High-Calorie, Low-Pain Nutrition Options for Head and Neck Cancer

“Radiation-induced mucositis can make eating and even talking painful, and that pain often leads to fear-driven avoidance, since patients eat less because they associate meals with discomfort,” says Taylor Janulewicz, RDN, founder of My Cancer Dietitian, a nutrition coaching program for cancer treatment and recovery, based in Gilbert, Arizona.

Smooth Thickening Agents and Soothing Textures

Thicker liquids are also beneficial if you have mucositis. “Smooth, thickened foods are gentler on inflamed tissue and easier to control when swallowing,” says Janulewicz.

It’s equally important to know which foods to avoid. “Two things make eating painful —friction and trouble swallowing,” says Alison Tierney, RD, an oncology dietitian based in Oconomowoc, Wisconsin, and founder of Wholesome, a nutrition coaching program for people with cancer from diagnosis to treatment and beyond.

“Anything rough, dry, or crumbly — toast, crackers, chips, raw vegetables — scrapes against raw tissue, which hurts and can even make it bleed,” Tierney says. Alternatively, smooth, moist foods glide over raw tissue instead of scraping, she adds. “Soft, even textures also come with a swallowing advantage —they hold together in one soft lump that's easy to manage, instead of scattering in the mouth.”

Both Tierney and Janulewicz recommend getting an assessment from a speech-language pathologist who is also a swallowing specialist. “Not everyone with mucositis has true dysphagia, so if you notice coughing, a gurgly voice after swallowing, or food sticking, ask your care team for a speech-language pathology referral to check swallow safety,” says Janulewicz.

An assessment can also help you figure out the correct food texture for you if swallowing has remained really difficult, despite taking measures, Tierney says. “Thicker isn't automatically safer for everyone,” she adds.

Janulewicz and Tierney suggest modifying the texture of your food in the following ways in order to make it smoother, thicker, and easier to consume:

• Thicken broth by stirring cornstarch or gelatin into it.
• Blend soft fruit like banana or avocado into smoothies for natural thickening.
• For soothing, protein-rich options, blend Greek yogurt with soft fruit, or blend bone broth with rice into a soft porridge.
• Try silken or soft tofu, which is neutral-tasting, high in protein, and blends invisibly into other foods.
• Thicken foods using instant potato flakes, blended white beans, mashed banana, or smooth nut butter thinned into a sauce. “There are also store-bought thickening products made for exactly this purpose,” says Tierney.

Healthy Fats for Maximum Calories

Fat is the most concentrated source of calories, giving you more than double what you get from the same amount of protein or carbohydrates, says Tierney. “That means you can pack a lot more calories into a small amount of food,” she says. “Which is exactly what you want for someone who fills up fast, tires out halfway through a meal, or can only manage a few spoonfuls — you're enriching what they can eat instead of asking them to eat more.”

Healthy fats are the “good” fats found in foods like avocado, nuts, nut butter, seeds, olive oil, olives, and fatty fish like salmon, says Janulewicz. “These fats are good for your heart and give your body energy. They're also packed with calories, so even a small amount can add a lot of extra calories to a meal without making the meal bigger. Fat also adds richness and moisture, so food slides down more easily.”

However, if you’re having difficulty eating or you’re losing weight, getting enough calories matters more than where those calories come from, Tierney adds. “If the only thing that goes down is cream, butter, or full-fat ice cream, that absolutely counts, too,” she says.

Tierney suggests the following options for adding fats into food:

• Full-fat coconut milk is high in fat and creamy, and works very well in soups, smoothies, and puddings.
• Avocados are high in fat and blend smoothly into almost anything, with a very mild taste.

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• Olive or avocado oil can be drizzled into purees, soups, and mashed potatoes.
• Smooth nut and seed butters and tahini can be stirred into oatmeal, smoothies, or sauces, and add a protein boost as well as fat.
• If you can tolerate dairy, whole milk, cream, and butter can be added to a wide variety of foods.
• Flavorless oils like medium-chain triglyceride (MCT) oil can be stirred invisibly into food to boost calories. Triglycerides are a major form of dietary fat found in the bloodstream, and MCT oil is sold as a dietary supplement. Talk to your doctor before trying any new supplements.

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Non-Acidic Flavor Enhancers

“Foods with strong acidic flavors, like citrus fruits, tomatoes, and sharp or spicy seasonings, can taste appealing during treatment, but they can also cause problems,” says Janulewicz. “When someone has a sore or painful mouth from radiation mucositis, these flavors can irritate the raw, sensitive tissue and make burning or pain worse. Salty foods can have the same effect.”

The additional irritation caused by eating these foods can also slow down the healing of mouth sores, she says. “That said, everyone is different, so some people may tolerate these flavors better than others. If acidic, spicy, or salty foods cause pain, try gentler flavors instead,” she adds.

Tierney suggests using the following gentle ingredients to add flavor and keep food from tasting bland:

• Mild fresh herbs such as basil, parsley, dill, and cilantro
• Warm sweet spices in small amounts: cinnamon, nutmeg, cardamom, vanilla — especially in smoothies and puddings
• Ripe banana, maple syrup, or blended dates add natural sweetness
• Coconut milk and nut butters add richness
• Soft blended cheese, cooked mushroom, or nutritional yeast add a little mild savory depth

Creamy, mild additions like mayonnaise, butter, or cream-based sauces can also boost flavor while being easy on a sore mouth, adds Janulewicz.

Sample Meal Ideas

Tierney suggests the following options:

• Enriched breakfast smoothie: banana, silken tofu or full-fat yogurt, smooth nut butter, whole or oat milk, and a spoonful of oats. “This is cold and soothing, and it packs protein, fat, and calories into one glass,” she says.
• Blended savory soup: pureed butternut squash or potato-leek, enriched with full-fat coconut milk or cream and a swirl of olive oil. Stir in blended white beans or silken tofu for protein.
• Creamy porridge: smooth oatmeal or rice congee (porridge) with mashed banana, a spoonful of nut butter, a splash of cream, and a drizzle of maple syrup.
• Nutrition shake or milkshake: full-fat milk or yogurt, avocado or nut butter, banana, oats, and a scoop of protein powder.
• Whipped mashed potatoes: Beat with butter and olive oil, then blend with soft or smooth cottage cheese for protein.
• Silken chocolate pudding: Blend silken tofu or avocado with cocoa, then sweeten with maple or banana. “This is cold, high in protein and fat, and easy to swallow,” says Tierney.
  

Janulewicz recommends the following simple recipes:

• Scrambled eggs: Make them extra creamy by adding a splash of whole milk and mixing in a pat of butter for a soft, protein-rich option.
• Oatmeal: Cook them with whole milk instead of water and top with a spoonful of almond butter to add both smooth texture and extra calories.
• Baked sweet potato: Mash with coconut oil or butter for mild flavor.
• Cream of chicken or cream of mushroom soup: Blend with canned chicken until smooth and finish with a drizzle of olive oil. “This adds extra protein while staying easy to swallow,” she says.
• Chia seed pudding: Use whole milk and a touch of honey for soft texture along with healthy fats and calories.

The Head & Neck Cancer Alliance has full recipes online, as does the Cancer Support Community and the Ohio State University Comprehensive Cancer Center.