For this assignment, I have used Gibbs reflective cycle to reflect on the impact of psychosocial and cultural issues on decision making in dietetic practice. In this reflective piece, I have focused on how these factors contribute to malnutrition in the elderly.
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My patient was a 79 year old Caucasian lady, referred for nutrition support. She had experienced an unintentional weight loss of 10 kilograms (‘kg’) over two years, since losing her husband. Her weight loss had become a serious concern for her, which led to her referral by her general practitioner (‘GP’).
During the consultation, she explained that she had lost 3kg in one month, which is when she started worrying as she noticed her clothes were loose. I examined her food diary and asked further questions to get an overall picture of how she was managing and if other factors were affecting her. She seemed to have an adequate diet, although at her last visit to her GP eight months prior, she was informed that she had impaired fasting glucose (‘IFG’). She therefore decreased her intake of sugary foods for fear of becoming diabetic.
When she mentioned she had lost her husband of 55 years, I immediately thought this was the reason for her weight loss. She admitted having battled with loneliness and depression for a while and that support from her son and family was helping her through this difficult time. However, although they visited at weekends, she had no other social support. She spent her time at home except for when she was out doing her weekly shopping.
Several psychosocial factors emerged from this part of the consultation including bereavement and the state of depression, which she endured following this traumatic event .
A significant attribute of bereavement and depression is appetite loss. She no longer had anyone to appreciate her cooking efforts and the deprivation of companionship at mealtimes became a reminder of her loss. A time of communication, joy and bonding had become a painful experience, leading to lack of interest in any activity related to food or eating, making it more of a chore .
Eating is a social variable and part of our self and social identity, which also makes it a cultural variable. It is a structured part of one’s everyday life and a valued social activity for most married people. Food habits developed throughout life are an important component of culture and strongly influence food decisions. The stress of bereavement can alter the social, psychological and cultural significance of food during this time .
Other psychosocial determinants include access to food, and ability to cook and share meals with others . The patient was shopping for herself and consuming ready meals as she still struggled cooking just for one. It is common for elderly people to consume ready meals as it is convenient since they can buy and freeze them, and they are single portions . She only cooked when her son came to visit.
I suggested joining a social club in the area, which could help improve her morale . Meal ambiance has been shown to improve levels of ingestion and is an important stimulus modulated to help increase appetite in places such as nursing homes . Unfortunately, she suffered from urinary incontinence (‘UI’) and found it embarrassing to urinate so frequently when around people, so she declined.
I decided it was best to encourage her in relation to her diet so that she felt she was already doing something to help herself and that her coming to see the dietitian would add to her efforts in trying to gain weight .
Relocation and change of environment can also yield negative outcomes in terms of psychosocial disturbances such as, anxiety, depression and loneliness, associated with transferring from one place to another .
She had recently moved to a smaller house, which was a stressful time for her. She had settled in but had had a hard time adjusting. This is an area I should have explored further. For example, had she made friends in the area; had she changed her eating habits due to limited access to foods she was used to having and so forth. These issues would have impacted on her intake and weight if they were causing her anxiety or depression .
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Financial constraint is another psychosocial factor to consider when giving dietary advice, as unaffordability affects intake . Cognitive decline is also associated with reduced intake in the elderly as they may not have the desire to eat or may forget to do so .
According to her food diary and where she mentioned she was shopping from, she was not restricting herself. She was consuming three meals a day with snacks. However, as research suggests, misreporting of food diaries is common where patients try to present themselves more favourably . Alternatively, keeping the food diary may have acted as a reminder for her to eat. However, this issue was not explored on this occasion.
Another psychosocial issue I considered was the food anxiety which had been created following the IFG test. Her GP had told her she was in the pre-diabetic stage and so she had eliminated most fruit and all high sugar foods from her diet as she was worried about becoming diabetic.
Food habits are a set of culturally standardised set of behaviours which have been reared in individuals from childhood. Therefore, every person has a culture which dictates their eating behaviour . The burden of disease caused her to change her eating habits . She was anxious about eating foods with sugar, which formerly was a safe component of her diet. I explained that she did not have to exclude sugar from her diet completely. This created confusion as my advice was conflicting with that of her GP’s. I clarified that she could still have small amounts of sugar in her but that she was wise to reduce on pure forms of sugar e.g. sweets. She was relieved to discover this and seemed happier that she could relax her diet.
When negotiating her goals, I explored the cultural aspect of her diet as her compliance would be affected if I did not consider her current dietary habits. I looked at her meal pattern and food items. When discussing the food fortification process, I was able to relate this directly to specific foods in her diet. Using the appropriate wording is also important as for some, dinner may be evening meal, and tea may be a tea break mid-afternoon .
By the end of the consultation, the patient said she felt better following our conversation as she had a clear idea of what she had to do. I wrote down her plan and she said she would buy herself some nice treats on her way home. I hoped that giving her tips on food fortification would give her more of an incentive to eat .
Having explored this case in depth, I feel I could have been more thorough about her social life. I could have found out if she had close friends whom she could catch up with over cake and tea. Also, I could have suggested she see her GP about the UI as research shows that behavioural treatment, drugs, exercise or a combination of these can help better control UI. In turn, solving or reducing this problem could restore her confidence in leaving the house more often and lead to her increasing her social network . I could also have asked about her hobbies as this may have helped generate ideas to help improve her morale aswell .
If I were to deal with such a situation again, in addition to what I did in this consultation, I would explore more of her cognitive function to see if this was having an impact on her intake. Decline in sensory function can also cause reduced intake as foods no longer taste or smell the same. Forgetting to eat is also common and may require distinct measures such as using an alarm clock as a reminder. I assumed that she was eating well from what she showed me in her food diary but I could have been more flexible in my questioning which may have helped to determine whether she was forgetting to have her meals .
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