This week (23rd-27th April 2019) is Experience of Care Week, a global initiative which celebrates work happening across health and social care to improve the experiences of care for patients, families and carers.
Carers play an important role in encouraging the person that they care for to eat and drink well. Not getting enough nutrition or eating a limited diet can hinder recovery from illness and put a person at higher risk of malnutrition (1). A recent survey by Carers UK found that 6 out of 10 carers worry about what the person they’re caring for is eating (2). Carers play a significant role in helping the person that they care for to meet their nutrition and hydration needs, however they need to have sufficient nutritional knowledge to do so.
In this article, we discuss the importance of dietitians engaging with carers in relation to nutrition support.
A team approach:
We often talk about the benefits of a multi-disciplinary team approach in the clinical setting, whereby healthcare professions from different fields work together to deliver treatment or improve patient care and outcomes (3).
But what about the carer? After all, they are often the ones who know the patient best. Involving the carer, and of course the patient, in the dietetic care process is important, as a person-centred healthcare service supports people to make informed decisions about their own health and care (4). The carer might be able to offer invaluable information about food preferences and special dietary requirements, meaning that the dietetic care plan put in place is acceptable and relevant to the patient.
Similarly, the carer might be the first person to notice a change in appetite, food habits or body weight in the patient. They can play a crucial role in identifying malnutrition, and explaining some of the signs of malnutrition to look out for may be useful. BAPEN have designed an online simple malnutrition assessment tool for carers to assess whether the person being cared for has or is at risk of malnutrition.
Challenging nutritional beliefs:
Carers may have deeply engrained ideas and beliefs about nutrition or healthy eating. You may need to gently explain to carers how typical “healthy eating guidelines” are not necessarily applicable to someone who is malnourished or at risk of malnutrition. For example, you might need to explain the importance of eating “little and often”, having regular and energy-dense meals and snacks and switching from the “low fat” or “low calorie” mind-set to full fat and high calorie equivalents such as whole milk, butter and double cream. Similarly, nutrition misinformation may need to be addressed or corrected in a supportive and non-judgmental way.
Implementing nutritional interventions:
Ultimately, dietary interventions (such as oral nutritional supplements or food fortification techniques) are only effective if they are implemented. Hence, it’s important to educate the carer about the reasoning behind the nutritional interventions. Having a carer who is knowledgeable, informed and on-board will help to ensure that the dietary interventions are carried out at home, therefore helping to meet the patient’s nutritional goals.
Compliance rates for oral nutrition supplements are highly variable with one systematic review reporting compliance rates of 37 to 100%, with highest compliance with high-energy sip feeds (5). Carers play a key role in encouraging patients to take their supplements, and you could encourage them to implement a variety of techniques to increase compliance, such as chilling or warming the supplements; or mixing with foods such as soup, breakfast cereal or desserts, for example, custard or rice pudding. Varying the flavour and offering variety by using whole milk or perhaps different fruit juices to mix powdered ONS can also help.
If the carer struggles to leave the home to collect prescriptions, you could encourage them to make use of the NHS Electronic Prescription Service, which delivers prescriptions to the patient’s door. Similarly, most nutritional supplement companies such as Nualtra offer a home delivery service, which dietitians can setup for their patients online.
It’s not just about the patient:
Showing empathy and an understanding of how caring impacts on the health and wellbeing of carers is important too. A 2018 survey of nearly 7,000 carers in the UK by Carers Week found that almost three quarters (73%) providing care said they suffered mental health issues such as stress or depression because of caring for others (6).
Carers often put their needs last, however eating a balanced diet will help them to stay strong and healthy, giving them enough energy to provide the best care for the person they are looking after. This is particularly important if they are elderly or have a medical condition themselves.
Simply asking the carer whether they are eating well will enable them to feel listened to. If they require help with their diet, there are an abundance of online resources by charities and hospital trusts on healthy eating, eating on a budget, and eating well as a carer, which are listed at the end of this article.
Working within constraints:
A review by Age UK in 2014 found that 1.6 million pensioners are in relative poverty, defined as having incomes below 60% median income after housing costs (AHC) in 2011/12 (7). Moreover, over a million emergency food supplies were given to people in financial crisis by the Trussell Trust Food Banks in 2017-2018, a 13% increase on the previous year (8).Therefore, your dietary advice might need to consider these wider socioeconomical factors.
If the spouse of the carer was previously the main household cook, the carer might lack basic cookery skills. Many local organisations and charities deliver free cookery courses to carers. As an example, Derbyshire County Council provide free cookery courses to people who would benefit from learning how to cook healthy meals and save money with their weekly shop. The delivery of the sessions can be varied to meet the needs of the group, and suitable individuals are offered six two-hour cookery lessons. Some local carer services provide free cookery courses and you can check what’s available in your local area here.
If a carer is elderly or struggles to prepare meals, you could suggest that they consider a meal home delivery service such as Wiltshire Farm Foods or utilise online food shopping and delivery services. Some local council and organisations may be able to provide home delivered meals such as Meals on Wheels. You can check eligibility your patient’s eligibility here.
Finally, patients with conditions such as Parkinson’s or MS sometimes experience difficulties with fine motor skills, and therefore struggle to hold a knife and fork (9). Connecting the carer and patient with an Occupational Therapist will enable them to find suitable tools and strategies to overcome these difficulties.
In conclusion, carers play a central role in meeting the nutrition and hydration needs of the people that they care for; however, it can place additional stress and burden on them. A collaborative approach which involves the dietitian, patient and the carer is essential for addressing potential barriers to eating and drinking well for both patient and carer.
Useful Online Nutrition Resources for Carers:
- Webpage by Carers UK on Eating Well for Carers
- Webpage by NHS on How to Feed Someone you Care For
- Video by British Heart Foundation onHealthy Eating on a Budget
- Directory for local cookery classesby Carers Trust
- Webpage by NHS on Eating Well for Less
- Webpage by Carers Trust on Online Food Shopping
- Leaflet by Malnutrition Taskforce onEating Enough in Later Life (Advice for Carers)
- Government directory and eligibility criteria for Meals on Wheels
- Online Malnutrition Screening Tool by Bapen
- Private meal delivery service by Wiltshire Farm Food
- Gandy, J. Manual of Dietetic Practice, chp. 6.2 Malnutrition(2014).
- Carers UK. Spotlight on Caring and Nutrition. Available at: file:///Users/tympeny/Downloads/ukreport-caring-and-nutrition%20(2).pdf
- NHS England. Multi-disciplinary Team (MDT) Development (2014). Available at: https://www.england.nhs.uk/publication/making-it-happen-multi-disciplinary-team-mdt-working/
- Barry, M. J. & Edgman-Levitan, S. (2012) Shared Decision Making — The Pinnacle of Patient-Centered Care. New England Journal of Medicine. [Online]
- Hubbard, G. P. et al. (2012) A systematic review of compliance to oral nutritional supplements. Clinical Nutrition
- Carers Week. Supporting Carers to be Healthy and Connected (2011). Available at: https://www.carersweek.org/images/Resources/CW18_Research_Report.pdf
- Age UK. (2014). Age UK Evidence Review: Poverty in Later Life. Available at: http://www.futureyears.org.uk/uploads/files/Age%20UK%20on%20poverty%20in%20old%20age.pdf
- The Trusseell Trust. End of Year Stats for 2017-2018 (online). Available at: https://www.trusselltrust.org/news-and-blog/latest-stats/end-year-stats/
- Dahdal, P. et al. (2016) Fine motor function skills in patients with Parkinson disease with and without mild cognitive impairment. Dementia and Geriatric Cognitive Disorders. [Online]