/nausea
• https://www.cancer.gov/about-cancer/treatment/side-effects/diarrhea
• https://www.cancer.org/cancer/side-effects/eating-problems/swallowing-problems.html
• https://www.foodsafety.gov/keep-food-safe/4-steps-to-food-safety
• https://www.cancer.gov/about-cancer/treatment/side-effects/infection
• https://www.cdc.gov/cancer-preventing-infections/patients/fever.html