PIP Activity 2: Eating and Drinking - Complete Scoring Guide

Activity 2 covers taking nutrition - cutting food, putting food and drink in your mouth and chewing and swallowing. This is PIP2 Question 4. This activity scores highest for people with swallowing difficulties, tremor, feeding tubes and conditions that make the physical act of eating difficult.

The Descriptors and Points

a. Can take nutrition unaided - 0 points.

b. Needs to use an aid or appliance to take nutrition, or supervision to take nutrition, or assistance to cut up food - 2 points. Adapted cutlery, non-slip mats, plate guards, two-handled cups, straws. If someone cuts your food for you, or has to watch you eat because of a choking risk or an eating disorder, this scores 2.

c. Needs a therapeutic source to take nutrition - 2 points. A therapeutic source means tube feeding (parenteral or enteral) using a rate-limiting device such as a feed pump, for example a PEG or NG tube on a pump that you manage yourself. Oral supplement drinks such as Ensure or Fortisip are not a therapeutic source.

d. Needs prompting to be able to take nutrition - 4 points. Someone has to encourage or remind you to eat or drink, meal by meal, because of an eating disorder, depression, dementia or a condition that removes appetite or the sense of hunger.

e. Needs assistance to be able to manage a therapeutic source to take nutrition - 6 points. PEG or NG tube feeding on a pump that another person has to set up, connect or manage for you.

f. Cannot convey food and drink to their mouth and needs another person to do so - 10 points. Someone physically feeds you or holds drinks to your mouth.

Conditions That Score on This Activity

Stroke (weakness affecting arm/hand), Parkinson's (tremor preventing use of cutlery), MS (fatigue, weakness, swallowing problems), motor neurone disease, cerebral palsy, severe arthritis (cannot grip cutlery), eating disorders (need monitoring), dementia (forget to eat), dysphagia (swallowing difficulties), gastroparesis.

What People Miss

If you need your food cutting up because you cannot use a knife and fork safely, that is descriptor b (2 points). Many people don't mention this because they think it's "normal" for someone to help. It is not - it is an indicator of disability that scores PIP points.

Supplement drinks (Ensure, Fortisip, Complan) do not score by themselves, because a therapeutic source means tube feeding on a pump. What can score is the reason you need them: if someone has to prompt you to eat or drink, meal by meal, that is descriptor d (4 points), and if someone has to supervise you while you eat, that is descriptor b (2 points).

What This Activity Actually Covers

This is about the PHYSICAL act of eating and drinking - cutting food, getting it to your mouth, chewing, swallowing - not about what you eat or your diet. If you have tremor that makes you spill, if you choke on food, if you can't use cutlery, if you need food cut up or pureed, if you need someone to prompt you to eat - all of this scores.

Tube feeding (nasogastric, PEG, jejunostomy) automatically scores highly on this activity because you cannot take nutrition orally in the normal way.

Conditions That Score on This Activity

Stroke causing swallowing difficulties or one-handed eating. Parkinson's tremor preventing use of cutlery. Dementia causing people to forget to eat. Eating disorders requiring supervision during meals. Gastroparesis requiring modified texture diet. MS causing swallowing problems. Any condition requiring a therapeutic diet under medical supervision.

Dysphagia (Swallowing Difficulty) - Detailed Scoring

Dysphagia is one of the strongest reasons to score on Activity 2. Different presentations:

• Modified diet (soft/pureed): If you need food cut up small or pureed, you score descriptor b minimum. If you cannot eat normal-texture food at all, often descriptor c.
• Thickened fluids: Many dysphagia patients use thickener (Nutilis, ThickenUp) in drinks. This is therapeutic and supervisory - scores under descriptor b or c.
• Recurrent choking: If you choke regularly, your eating is unsafe - reliability test failed. Score b or higher.
• Need supervision while eating: Many dysphagia patients need someone present in case of choking. Scores under descriptor b or c.
• NG tube feeding (short term): Scores descriptor e or f.
• PEG/RIG tube feeding (long term): Scores descriptor f (10 points).
• TPN (intravenous nutrition): Highest impact. Almost certainly enhanced rates.

Conditions Commonly Causing Activity 2 Impact

• Stroke: Dysphagia very common acutely; persistent in around 15% chronically
• Motor neurone disease: Progressive bulbar involvement leads to dysphagia and tube feeding
• Parkinson's disease: Tremor affecting cutlery; bulbar symptoms in later stages
• Multiple sclerosis: Dysphagia in 30-40% of MS patients at some point
• Dementia: Later stages - forgetting to eat, swallowing difficulties, often PEG decisions
• Cerebral palsy: Oral motor control affected from childhood
• Head and neck cancer survivors: Post-surgery/radiotherapy dysphagia, often permanent
• Eosinophilic oesophagitis: Causes food impaction, strict elimination diet
• Achalasia: Oesophageal motility disorder. Need special positions and diet.
• Severe arthritis: Cannot grip cutlery, needs adapted cutlery
• Severe tremor (essential tremor, Parkinson's): Cannot use cutlery without spilling
• Hemiparesis post-stroke: One-handed eating, food cutting needed
• Eating disorders: Anorexia, bulimia, ARFID - may need supervision and supplements

Specific Aids and Their PIP Significance

Using any of these scores descriptor b (2 points) at minimum:

• Weighted cutlery (for tremor)
• Built-up handles on cutlery (for grip)
• Plate guards or scoop plates
• Non-slip mats under plates
• Two-handled cups, beaker cups, straws
• Universal cuff for holding cutlery
• Drinking aids (Provale, hydrant systems)
• Bib or apron to protect clothing
• Tube feeding equipment (pumps, syringes, extension sets)

Dietary Supplements - When They Score

Prescribed supplement drinks (Ensure, Fortisip, Complan, Scandishake, ProSource) are not a "therapeutic source" under the regulations, which define that term as parenteral or enteral tube feeding using a rate-limiting device such as a feed pump, so the supplements themselves do not score. They are still strong evidence. Use them to show why you cannot manage food and drink unaided: "I am prescribed Fortisip twice daily because I cannot eat enough regular food due to [reason]. My partner has to remind me to drink each one and sit with me until it is finished, and without that I lose weight." That describes prompting (descriptor d) or supervision (descriptor b), and it is the prompting or supervision that scores, not the drink.

Weight Loss and Malnutrition as Evidence

Unintended weight loss is powerful evidence. Document:

• BMI changes (especially if under 18.5 or rapid drop)
• Recent weight loss as percentage of body weight
• Dietitian assessment scores (MUST score 2+ indicates high malnutrition risk)
• Albumin or prealbumin blood levels if low
• Sarcopenia diagnosis if assessed

Frequently Asked Questions

I skip meals because of depression. Does that count?

If someone needs to prompt or remind you to eat, you score under this activity. Depression that removes all motivation to eat means you need prompting - "My partner has to tell me to eat and bring food to me. Without prompting, I would go the entire day without eating on at least 3 days per week."

I use a straw for all drinks - is that an aid?

Yes. If you need a straw because you cannot drink reliably without it (tremor, weakness, swallowing concerns), this is an aid scoring descriptor b (2 points). Adapted drinking aids like Provale cup (only releases controlled amount of liquid) similarly score.

I have an eating disorder - what should I claim?

If someone has to supervise you at meals, that is descriptor b (2 points); if they have to prompt you to eat at all, that is descriptor d (4 points). Supplement drinks do not add points on their own. If the eating disorder has led to tube feeding on a pump, descriptor c or e applies depending on whether you can manage the tube yourself. List the eating disorder formally with the psychiatric diagnosis.

What if I have severe nausea most days?

If nausea prevents you from eating reliably, mention it. What scores is the help you then need: someone prompting you to eat and drink, meal by meal, is descriptor d (4 points), and someone supervising you while you eat is descriptor b (2 points). Weight loss, prescribed supplements and dietary changes are the evidence that backs this up. Causes include chemotherapy, severe IBS, cyclical vomiting syndrome and gastroparesis.

I cannot eat in public because of anxiety - does that score?

Social anxiety affecting eating typically scores under Activity 9 (engaging with others) rather than Activity 2. However, if you cannot eat enough at home alone either (severe avoidance), you may score under c.

My dietitian put me on a strict elimination diet - does that count?

Not under this activity on its own. Activity 2 is about the physical act of taking nutrition, so a special diet scores here only if it means someone has to prompt or supervise you at meals. A dietitian-prescribed diet that someone has to help you follow at home may count as therapy under Activity 3 instead, and the time spent preparing special food belongs under Activity 1.

I have a feeding tube but use it only at night - what do I score?

Overnight tube feeding on a pump is a therapeutic source. If you set up and manage the feed yourself, that is descriptor c (2 points); if another person has to connect, set up or manage it for you, that is descriptor e (6 points). Descriptor f (10 points) is for someone who cannot get food and drink to their mouth at all and needs another person to feed them, whether or not a tube is involved.