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Hip, Hip, Puree….

On a day to day basis speech therapy teams across the UK will suggest to patients and their families that a pureed diet and/or thickened drinks are advised to reduce the risk of them aspirating (which potentially leads to pneumonia) or simply choking to death on foodstuffs that prove challenging for them to swallow.  For some of these individuals it may be a short-term measure through recovery phase, for others it can be long term, in some cases that mean forever..

So our SLT team agreed it would be useful on both a personal level and to support EU swallowing awareness day, to undertake the challenge of a pureed diet for a 24 hour period.

If I’m completely honest, while I wasn’t looking forward to it, my reaction was fairly relaxed.  How hard could it be?  I like yoghurt, I love chocolate milkshake, I enjoy a bit of mash and it’s been known for me to optimistically attempt a celeriac puree after a decent episode of Masterchef professionals.

 

At risk of seeming to exaggerate, the reality was starkly different to my expectation – in short, my experience of a pureed diet was grim start to finish.  I am wary of painting too dark a picture but it is hard to flower the summary as there was little positive to report even from such a short stint as 1 day.

I expected the food to taste worse once blitzed, in some cases it did in others it didn’t.  The sweet potato puree was nice but the pea puree was awful!  The real difference was the lack of comfort I could take from the food I ate, seemingly all of the food that makes me feel satiated and happy is crunchy, chewy or crispy! I love hummus but only on a carrot stick or a crisp! I love mash but only next to a pastry crust pie!  It really brought it home that this dietary restriction takes the enjoyment from eating and ultimately, from food.   We found the food also gets worse in terms of taste as it cools – which should certainly be a consideration for relatives and care staff supporting patients. 

I also found the food made me bloated and I suffered heartburn from breakfast onwards.

Another issue which must be horribly frustrating for those following this type of eating plan is that I couldn’t quench my thirst – at all.  The easiest way I could describe it would be if you had done strenuous exercise and needed a drink you probably wouldn’t choose a thick milkshake and certainly not a thick soup! It just doesn’t hit the spot. 

The bleakest paradox is this: being on a pureed diet puts food on your mind, you have to put thought into what you will eat, when you will eat it, where you will get it from (who knew that loads of shops don’t sell milkshake!?) and how you will prepare it… so the nature of the recommendation puts food on the agenda, then the diet itself stops you feeling satisfied by the food you want and are being forced to think about.  It would also make you highly aware of any illness leading to this requirement; when I am poorly I reach to a biscuit tin, bag of midget gems and a bottle of Lucozade for comfort, in this circumstance all are off limits which for me would compound the feeling of being unwell and out of sorts.

On a mildly lighter note a thickened gin and tonic beats a thickened bottle of cider hands down!! But again the grim reality we realised is that a relaxing glass of wine is again off limits and a trip to the pub would be made much more challenging than normal.

Retrospectively it now seems glaringly obvious, of course a pureed diet with thickened drinks would have a major impact on your diet but much more than this it can really impact your life, potentially your activities and it should be considered that this could possibly go on to affect mood and morale and hydration.  This is a tough gig – 1 day was bleaker than anticipated and I feel I will be more sensitive and understanding to those who have to undertake this recommendation.

I am glad that we took the opportunity to sample this diet and I expected to be able to write a far more light-hearted and anecdotal review and blog.  The experience brought it to light that the restrictions of a pureed menu could easy push into all aspects of your life and have a far wider impact than simply a less enjoyable, worst tasting lunch and dinner.   For people whose treatment plan includes this strategy the huge positives are that these modifications can; dramatically and rapidly impact their ability to eat, reduce their likelihood of choking, immediately lessen their risk of developing painful and dangerous chest infections.  For some people, the positives on balance outweigh the drawbacks but since this challenge I feel I will have first-hand understanding and consideration of the challenges patients may face and I can now provide more support through this process. 

 

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Puree for a day – Heather’s turn

So like my colleagues I took part in the puree and stage 1 for a day experience. I was one of the first to do it but the last to post – story of my life!

I started my day with thick and creamy yoghurt and a smoothie – now my friends and family know smoothies are not my favourite way to take fruit – but this, one a blackcurrant and blueberry,  was actually very nice.  Thickened tea not so much!  Maybe because it just doesn’t taste like I expect or want it to – to be fair I should be used to that with my cooking!

I took thickened flavoured water to work – not bad but very sweet which I think is a running theme here. Lunch consisted of thick tomato soup (condensed soup no added water) – no bread – and pureed stewed apple with a touch of cinnamon – (oooh get you,  Mary Berry eat your heart out) – not bad actually . The soup however was a tad .um… intense and I felt quite queasy afterwards and was concerned I may have looked like I had been tangoed – as I am sure I sweated pure tomato through my pores for the rest of the day.

Arrived home to find my beloved tucking into steak, roast potatoes and vegetables – I know – on a SCHOOL night! Seriously I had said for him to continue as normal (!) as most people, unless they are very unlucky, don’t have a whole family on pureed diet with them. My meal consisted of roast potatoes (those are the odd grey coloured constituent), pureed vegetables – cauliflower, peas, green beans (bet you can’t guess which they are) and pureed chilli.  Not, I think you will agree a particularly attractive meal but quite tasty.   I do like food presented in an appetising way – obviously I don’t refuse it presented school dinners style but do prefer it to look tasty (pre –oral stage). The thick and creamy yoghurt,  (skinny latte flavour) was a nice way to end the meal but again not as palatable when aforementioned beloved was tucking into a Cornetto with not a gondola in sight.

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My thoughts:

I enjoy crunchy food and was very glad to get back to my salad the next day. I enjoy bread (crusty) and toast (the crunchier the better) and did miss it. Every year I give up many foodstuffs for Lent and don’t often ‘fall off the wagon’ but in this challenge I’ll admit I did consider having just a small glass of water / tea/ Horlicks and that was for 1 day.  Also Lent is self imposed and lasts for 40 days – very different if this is for life.

I like sweet food as much as the next person but also enjoy savoury and there are few, no let’s face it, no readily available savoury snacks that don’t take planning, preparation and imagination.

I like a cup of tea – am not fussy about whether it is ‘blond’  or ‘council road worker’ strength, but do prefer it to be thin in texture.  Coffee wasn’t bad though:dsc_0032

I have had many discussions with patients to try to vary their meals, using suggestions of spices and alternative ways of having their favourite.  How naive I was!

Of course you can live on puree and stage 1 – many people do and others have even more modified consistencies but it takes planning, imagination and time.

I most humbly take my hat off to those who persevere!

And so to bed..

Thickened cocktail anyone?

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The Final Day of the Challenge: Frieya’s Turn!

As some of you may know, this is the second time I’ve done the stage 1 fluids and purée diet challenge (last time it was for a full week for stroke awareness)..a glutton for purée punishment perhaps!..but for me it was important to get a taste (quite literally!) of what my patients experience when a Speech and Language Therapist like myself comes along and recommends modified fluids and/or diet, so I was happy to take on the challenge once again – this time for EU Swallowing Awareness Day 2017.

When it came to my turn to do this it was the last day of the challenge (a Friday!) and that definitely brought challenges with it! By Friday I am usually well and truly knackered and food preparation has gone right out the window and I usually end up buying my lunch from the hospital canteen! Not an option this week unfortunately…

So here was my menu for the day:

Breakfast: Smooth Ready Brek with puréed pears, a stage 1 cup of tea and kefir.

Lunch: Chantenay carrot and honey roast parsnip thick soup (thickened up slightly with instant mashed potato flakes) and natural yoghurt with puréed pears.

Snack: A chocolate custard (just like the ones we spend most of our day assessing our patients swallows with!!).

Dinner: Puréed gluten free wholegrain rice and vegetarian chilli con carne. Followed by dessert of puréed strawberry cheesecake and puréed pears (again!).

Fluids:
– Stage 1 tea and coffee
– Stage 1 elderflower cordial
– Strawberry and banana smoothie

Breakfast was fairly easy and normal, although I did find myself leaving for work much later than usual due to all the preparation time my puréed breakfast and my morning cuppa took. In my rush to make my cup of tea I also may have added a tad too much thickener and quickly ended up with more of a stage 2/3 viscosity. Not a great start. I also missed my usual Costa Coffee Friday treat..I could have bought and thickened one up, but I imagined it would be a let down so didn’t bother.

Lunch was also relatively easy and the soup and yoghurt with puréed pears is not too dissimilar to what I would normally eat. I missed the bread though and I think that’s been a running theme with the rest of my work colleagues this week..bread really is the best thing ever and the main thing I would miss on this diet.

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I did find I got hungry again quite quickly and by 5.30pm I was ready for a snack..not an easy thing to find on this diet unless you find yoghurts a satisfying snack. I made do with a chocolate custard- not something I would normally eat.

Dinner was the worst meal of the day for me on this challenge, which was sad as dinner is usually the meal I enjoy most. It tasted nice, but I found I got full quickly, as I had less work to do at the oral stage and I got sick of the same puréed texture and taste. I will admit my puréed rice was NOT a success and as it cooled it became more and more congealed and difficult to swallow. It also lacked flavour. I had had high hopes that gluten free rice may work better than normal rice which I had previously found to be very glutinous once puréed (same as pasta), but sadly not the case. Not something I’ll be recommending to my patients on puréed diet. Dessert saved the day though and was the sugar high I needed after a disappointing dinner!

So here are some of the key things that really stood out for me when I was carrying out this challenge and what I learned from doing it:

– Preparation, preparation, preparation!:
When eating puréed food you definitely get a sense of the immense preparation that goes into trying to prepare a nourishing and appetising puréed meal and also the feeling of disappointment when the meal you spent ages preparing turns out to not be quite as tasty as you had hoped and you end up binning half of it! This made me realise the value of companies such as Wiltshire Farm Foods and Oakhouse Foods where puréed meals can be ordered in and stored in the freezer. Possibly a good back up for when you haven’t got the time to prepare a meal yourself. Also I imagine that for some of our patients who may not be in good health, pureeing meals may be even more challenging.

– Hydration:
I am really terrible for consuming fluid at the best of times and probably drink about 2 cups of tea a day in total, so long-term I would probably end up quite dehydrated on thickened fluids. For me smoothies were my salvation when I did this challenge for a week and helped me to keep hydrated, as I became so sick of the thickener which I found left a slimy coating in my mouth and sat heavy in my stomach. I think this really brings to light the real balancing act that we all need to consider for patients- the risk of aspiration vs. dehydration..not easy risks to weigh up I know, but very real as we see many patients admitted to hospital with dehydration, UTIs etc etc. So easy to reach for the thickener, but is it really always in the best interest of the patient?

– Nutrition:
Pre-challenge I had wondered how eating pureed food would challenge me nutritionally. I really enjoyed my puréed breakfast (a novelty for me as I rarely eat breakfast!), my lunch (a pretty normal lunch for me) and my snacks, but REALLY struggled with my puréed dinner and ended up leaving half of it. Over time I could certainly see myself losing my appetite for food and losing weight. It highlighted for me how at risk of malnutrition our patients on puréed diet are and the role for Dietetic support with this.

– Mood:
Carrying this challenge out on a Friday..the start of my weekend..was hard. My partner and I will often go out for a meal or drinks on a Friday night and it’s our opportunity to have time together, relax and get ready for the weekend ahead. Instead we stayed in, prepared separate meals and ate our dinners at different times, as his dinner was ready whilst I was still grappling with the blender! It makes me wonder how our patients deal with these challenges and how this impacts on their mood and relationships with family and friends. I know that when I did this challenge for a week I began to feel more and more low in mood as the week progressed, especially when the weekend hit and I would normally be going out for coffee and food in a cafe or restaurant with friends. I can see how fluid and diet modification could easily lead to social isolation and impact on your relationships. I feel this is something we really need to acknowledge more when working with our patients and discuss this more openly perhaps?

Conclusion:
This experience has been such a valuable one. It challenged my clinical practice in a very positive way and hopefully has made me a better therapist for it. Firstly I must say I now have an incredible amount of respect and admiration for people who live with modified fluids and diet on a daily basis. I recognise even more now the importance of supporting patients with this and ensuring I help to prepare them for what may initially be a real challenge, but what hopefully will be made easier with support, time and help to adjust to changes in eating and drinking. I also now have a better understanding of some of the reasons why some of our patients don’t always stick with SLT recommendations..quality of life and a love of normal food and drink often wins. Hopefully as a team we can reflect on all of our experiences and think about how we can use this experience to support our patients better with their own challenge. Finally I would invite others to try this challenge – even 1 day can give you a real insight into what our patients on modified fluids and diet experience on a daily basis and certainly gives you a new appreciation of how lucky most of us are to be able to eat and drink normally and safely.

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Purée for a day… Jen’s turn

So, on Thursday it was my turn to embrace the purée diet and thickened fluids experience. In all honesty, I had looked on in awe as my SLT colleagues planned and whipped up carefully crafted, culinary delights, whereas I didn’t feel nearly so organised. Nevertheless, between stealing some items from my toddler’s food supplies, endeavouring to locate anything ready-made/shop-bought and firing up my nutribullet, I did it!

To begin, it was ready brek for breakfast. Not to be outdone by my colleague’s supreme efforts, I thought I’d best blend up a bit of banana and raspberry to add some aesthetic flair… and taste. (It obviously worked well as my toddler felt inclined to steal a good portion!)

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Breakfast
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Purée thief!

For lunch, I plumped for a shop bought soup and yoghurt, which was as convenient as I could manage under the restrictions. I felt full, and it had been an easy, ordinary lunch (although I missed bread!). I did find myself ‘stocking up’ a little as I worried I wouldn’t be full.

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Lunch in the staff room

Dinner was my most interesting and perhaps most realistic experience of being on a purée diet. Whilst my parents (who were visiting) and husband tucked into a colourful, chunky ratatouille with a side of cheesy bread, my version looked a little less attractive (although a colleague pointed out from my photo that it looks like it has a face – perhaps that adds a level of interest?!) and I finished much sooner than everyone else. That said, it was tasty, nutritious and I felt full. My family, however, were concerned I hadn’t eaten enough and looked on in sympathy at my meal. I expect this is a very typical reaction; it doesn’t seem natural to blend your food. I had to remind them, and perhaps myself, that it was exactly what they were having. Compared to sharing the experience in the day with colleagues, dinner felt more challenging in both a sense of ‘missing out’ and self-restraint, I mean who would’ve known if I’d reached for a slice of bread? I didn’t by the way! At this point, I couldn’t help but think of our patients as they attempt to navigate the world of modified diet alone.

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Can you see the face?
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Purée for 1… dinner for 4.

I concluded with a delicious blended apple crumble and custard – this was probably my favourite dish of the day, which won’t come as much of a shock to my colleagues who know I have a sweet tooth.

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Apple crumble! Mmmm!

In the meantime, I started the day with thickened orange juice, I also tried coffee, cooled boiled water and squash. Whilst it wasn’t unpalatable, I found I had to sip fluids more regularly through the day as it wasn’t as easy to take on larger quantities at once. It was different, but I feel that if my alternative was repeated hospital admissions with pneumonia, as is the case with many of our patients, I feel I’d be on board.

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Kerry on thickened coffee duty, thank you Kerry!
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Thickened coffee

So having completed the challenge, here are a couple of my key reflections:
– I still found my food tasty and filling, although I missed the satisfaction derived from chewing and negotiating the texture of my food
– Both thickening fluids and pureeing food takes away the convenience
– Whilst I still enjoyed food when puréed, it takes creativity and most importantly, time to make this work well – both of which I can sometimes struggle to find!
– finally, as a self-professed sweet lover, I did find there was an over abundance of sweet food in my day, as these were easier to buy ‘ready made’ than savoury items.

What a great experience this has been! I have a greater empathy for our patients’ experiences and a real (albeit short) experience to hinge my advice and ongoing practice on. It has also been a great talking point amongst the team and brought out some interesting reflections, as well as some healthy competition and camaraderie. I’d highly recommend other SLTs to give it a go!

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Ben’s Puree Day

I am a Speech and Language Therapist and part of my job is to treat hospital patients who have difficulty swallowing food and drink. They don’t tell you THAT in “The King’s Speech”! My job is necessary because our food pipe and our wind pipe are right next to eachother (thanks evolution!) and our swallow mechanism, that stops food and drink from going down the wrong way, can fail. This mechanism is particularly vulnerable for elderly people and for people with medical conditions such as cerebral palsy, motor neuron disease, multiple sclerosis and stroke. One of the ways to help people swallow more safely is to modify their food and drink so that it is smoother, softer or thicker. This week each of my colleagues have volunteered to take up a challenge of eating the most modified diet (pureed food) and drinking stage 1 or syrup consistency thickened drinks. From this experience I wanted to answer three very important questions:

1) How easy/difficult is it to prepare a modified diet?

2) What does it feel like?

3) What happens when you put a Berocca in thickened water? (video below)

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Breakfast: Weird Liquid Breakfast Drink Thing, Thickened Coffee, Berocca (see video below) and Pureed Apple

1) Preparation

Buying and making one day’s worth of pureed food required time, lots of time, oh and a heck of a lot of washing up. For something to be a puree meal it needed to be thick and smooth, no lumps or chunks. This involves cooking your meal and then putting it in a blender and pressing “Go”. In order to stop everything turning into a brown sludge I tried to separate the colours, however this involved lots of pots and pans and lots of washing up. My evening meal took twice as long to make and half as long to eat (no time wasted on chewing!). It also felt very difficult to make sure I was having a balanced meal. I love to snack and pretty much all puree snacks are made of sugar (yoghurts, chocolate mousse, apple puree). Which wasn’t bad for a day, but after a week my colleagues wouldn’t appreciate my sugar highs and lows. Also for patient’s with diabetes I can imagine this being particularly difficult to manage.

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Lunch: Beef Stew, Mashed Potato, Carrots and Peas

When it came to thickened drinks I used scoops of Nutrilis Clear powder. It works a bit like corn starch except when you add it to water it stays almost completely clear. I will admit that I had a few failed attempts getting my drinks to the right consistency (it’s supposed to be like syrup or single cream) especially when making it in larger quantities. I made one drink just with water and one with lemon barley. I much preferred the one with barley in because somehow it seemed more natural for something flavoured to be more viscous, whereas thick water sounds like an oxymoron.

2) How it Feels

As I’m writing this now, the morning after, I do have a heavy sort of feeling in my gut. As with any dramatic changes in diet there are bound to be some sort of gastric consequence (of which I will spare you of the details). In summary, my experience… not that bad! I love food more than Trump loves Trump and I was expecting to hate this challenge. As I watched my gourmet meal being emulsified by a blender it broke my heart a little, but, you know what, it still tasted good! I really missed bread and I missed the crunch of an apple (okay, I really mean crisps) but I managed to find other things to fill me up. I think I struggled more with the thickened drinks because they had a way of making you feel full without actually quenching your thirst. I attempted two thickened coffees, the first went cold very quickly but the second was absolutely fine. It felt like drinking a slightly thicker latte! However, I must admit in my haste to leave work on a Friday afternoon, I mistakenly abandoned my thickener on my desk, so I unfortunately I didn’t get to experience thickened beer with my puree curry. Alas!

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Dinner: Lentil and Sweet Potato Curry, Saag and Mango Chutney

Things I learned

  • It’s easier if you’ve got support. Today it mine and my colleague Frieya’s turn and like Jill said in her blog, you can share your highs and lows. However, when I got home and my girlfriend was munching on popcorn and there was a freshly baked baguette on the counter it became a battle of self-restraint! It cannot be easy for patients and their families to adhere to a modified diet when so much of eating food is sharing the experience with others.
  • You need a good blender and a dishwasher. I spent a lot of time washing up. A lot.
  • Not everyone has a sweet tooth. I don’t and I found it difficult to find savoury snacks to eat throughout the day. If I can find a good savoury snack to assess patients with I will, so that they can have more of a choice.
  • And most importantly…

3) What happens when you put a Berocca in thickened water…?

You’re welcome.

Ben

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My ‘Puree tastic day’ by Jill

Blimey, it has been a ‘reyt proper eye opener’ as we say in Yorkshire. As a person who loves to talk, think about and most importantly eat food this has been a really interesting experience.

Thank you guys for coming up with the idea, and sorting out the pureed diet and thickened fluids challenge. I am really glad I had a try.  !

My day

Breakfast: I really missed my daily boiled egg, bread and  banana. I ate yoghurt, maple syrup and pureed fruit. I didn’t finish eating it! ! ! ! ! ! ! ! !

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I was hungry by the time I got on the train 30 mins later. I ate a coffee mousse. I then I had coffee breath and couldn’t have a mint!!!  !

I didn’t eat my usual snack, I ate at 1:30 I was rather peckish! I ate thick soup.

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However, this was a bit of a fail, you live and learn. Spicy butternut squash and sweet potato soup.
I drank stage 1 thickened fluids all day Rachel provided my drink for the multi disciplinary team meeting, this helped to spread the word. Thanks Rachel  !
After the meeting I ate another mousse and went straight to a group after work!

I got home late and ate pureed chickpea curry and pureed potato, my partner had prepared this for me. I added extra spicy sauces. I preferred the potato and got bored of the curry. I wondered if this is because it is more usual to have pureed potato  ! ! ! ! ! ! ! ! !

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I gave thickened hot chocolate a whirl!

I waited all day for my banana !!!  ! ! ! ! ! ! ! ! !

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My thoughts…….. !

• Pureed food takes so much blooming preparation. I hadn’t really considered this fully before. I am not surprised that it is hard to stick to long term.  !

• When you are out and about it is hard to find pureed snacks, it is mainly smooth yoghurt or er….. smooth yoghurt!

• I ate lots more processed foods and lived on mousse !! I missed fruit, savoury snacks and it cost me more money. It wasn’t me usual balanced diet !
• One size puree does not fit all, our blogs shows variety in choices and likes. I will bear this in mind when starting any oral intake with a patient. Does the person actually like yoghurts? Also, can we find savoury oral trial options? What are the patient’s food goals to aim for? !

• I found thickened fluids made my mouth feel slightly coated. It was easier to sip them over a period of time. I always thought that thickened juice was better than thickened water. However, I preferred thickened boiled and cooled water. It was more refreshing  !

• The experience is much easier with your work mates !!! We shared the highs and lows. People with swallowing difficulties are unlikely to have this support. They may be eating separate meals from family and friends. I think that support for people with swallowing difficulties from other people with swallowing difficulties would be good!

• I am a banana fan and I looked forward to my pureed banana all day !!! But I hated it pureed. The food you love may not be so great pureed. Experimenting with your food may be the key!

I have really valued this experience. Any experience which helps us to shine a bit of light into the daily experiences of people with swallowing difficulties is really useful  !

I hope to keep learning and questioning my clinical practice alongside my lovely SLT colleagues. I also hope to keep learning from the people with swallowing difficulties we support.  ! But, pureed banana never ever again!!!

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Oh dear, Helen’s turn

I was intrigued to see if I could successfully complete this challenge, Stage 1 fluids and Puree diet for the day. Motivated and inspired by my colleagues who had already completed the day and by the ones planning their meals etc for the remainder of the week. I am by nature a grazer and spend the majority of the day eating, mostly savoury foods. I have as anyone who knows me a strange relationship with food, the texture has to be correct and I struggle with boring food (possibly over sharing here).

I usually begin the day with a pint of water, I soon discovered that physically I couldn’t drink that quantity of stage 1 fluids and gave up at half a pint. Breakfast consisted of Ready Brek with smooth nut butter and a cup of coffee (tasted slightly more bitter than normal but ok)….so far so good.

A smoothie for mid morning followed by a lunch of blended butternut squash curry,(maybe I should have removed the spinach before blending) and mashed potato. I felt full to bursting point but strangely my hunger was not satisfied. I missed crunchy food!!! I managed to drink approximately another pint of fluid during the morning.

At this point it all fell to pieces. My stomach began to swell like a balloon and I felt decidedly uncomfortable. Apart from a drink of water (stage 1) I didn’t eat or drink anything else for the rest of the day.

I am glad I decided to undertake the challenge in spite of this. A few reflections for the day are as follows;

PRO’s

  • Empathy for the patients we work with daily
  • A feeling of being a part of a great SLT team (we’re all in this together)

CON’s

  • I did this for one day, the food was very dairy and sugar heavy, I craved savoury crunchy food
  • Social isolation, being unable to for example eat out at a restaurant or buy convenience food that wasn’t dairy or soup.
  • Preparation time, food prep took much longer and had to be thought out to ensure a balanced diet was achieved
  • My stomach rebelled, possibly due to lack of fibre
  • I WAS GRUMPY!!!!!!