There is more to eating than what someone ingests. Eating is important for obtaining nutrition, and eating usually also holds strong personal meaning for us. Ensuring that a loved one eats is an opportunity to express our care for them. Eating "a hearty amount" also symbolizes good health and good mood. This is why family members and close friends can feel especially distressed when they see a loved one eating less and less.
If a loved one is eating less over time, consider first having them evaluated by their primary care physician (PCP) or closely following specialist to determine if there is a potentially fixable cause such as
· uncomfortable constipation
· diarrhea and/or bloating (which may cause some people to scale back on their eating in an attempt to decrease the diarrhea)
· stomach cramping pain
· heartburn or acid reflux discomfort
· difficulty swallowing with "choking," "gasping," or "coughing" with each swallow, whether it be solids or liquids
· sensation of food feeling "stuck" at the chest area
· ill fitting dentures and difficulty chewing
· change in taste (though this is sometimes difficult to "fix")
· mouth pain from ulcers, thrush, mucositis, or other reason
· any uncontrolled uncomfortable symptom such as persistent severe pain, persistent severe shortness of breath, or severe fatigue
· an untreated depression, thryoid disease, or any other medical disorder
· medication side effect
· financial or physical inability to obtain groceries, which the person may feel too embarrassed or ashamed to admit
· physical or mental inability to prepare meals, which the person may feel too embarrassed or ashamed to admit.
Sometimes a loved one eating less is not due to a fixable cause and rather due to worsening illness. Family members and other caregivers may feel helpless as the situation worsens, frustrated with their loved one for not "making more of an effort," rejected or dismayed when their loved one only takes a couple bites of a specially prepared meal, and/or fear of what eating less and worsening health could signify. These feelings may manifest as conflict with their loved one, who may already be trying their best to eat as much as possible to satisfy their family's demands.
The distress may be exacerbated if family members and other caregivers do not know that this loss of appetite, eating less, and losing weight is unfortunately, a normal manifestation of their loved one's worsening illness or disease.
Modern medicine can offer many interventions, however it does not currently have an effective pill that can halt this aspect of nature's taking its course. Only after speaking with your loved one's healthcare providers could the following potentially be considered:
· an appetite stimulant - There are a variety of medications that could be trialed in an attempt to increase appetite, each with its own set of potential side effects. Keep in mind, if an appetite stimulant initially helps, it will still lose its effectiveness as a person's underlying illness worsens.
· a dietician or nutritionist referral - A dietician consultation often includes a nutritional status evaluation (which may include recent changes in weight, current amount of food intake, current activity level, any potentially contributing symptoms to decreased eating, underlying diseases, and physical exam). A dietician may be able to offer helpful information, tips, and recipes to encourage your loved one's caloric intake.
· liberalization of diet - Some people with heart disease, diabetes, and kidney failure may be used to certain diet or fluid restrictions, which they may have to continue to keep their disease symptoms under control. For example, a person with severe congestive heart failure suddenly ingesting more sodium via take out could end up with uncomfortably heavy, swollen legs from fluid retention. At other times, one may discuss with their primary care physician or specialist whether diet restrictions are still helpful or necessary. This may be the person whose prognosis is months and therefore sticking to a fat and cholesterol restricted diet to minimize risk of heart attack over the next decade no longer makes sense. This may be the person with diabetes who has unintentionally lost 30 pounds from severe dementia and whose blood sugars are so low that they no longer need diabetes medications. Perhaps their diet could be liberalized to include more of the carbohydrates that they used to avoid. At some point, comfort and taking pleasure in certain tastes may become the greatest priority as restrictions fall by the wayside.
The following are additional suggestions for encouraging a frail loved one to eat more:
1. Offer small meals five times per day at the same time each day to establish a routine. A large plate can seem overwhelming and turn someone off of eating altogether.
2. Consider the texture your loved one prefers (soft foods or even liquid foods), the smell (some may prefer bland foods without a strong odor whereas others may prefer more strongly flavored foods), and the ability of your loved one to use utensils (finger foods might be more encouraging if the use of utensils has become difficult).
3. Keeping in mind that every bite or sip counts, offer foods that are high in calorie or protein per bite or sip.
4. Sit with your loved one to eat, engaging them and encouraging them to eat. Sometimes people tell me (read Post 1: What Exactly Does a Palliative Care Specialist Do?) that they forget to eat or do not care to eat because they feel bored or lonely eating by themselves, and their children tell me that their parents eat much more when they are eating with someone at the table.
5. Keep water/fluids easily accessible at all times to encourage hydration. If a loved one does not like the taste of water, consider flavoring it. If a loved one has difficulty remembering to drink water, consider associating taking a sip of water with a routine such as taking a sip every time they see a commercial on TV. Consider helping your loved one keep track by marking on a water bottle how much they should drink by a certain time each day (for example, half of a 16 ounce water bottle by the end of breakfast, the second half by the end of lunch, and at least half of another by the end of dinner).
6. Keep preferred snacks at an easily reachable distance throughout the day.
7. Offer high calorie liquid supplements in addition to actual meals, perhaps as the fluid to drink with meals or as a snack between meals. People can make their own high protein, high calorie smoothies or shakes at home. They can purchase fruit, vegetable, and/or nut based shakes and smoothies, though these can be expensive for daily use. Some people attempt vitamin-fortified shakes specifically designed to contain increased calories and protein such as Boost, Ensure, or Glucerna. There may come a time when a person cannot eat much and the supplement becomes a meal replacement rather than a supplement.
8. Reframe "eating," and realize that at some point in a loved one's notably declining health that eating may be more about socially connecting and enjoying and less about obtaining nutrition and striving to hit a certain number of calories. A loved one not eating is not due to anyone's fault and realizing this may help alleviate both the caregiver's and their loved one's distress over this struggle.
In conclusion, if a loved one is eating less and losing weight over time, work with your loved one's healthcare providers to determine if there is a fixable cause for this. If not eating is due to progressing illness, worsening disease, and declining health, consider asking for a dietician or nutritionist evaluation if available. Finally, at some point we may have to accept that eating is more about comfort, joy, pleasure, and bonding than about regaining strength, stamina, energy, and alertness (read Post 26: A Cloudy Crystal Ball - Predictors of Prognosis Part 2 of 3).
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