Food for thought: Eating and nutrition

People with dementia need to make sure they eat a healthy balanced diet. A balanced diet provides all the nutrients the body needs in the right amounts to stay healthy.

What is a healthy diet? 

As dementia progresses, changes in a person's eating habits and ability to eat often take place. Difficulties swallowing, changes in taste or a poor appetite can make it increasingly difficult to ensure that an adequate amount of nutritious food is eaten.

A healthy diet is only as healthy as the food that is eaten. It is therefore important to take into account the person's likes and dislikes and their ability to manage certain foods. Consider ways of preparing food to stimulate interest, particularly if the person's appetite is poor.

Remember, eating healthily does not mean that certain foods have to be avoided. Everything in moderation and a little bit of what you fancy is the key to enjoying food and staying fit and well.

Food and health - what's the connection?

Many foods provide a range of nutrients and similar foods are often grouped together into 'food groups'. Listed below are the different food groups and the nutrients they provide. Choosing a variety of foods from different food groups is the best way to ensure a balanced intake of all the different nutrients needed for good health.

Milk and dairy food

This group includes milk, cheese and yoghurt and foods made with milk, such as custard, milky drinks or milk puddings.

These foods are a good source of protein, which is needed to build and repair body tissues. They also provide a rich source of calcium, needed for strong bones and teeth.

To help the body absorb calcium from food, we need vitamin D. Vitamin D is mainly formed by the action of sunlight on the skin, but can also be found in foods such as oily fish, margarine and eggs. However, for older people who are housebound, or spend little time outdoors, a vitamin D supplement may be required. Check with your GP or dietitian.

Meat, fish and alternatives

This group includes meat, poultry, fish, offal, eggs, nuts, beans, lentils and soya products such as tofu.

These foods are a good source of protein and also provide some of the B group vitamins (see Bread, cereals and potatoes).

Foods of animal origin, such as meat, fish, offal and eggs, are good sources of vitamin B12. Vitamin B12 is needed for a healthy nervous system and the formation of red blood cells.

Folate and iron are also needed to keep the blood healthy. Liver is a good source of folate (see Fruit and vegetables) and iron can be found in red meat, oily fish, liver, kidney, beans and lentils. Eating fruit and vegetables that are rich in vitamin C can help with the absorption of iron from food (see Fruit and vegetables).

Oily fish, such as salmon, mackerel, herring and sardines, is a rich source of essential fats called omega-3 oils. These oils play an important part in maintaining the health of the heart and the nervous system. Eating oily fish at least once a week is recommended.

For those who choose not to eat meat or fish, foods such as pulses (beans, peas and lentils) nuts, eggs, cheese and soya can be eaten instead. A variety of these foods should be eaten to ensure a good range of nutrients. Some people who avoid all animal foods - meat, fish, eggs and dairy foods - will probably need a vitamin B12 supplement. Check with your GP or dietitian.

Bread, cereals and potatoes

This group of foods provides energy and is a good source of B group vitamins. As well as keeping the blood and nervous system healthy, B vitamins break food down to release energy. Foods in this group include:

• Bread (wholemeal or white), including chapatti, nan and pitta bread; crackers; crumpets; muffins, and teacakes
• Pasta, such as spaghetti or macaroni; noodles, and rice
• Potatoes, plantain and yam
• Breakfast cereals and flour. Breakfast cereals are fortified with added vitamins and minerals, such as folate, vitamin B12 and iron. Served with milk, they provide a nourishing snack that can be eaten at any time of the day, not just in the morning!
• Wholemeal bread, wholemeal pasta and wholegrain breakfast cereals are all good sources of fibre. Examples of wholegrain breakfast cereals include porridge oats, bran flakes and wholewheat biscuits (see A word about fibre).

Fruit and vegetables

This group includes all fruit and vegetables, dried fruit and fruit juices.

Fruit and vegetables are packed full of fibre and vitamins - in particular, the antioxidant vitamins C, E and beta-carotene. These vitamins help to protect the healthy cells of the body from damage and support the immune system to fight infections. Beta-carotene is found in yellow and orange fruit and vegetables and in dark green leafy vegetables. Once in the body, it is converted into vitamin A as required. Vitamin A can also be found in animal foods such as liver, eggs, cheese and butter.

Vitamin E is present in green leafy vegetables, vegetable oils, butter
and nuts.

Vitamin C is needed to keep gums, teeth and skin healthy. It also helps the body absorb iron from food (see Meat, fish and alternatives). Citrus fruit, such as oranges, strawberries and kiwi fruit, and tomatoes and potatoes are good sources of vitamin C. For those who find it difficult to eat or prepare fruit and vegetables, drinking a glass of orange juice every day is a good way to ensure an adequate intake of vitamin C.

Green leafy vegetables, Brussels sprouts, oranges and other citrus fruit are all good sources of folate.

A general guide is to try to have five servings of fruit and vegetables a day to ensure a good range of nutrients for health. However, individual dietary needs can vary, particularly for people with dementia, and may be influenced by the stage of dementia, ability to eat certain foods, the person's medical condition and other circumstances. This guide may not be appropriate or achievable for all people with dementia. However, every little helps, so encourage and accept what each person can manage.

Fats, oils and other foods

This group includes margarine, butter, ghee and vegetable oils such as sunflower oil and olive oil.

These foods are concentrated sources of energy, so are not needed in large amounts. They do provide some vitamins. Margarine contains vitamins D and E and vegetable oils are a good source of vitamin E.

'Other foods' include cakes, pastries, biscuits, confectionery, crisps, and soft and alcoholic drinks. These foods are not nutrient rich. They mainly provide calories or energy from fat and/or sugar. They can be included as part of a healthy balanced diet, but if eaten too frequently they may dampen the appetite for more nutritious foods. It is a question of moderation.

A word about fibre

Fibre is important to help prevent constipation. The risk of constipation is greater for people who are inactive, do not drink enough (see Drink to think) or eat a low fibre diet. Certain medications can also aggravate the problem.

A good way of preventing constipation is to include foods that are a good source of fibre in the diet - fruit and vegetables, salads, beans, lentils, wholemeal bread or wholegrain breakfast cereals, for example. However, it is best to introduce high fibre foods gradually if the person is not used to eating them. Too much fibre in the diet can be bulky and uncomfortable; small changes are usually sufficient.
It is not advisable to add raw bran to foods as this can cause bloating and discomfort. It can also make it difficult for the body to absorb nutrients such as calcium and iron.

To help prevent constipation also try, if possible, to encourage daily activity for those who are able. A short gentle walk is a good start.

Drink to think

Drinking enough fluid every day is vital for good health. A low intake of fluid is likely to result in dehydration. This can increase the risk of constipation and affect mood, resulting in increased irritability and confusion. Some people with dementia may not recognise that they are thirsty or may simply forget to drink.

A healthy guide is to drink at least eight cups of fluid a day. Fluids include water, tea and coffee, fruit juice, milk and other soft drinks. Gentle reminders and prompts to drink may help. Offering the person the cup rather than leaving it on the table may prompt a person to drink.

Some supermarkets offer a delivery service, where orders can be placed by phone or through the internet. This is a good way of ensuring a regular stock of fresh food and can help if time is limited or it is difficult to get to the shops. There may be a charge for this service, so it is best to ask first.

Poor appetite

There are several reasons why a person with dementia may have a poor appetite or seem uninterested in eating.

• In the early stages of dementia some people lose interest in food because they are depressed. Depression is very common but there are effective drug treatments available. If you suspect this is a problem, consult your GP. When the depression lifts, the person's appetite should return.
• A sore mouth, badly fitting dentures or sore gums can make eating uncomfortable. Regular dental care is important, so seek the advice of a dentist.
• If the person is inactive during the day, they may not feel hungry. Encourage activity such as walking, if appropriate.
• In the later stages of dementia, people may no longer understand that the food in front of them is there to be eaten, even if they are hungry. This is because the nerve pathways in the brain are damaged and the messages do not get through. Gentle prompts and reminders to eat may be helpful. Eating in company can act as a useful cue, reminding the person what to do and how to eat.
• Medication can sometimes affect the appetite. Side-effects such as constipation, changes in taste or a dry mouth can reduce the desire to eat. Constipation can be helped by increasing fibre and fluid intake. Keeping food moist by adding sauces or gravy can help the person to eat more easily if their mouth is dry. Small sips of water taken while eating may also help.
• Chewing and swallowing sometimes becomes a problem as dementia progresses. People may find chewing solid food difficult; they may hold food in their mouths rather than swallow it, or you may notice that they cough after swallowing. If you have any concerns about chewing and swallowing food, a speech and language therapist can advise you (see Getting help).
• Some people with dementia find eating with a knife and fork difficult because they have problems with co-ordination. This can be frustrating and they may feel embarrassed if they drop food or if the task becomes messy. This can be sufficient to put a person off eating at mealtimes. Try offering finger foods to boost confidence and maintain independent eating (see leaflet Finger food ideas).
• People with dementia often experience changes in food preferences. This is thought to be a result of damage to specific areas in the brain or it may be due to the person simply forgetting which foods or drinks they used to like. Changes in taste and smell can all impact on the amount and variety of foods eaten. If food preferences become very limited, the person will probably not be getting all the nutrients they need to stay healthy and they may lose weight. A dietitian can offer practical advice on how to enrich food and drink to help with a poor appetite and weight loss (see Getting help). Some people with dementia may need food supplements, such as energy- and protein-enriched drinks. These are usually prescribed and should be taken under the guidance of a dietitian and GP. Some supplement drinks can be purchased from chemists and supermarkets. These often come in a powdered form and can be made into a drink, usually by adding milk.

Three square meals or little and often? 

This depends on the individual and how they prefer to eat. A person with a good appetite may have no problem eating sufficient food at regular mealtimes.

However, a person with a small appetite may not respond well to generous servings of food three times a day. Too much food on the plate can be offputting to someone whose appetite is poor. In this case, try serving smaller portions at mealtimes and offer nourishing snacks in between mealtimes to supplement food intake. Offering dessert as a separate course an hour or so after the main meal, rather than presenting both courses at the same time, may also help.

Alternatively, you may find the person prefers to eat 'little and often' - five smaller meals spread over the day instead of the usual three, for example. It is a matter of finding out what works best for the individual.

Drinks

Milky drinks, hot or cold. Make malted milk drinks or hot chocolate with milk.

Snacks

• Sandwiches with fillings such as egg, tinned fish, meat, cheese or peanut butter
• Cheese and biscuits
• Toast with cheese, pâté, peanut butter or yeast extract
• Buttered scones, toasted teacakes, buttered crumpets or muffins
• Fruit loaf or malt loaf
• Milk pudding, breakfast cereals and milk, yoghurt
• Fruit cake or gingerbread.

A little too much?

Some people with dementia may eat too much food. They may forget they have just eaten or they may have a persistent desire for certain foods, such as sweet biscuits or confectionery, and snack on these throughout the day. Overeating can become a problem if the person gains too much weight. Carrying extra weight will make it more difficult to get around and the person will start to feel uncomfortable.

Snacking frequently on foods such as confectionery or biscuits can reduce a person's appetite for more nutritious food at mealtimes, which means they may not be getting all the nutrients they need to keep them healthy.

Try to limit the availability of these snack foods if they are being eaten too often and the person is gaining excess weight. Provide healthier alternatives, such as pieces of fresh fruit and vegetable. Some people may eat out of boredom or loneliness, or they may not be active during the day

Getting help 

If you have concerns about a person's eating or drinking, help is available. Key healthcare professionals who can offer advice and guidance include:

• Dietitians, who can provide advice on issues such as poor appetite, weight loss or weight gain, food enrichment and vitamin and food supplements.
• Speech and language therapists, who can give advice and guidance on swallowing difficulties. It is important that changes to the texture of food are only made as necessary and with their professional advice.
• Occupational therapists, who can advise on adapted eating aids, such as cutlery, cups and plate mats, that help to maintain independent eating.

These professionals can be contacted through your GP or consultant, who will be able to arrange for a referral. Some professionals may be able to offer a domiciliary visit to people who are housebound. Others may be based at a local health centre, GP practice or hospital. Services vary from area to area.

How to find out more

If you would like more information on Food for Thought publications and events, please contact:

Food for Thought Project
Alzheimer's Society
Ground Floor Suite
Holgate Villa
22 Holgate Road
York YO24 4AB

Telephone: 019 0463 3640
Fax: 019 0465 9561
Email: foodft@alzheimers.org.uk

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