Induction Training. Nutrition. Next. Back. Home. Welcome…. Welcome to this web based information session on Nutrition. It should take you approximately 20 minutes to complete this material. How to use this pack To go to the next page, please click the button.
Welcome to this web based information session on Nutrition. It should take you approximately 20 minutes to complete this material.
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By the end of this session you will have knowledge of:
What good Nutrition is
Different Nutrient groups
The Balance of good health
The effects of malnutrition
Nutrition requirements for older People
Nutrition requirements for older People with Dementia
Nutrition requirements for people with Learning Disabilities
Nutrition requirements for children and Young people
Nutrition is an important subject for all of us but maybe even more so for the service users we work with. Mealtimes are important parts of the day in the lives of service users whether they are older people in Residential Homes or younger people cared for in their own homes.
Good food is necessary for a person’s well being and this applies in equal measures to the nutritional values that keep us healthy as well as the pleasurable experiences that food give us.
When working with service users your role will be to raise awareness of the importance of nutrition in older people, vulnerable adults as well as children and young people.
So how much do you know about nutrition already? You’re probably aware of your 5 a day fruit and vegetables, not too eat too much fast food and drink plenty of water. But how are nuts good for us if they are really high in calories and which vitamins does the body need?
First let’s have a look at the 5 food groups that we consume:
Fruit and Vegetables
Bread, Rice, Potatoes and Pasta
Milk and Dairy Foods
Meat, Fish, Eggs and Beans
Foods and Drinks high in fat and/or sugar
We can eat foods from each of the groups, but this should happen in the proportions indicated in the chart below.
A variety of foods is the key to good nutrition, therefore, it is important that all the food groups on the previous page are included in meals. This doesn’t have to happen for every meal, but should happen over the course of a day. Click the Show Me arrows for information on these groups.
Fruit and vegetables
Eat at least 5 portions a day. Overall this should make up 1/3 of your daily food intake and can be used as healthy snacks.
Bread, Rice, Potatoes, Pasta
This group is called carbohydrates and should also make up 1/3 if your diet. Unrefined carbohydrates i.e. wholegrain foods are rich in fibre and better for you than refined foods such as white bread.
The next three groups should make up the final third of your diet.
Eat or drink in moderate amounts as they have a high saturated fat content but are also an important source of calcium.
Milk and dairy foods
Foods and drinks high in fat and/or sugar
Eat only small amounts of foods containing fat and sugar, as they are ‘empty’ calories, i.e. they are high in energy but low in nutrients. These can be regarded as occasional treats.
Meat, fish, eggs and beans
Eat moderate amounts of these. This food group includes both animal and plant sources of protein, which is needed for cell growth and repair.
Over the next few pages we will have a look at the different nutrient groups to help you understand their values.
Carbohydrates provide energy and is the term used to describe both starch and sugar in food. Starch is the main component of cereals, pulses, grains and root vegetables. The term ‘sugar’ is often assumed to describe something white and granular found in
sugar bowls, but in fact the sugars found in foods can be quite variable and include sugars found naturally in foods such as milk, vegetables and fruits.
Examples of the food that contain carbohydrates are:
All types of bread and rolls
Chapattis and other flat
Rice and other grains
All types of pasta and
Milk sugars (lactose)
Cakes & Biscuits
This is food material from cereal and vegetable foods which is not broken down in the small intestine of humans and is essential for maintaining a healthy digestive system. Fibre is important to prevent constipation and other bowel disorders. Some types of fibre known as soluble fibre are important for lowering blood cholesterol levels.
Fibre is contained in
Wholemeal bread , Wholegrain breakfast cereals,
Pulses (peas, lentils and beans – including baked beans,
kidney beans and butter beans), Dried and fresh fruit and
Soluble fibre is found in fruit, oats and beans and pulses.
Protein is needed for growth and the maintenance and repair of body tissues. From hair to fingernails, protein is a major functional and structural component of all our cells.Proteins are large molecules made up of long chains of amino acid subunits. Some of these amino acids are nutritionally essential as they cannot be made or stored within the body and so must come from foods in our daily diet.
Protein is contained in
Milk, Meat, poultry and fish, eggs, cheese, Tofu, Pulses such as
peas, lentils and beans (including baked beans), nuts and seeds,
Cereal foods such as bread and rice.
It is important to get enough different vitamins and most people should be able to get all they need by eating a varied and balanced diet. Some vitamins are mainly found in animal derived foods, whereas others come from plant foods. Vitamins fall into two groups:
Vitamin A, D, E and K
These are stored in the body.
Vitamin A in food can be
destroyed by heat or by
oxidation if left exposed
to the air.
B vitamins: thiamin, riboflavin,
niacin, B6, B12, folate and
These are not stored in the body
and are water soluble, so they are
more likely to be destroyed by
heat or by oxidation if left
exposed to the air.
Fat provides the most concentrated form of energy in the diet. It provides 9kcals per gram of fat, compared with 4kcals per gram for protein and carbohydrate.
Do you know what the types of fat are that are found in food sources?
which are found mainly in plants and fish, also including monounsaturated fats and polyunsaturated fats.
which are mainly from animal sources.
which are found mainly in manufactured foods that use hydrogenated oils.
Although we all try to avoid eating too much fat, some fat in the diet is actually essential because fat-soluble vitamins – vitamins A, D, E and K – cannot be taken up by the body otherwise.
However, diets that are high in total fat and saturated fat are associated with high blood cholesterol levels and this is a major risk factor for coronary heart disease. It is best to use unsaturated fats in cooking and as spreading fats, and to cut down on the amount of food that is high in saturated fat.
Let’s have a look at some examples of foods containing these different types of fat.
Olive oil &
Nuts and seeds
Some margarines and
spreads are made
Corn oil, sunflower
oil and soya oil
Nuts and seeds
(walnuts, pine nuts,
and spreads are
Oily fish such as
salmon, trout and
Fat in meat and poultry
(such as sausages, processed
meats and meat pies)
Coconut oil and palm oil
Some pastries, cakes, biscuits,
crackers, deep-fried foods,
take-away foods and
ice cream desserts.
Foods that have
‘hydrogenated oils’ or
‘hydrogenated fat’ in
the list of ingredients
are likely to contain trans fats.
We’ve already discussed that healthy eating means getting the balance right between all the food and nutrient groups. In addition to that, water is an important component of healthy eating.
Water makes up about two-thirds of our body weight. And it's important for this to be maintained because most of the chemical reactions that happen in our cells need water. We also need water for our blood to be able to carry nutrients around the body. So how much should we drink? The Food Standards Agency says:
In climates such as the UK, we should drink approximately 1.2 litres (6 to 8 glasses) of fluid every day to stop us getting dehydrated. In hotter climates the body needs more than this.
Some people don’t particularly like plain water, so if you come across any service users like that what do you think you could encourage them to drink instead?
Sparkling water – it has a little more taste than plain water
Water with a little fruit juice or squash for taste
Add a slice of lemon or lime to the water to brighten it up
Fruit Juice or Fruit Smoothies
Tea or Coffee – however, caffeinated drinks act as diuretics, which mean the body produces more urine and through that loses fluids again. It’s important that caffeinated drinks aren’t the only source of fluids.
Finally, to achieve a balance of good health we need to add exercise to the list.
Our energy needs are based on a) our Basal Metabolic Rate (BMR) which is the basic energy requirement to keep our bodies functioning, and b) our levels of physical activity. People who are not very active have much lower energy needs and therefore will need less food to maintain their body weight. This means that it may be harder to include all the nutrients needed for good health.
On the other hand, people that are inactive but don’t alter their level of energy intake are at risk of being overweight or obese. This can lead to a number of health complications such as coronary heart disease and diabetes and often means that they have reduced energy levels.
We’ve just seen why exercise is such an important component to healthy eating and general well being, therefore, everyone should be encouraged to take exercise. Of course some of the service users you look after may be very frail or may be wheelchair users, but even then, anybody that can do a little walking should be encouraged to do so and wheelchair users can be encouraged to move their arms or legs if they are able to do so.
Let’s have a look at what the effect can be if a service user doesn’t have all their nutritional needs served. Malnutrition is a real danger and can often go unnoticed because service users themselves and their families don’t have much knowledge about it.
Malnutrition can contribute to a wide number of health problems in older people. Do you know what those are?
Constipation and other digestive disorders
Muscle and bone disorders, including osteoporosis, osteomalacia and osteoarthritis
Coronary heart disease and stroke
Constipation is most common among old and frail people, especially if they don’t get enough exercise, have difficulties in moving and getting about or are confined to bed. It can be caused by not getting enough fluids, not getting enough fibre and sometimes as a side effect of medication.
Therefore, it is important to encourage service users to drink approx. 6-8 glasses of fluids a day. You should also watch out for service users who have chewing difficulties, no teeth or poorly fitting dentures, as they tend to be the ones not getting enough fibre. We have already covered the types of food that include fibre earlier in the module.
This is caused by low iron levels and can cause paleness, tiredness, breathlessness on exertion and palpitations. People with anaemia may also be more prone to infections. In a large American study, low iron levels were shown to be a predictor of death from all causes, particularly coronary heart disease among men and women over 70 years.
Corti MC, Guralnik JM, Salive ME et al. 1997. Serum iron level, coronary heart disease and all cause mortality in older men and women. American Journal of Cardiology; 79: 120-27
It is possible that anaemia is caused by internal disease, however, if this reason has been excluded then service users should be encouraged to eat iron rich food such as liver, kidney, red meat, oily fish, pulses and nuts as well as folate rich foods such as green leafy vegetables, citrus fruit, fortified bread, breakfeast cereals and yeast extract to combat anaemia.
It is estimated that between 7% and 10% of elderly people in residential and nursing care have diabetes. A healthy diet including plenty of fruit and vegetables, less fat, especially saturated fat, less sugar and more fibre will go a long way towards treating this illness. For further information on Diabetes, please complete the Diabetes eLearning module.
Muscle and Bone disorders
As well as a healthy diet, physical activity is needed to maintain bone and muscle strength and preventing falls. Also, Vitamin D will help with this and the main source of vitamin D for most people is that formed in the skin by the reaction to sunlight. Therefore, do encourage service users to spend time outside on a nice summer’s day.
People that are overweight or obese may be restricted in their movement, resulting in the muscle and bone disorders mentioned previously. Also, if they have been advised to lose weight by reducing their food intake, they may be at risk of not getting enough nutrients. Any specific eating plans should be drawn up by a professional, but you can still encourage them to follow the principles of healthy eating.
Coronary heart disease and stroke
Forty per cent of all deaths among over-65-year-olds are caused by
coronary heart disease or stroke! This is specifically connected to high blood pressure and high cholesterol levels, both of which can be improved through a healthy diet.
Coronary heart disease and stroke … continued
Evidence shows that increasing fruit and vegetable intakes by 1-2 portions a day may decrease cardiovascular risk and increasing intakes of oily fish has also been shown to reduce cardiovascular death.
Gillman MW, Cupples LA, Gagnon D et al. 1995. Protective effect of fruits and vegetables on development of stroke in men. Journal of the American Medical Association; 273: 1113-17.
Department of Health. 1994. Diet and Cardiovascular Disease. London: HMSO.
Therefore, you may have a significant positive impact on your service users through encouraging them to eat more fruit, vegetables and fish and also more starchy foods such as bread. Some older people may have a very small appetite and should be encouraged to eat whatever foods they can, but if they have a good appetite you should encourage them to limit their intake of saturated fats as well as salt. Where more flavour is needed it may be possible to add herbs, spices, lemon juice, mustard, onions and celery instead of just salt.
Finally, there is evidence that good nutrition helps older people to recover better from operations and illnesses. Your service users may need to undergo surgery and good nutrition has been shown to play an important part in the prevention of complications such as infection and to assist in the healing process.
As you can see encouraging your service users to follow a healthy diet and helping them to make good choices is likely to have a very positive impact on their well being and health.
Let’s have a look now at some of the service user groups that may be at risk of malnutrition because of their special conditions.
As people get older their bodies change and this can affect the intake, digestion, absorption and utilisation of nutrients. A lot of the older people you look after also take medication, which can equally have an impact on this.
It is quite normal for people – of any age – to eat less food if their calorie requirements fall. However, at very low levels of calorie intake, there is a greater possibility that the level of intakes of some nutrients in the diet will become dangerously low. This can lead to muscle loss, weakness and a further decrease in activity generally. Weak muscle power can make some older people feel unsteady on their feet, and fear
of falling may deter them from trying to be more active.
Malnutrition is a very real concern for older people and includes both undernutrition and overnutrition. However, in residential care there tend to be more underweight than overweight people and in old age being underweight poses a greater risk to health.
The National Diet and Nutrition Survey (NDNS 1998) of people aged 65 years and over found that 3% of men and 6% of women living at home were underweight, while comparable figures for those in residential care were 16% and 15% respectively.
Given these figures it is important that you are aware of the things that can negatively impact somebody’s appetite or ability to eat, watch out for them and alert the relevant people where necessary.
One common area where problems can occur for a service user is in their mouth. Older people should continue to have check-ups annually to identify potential problems, whether or not they have natural teeth.
How to you think mouth and teeth can be affected by age?
Taste buds are lost leading to diminished taste perception
Salivary glands become more fibrous, this leads to dry mouth and increased potential for decay
The tongue enlarges which may affect chewing
Tooth pulp deteriorates
Gum disease is common leading to inflammation and exposed roots, also there is poor bone support
Dentures may be ill fitting
Dysphagia, i.e. difficulty swallowing, often occurs after a stroke, throat and mouth cancer or gastro-oesophageal reflux disease (GORD) which is a condition where stomach acid leaks back up into the oesophagus. It is estimated that 30-40% of elderly people staying in nursing homes have some degree of dysphagia!
People can range from having no swallow reflex at all, to managing modified textures of food. It is often easier to control the swallowing action with foods that are of a smooth, thick consistency rather than liquids e.g. mashed potatoes with gravy or thick custards.
Where the swallow reflex is completely lost or if someone is unable to manage sufficient nutrition, they may be fed using a special tube down their nose into their stomach (nasogastric) or directly into their stomach (gastrostomy).
A high number of the elderly service users you will be looking after will be ones suffering from Dementia. Dementia causes cognitive changes, such as forgetfulness as well as neurological changes, such as slowing of movements, which can lead to a decrease in muscle tone and poor balance.
Dementia can cause physical, physiological and emotional changes in a person and all this can have an impact on their eating habits. The next pages will explore these.
All of the points of the previous page may have a negative impact on the eating habits of people with Dementia. Sometimes medication can also hinder a person to eat by making them too drowsy.
Some less common behaviour patterns can include service users insisting on the same food at every meal, refusing food because they
don’t believe they can pay for it, hoarding food in the mouth but not swallowing it, not chewing food, spitting food out or asking for unusual food choices. Part of your role will be to help service users make good choices, reassure them and encourage them to eat and eat a healthy diet.
Make sure service users with dementia have enough time to eat.
Maintain eye contact and don’t talk to somebody else whilst offering food to your service user.
Encourage dementia patients to keep their independence as long as possible. If you do need to assist them, treat them with dignity and respect.
Give small mouthfuls and adequate time to swallow each mouthful before continuing.
Make sure the eating environment is calm and quiet.
Use verbal prompts, talk about the food you’re offering.
Offer a variety of food. There is a common misconception that people with dementia find choice too confusing, but with your help and support they they may be able to make choices.
Sensory cues may help, this can include the sights and smells of food preparation or picture cards.
People with dementia may need specialist cutlery to help them.
We’ve have just had a detailed look at older people and older people with dementia, but that may not be the only group of service users you look after. Let’s now move on to looking at people with Learning Disabilities, this will include both children and adults.
Of course, the general principles of healthy eating apply to this group in exactly the same way as any other group, however, people with learning disabilities have their own unique characteristics and challenges, so it is worth exploring those here.
Let’s first have a brief look at how Learning Disabilities can affect different aspects of people’s lives. For further information on Learning Disabilities, please complete the Learning Disabilities eLearning module.
Learning Disabilities range from mild to severe and at the severe end of the spectrum people may find most tasks associated with daily living impossible to carry out without assistance, and may well have a number of physical and health difficulties which impact on their quality of life.
Communication– Communicating thoughts and feelings can be difficult and frustrating for people with severe learning disabilities. The person may not be able to talk clearly and communication may be by signing (eg. Makaton) or through other forms of non-verbal communication such as gestures, body language, facial expressions or by using resources such as Talking Mats. In addition the person may not be able to understand speech unless very simple language and short sentences are used.
Challenging behaviour– People with severe learning disabilities may show aggressive, disruptive or socially unacceptable behaviours and may have little or no sense of danger. Such behaviour may well be an expression of an underlying problem such as pain or distress.
Physical difficulties– restricted mobility, motor skills, posture, wallowing, chewing and eating difficulties may make simple tasks of daily living difficult.
Illhealth– People with severe learning disabilities are more likely also to have other physical and mental health difficulties which impact on daily life such as epilepsy, autistic spectrum disorders, sensory impairments, gastrointestinal disorders (problems with the digestive system) and respiratory problems.
You can probably already see from the list how some of those difficulties can impact on eating habits. How do you think this impact manifests itself?
Faddy and selective eating
Inability to correctly use knives, forks, cups etc
Difficulty getting food onto utensils
Hoarding, hiding or throwing food
Wandering or restlessness during mealtimes
Distress at changing routines
You may meet service users with learning disabilities that also have eating disorders, as these have been reported to be more prevalent among this group compared with the rest of the population.
In a project carried out for people with learning disabilities in South London, 13% were found to have binge eating disorder and about 1% anorexia nervosa. The causes of eating disorders are complex and poorly understood, but among people with learning disabilities they have been associated with being younger, having reported abuse, having poorer social networks, having difficulties with eating and drinking, and having other behavioural disorders. If you notice any behaviour that you think could indicate an eating disorder be sure to report it so the service user can be observed and helped.
Other problems that people with Learning Disabilities often face are:
Constipation – People with cerebral palsy are at particular risk of constipation because of abnormal gastrointestinal motility and some drugs that people with learning disabilities have to take cause constipation as a side effect.
Swallowingdifficulties - There is a high incidence of eating, drinking and swallowing difficulties among people with learning disabilities.
Coeliacdisease - People with Down’s or Turner syndrome are more likely than the rest of us to have coeliac disease. Coeliac disease means that gluten (a protein found in wheat, rye, barley and oats) cannot be tolerated and this may cause diarrhoea and malabsorption of nutrients.
Earlier in the module we already covered what can help with regards to constipation and swallowing difficulties (disphagia) for older people and although the causes may be different in people with learning disabilities, the way to address it them the same.
If a person is diagnosed with coeliac disease they require a gluten-free diet for life, and advice on how to manage this should be given by a registered dietitian.
Let’s now have a look at what could help people with learning disabilities when it comes to eating.
Provide verbal cues to aid chewing and swallowing where necessary.
Offer easy to use eating utensils, cups with handles or straws where appropriate.
If chewing and swallowing is difficult and choking is a hazard purée and thicken food.
Make sure that mealtimes are calm and try and encourage people to eat together.
If a service user interrupts food service or wants to help, give the person a role in the meal service, such as setting the table, or
If wandering compromises food intake, encourage the
person to use finger food while wandering.
If the service user is getting distracted from eating make sure they have been to the toilet, have their glasses, dentures or hearing aid and are sitting comfortably. Other people modelling eating may help.
If a service user gets very impatient, make sure that they are not alerted to meals too early, are offered something to eat if they have to wait for a meal to arrive, or that meals are served in small courses to minimise waiting times.
Let’s finally have a look at some of the things important for children and young people. Again, the principles of healthy eating, taking exercise and drinking plenty of water apply to children and young people in the same way as they do for the other groups.
This group may however be more concerned than the others about body image, so you should consider what you can do to help achieve having a positive body image. For many young people the relationship between food, eating and body weight are highly complex. It is therefore essential that you deal sensitively with issues of being underweight and overweight.
If you are involved in the care of looked after children and young people you should make sure you give positive messages about healthy eating, reinforced by positive attitudes to healthy lifestyles. How do you think this can be achieved?
Do not use derogatory language about your own or other people’s body shapes
Do not comment on people’s food choices
Promote good health and physical fitness (where possible)
Promote an acceptance of a variety of healthy body shapes
So in a nutshell, carers should promote healthy body weight and body image among looked after children and young people by providing an environment in which they have the opportunity to eat healthy food and where the play and exercise they enjoy are actively enabled and encouraged.
Children and young people who need to gain weight should eat regular meals and snacks throughout the day. They also need to keep active to stimulate their appetite.
Increasing any activity or sport that
children and young people enjoy and are able to do is vitally important for encouraging well-being and promoting a healthy body weight for children and young people that are overweight.
This module has covered the subject of Nutrition and how it affects older people, older people with Dementia, people with Learning Disabilities and children and young people.
The principles of good nutrition apply in the same way to all these groups, but each group has their own requirements and challenges and it is important for you to understand how you can help them to achieve good nutrition. This might be with encouraging words, promoting positive body image or in more practical ways by helping create an calm environment for eating, prompting and assisting people to eat.
Where exercise is possible, it is highly encouraged as part of a healthy lifestyle and can include gentle walking or moving arms and legs for people that are in a wheelchair.
The Caroline Walker Trust http://www.cwt.org.uk/
Eating well: children and adults with learning disabilities
Dr Helen Crawley (2007) ISBN: 9781897820230
Eating well for looked after children and young people
The Caroline Walker Trust (2001) ISBN: 9781897820124
Eating well for older people
The Caroline Walker Trust (2004) ISBN: 9781897820186
Eating well for older people with dementia
VOICES ISBN: 0953269260X
The full reports can all be downloaded from the Caroline Walker Trust website and a donation is encouraged.
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