Introduction: Independent eating is something that most cultures consider an important activity of daily living. It is not always fully understood that people who are unable to feed themselves can benefit greatly if they can gain control over eating. The activity of eating influences many of the known psychological benefits associated with greater independence, such as improved dignity and self-esteem and reduced feelings of being a burden to their caregiver (Gustafsson)1. Hermann, et al.2, supports a similar view stating that “eating activity influences many aspects of our overall medical, physical, and social well being”. The ability of food self-selection and the capacity to set ones own pace in eating can potentially ameliorate some of the undernourishment and/or gastric problems, as well as some of the risks of being fed, that often occur for people who are fed.
We all start out our lives being fed. During the first year or two of life most people develop the skills necessary to feed themselves. Eating becomes an automatic activity that is given little or no conscious thought. However, some people are unable to develop the skills needed to self-feed due to a variety of causes and being fed is continued out of necessity. This group will potentially be dependent upon another person for all of their nutritional needs, and in many cases for hydration, for their entire life.
An additional group of people, who have been independent eaters, lose the ability to self-feed due to illness or injury and become dependent upon another person to feed them and, often, to also provide them with a drink. To facilitate mealtime independence it must be understood that for those who have never experienced independence in eating, the perception of self-feeding is different from those people who have had self-feeding experience. Therefore, teaching someone, who lacks familiarity with self-feeding, to feed them self must be approached with that understanding. If food has always been placed in their mouth without them being required to participate in removing the food from the utensil, they will not understand the concept and will have to learn it before they will be able to gain any degree of independence.
Potentially, many individuals from both groups of people can gain the ability to eat and drink independently through the use of assistive technology (AT). However, it is common to find that many caregivers including family members (especially older members), paid caregivers, and healthcare insurance company reviewers do not see a need for, and are resistant to, making this change. Yet, eating independently can be justified as being medically necessary for many physical and psychological reasons.
Assistive Technology (AT) can range from a simple non-slip mat placed under a plate, to a custom built splint, all the way to sophisticated powered dining equipment like the Mealtime Partner Dining Device. Unfortunately, there is a common misconception that empowering someone with mealtime independence is simply a convenience to the caregiver and provides no significant benefit to the consumer and, therefore, is unessential.
Safety Issues. The greatest safety benefit of eating and drinking independently is that it reduces the chance of choking and/or aspiration. There are approximately 40,000 deaths in the U.S. each year due to aspiration pneumonia with a cumulative cost of treatment that is estimated to be more than $3 billion (Calhoun, Wax & Eibling3, DeLegge4). DeLegge’s study identified the best predictors for the development of aspiration pneumonia as: dependency on others for eating; dependency for oral care; neurological status; and position while eating. Fundamentally, people who require feeding are more vulnerable to aspiration than people who self-feed. (Aspiration occurs when food, liquid or regurgitated gastric materials are inhaled into the pulmonary system. Pneumonia can result from aspirated materials causing infection in the lungs and can have very serious health consequences.)
Proper positioning for the task of eating can reduce this risk. Also, simply controlling when food and/or liquid is placed in the mouth, enables a person to be more prepared to receive the food or liquid. Their sequence for breathing will better coordinate with the placement of food in their mouth, and, consequentially, reduce the risk of aspiration.
When one is being fed it is not always easy to know exactly when food is going to be placed in your mouth. Those providing food can change their mind and pause, or alternatively, speed up the food presentation depending upon what is occurring at the time. Also, they might change the angle at which the utensil is presented. Furthermore, if the person providing the food is in a hurry they might feel compelled to rush the meal. This is an especially common occurrence in facilities like nursing homes. Presenting food hurriedly, typically results in the person being fed taking the food from the utensil, regardless of whether or not they are ready for it. They will continually take the food when it is offered, even if they have not swallowed the previous bite. This pattern increases the likelihood of choking and/or aspiration.
Health Issues. Hurrying food consumption impacts most people’s digestive system and results in heartburn, indigestion or acid stomach (most of us have, at one time or another, experienced having a hurried meal and then feeling the need for an antacid). Gastroesophageal reflux disease or GERD, commonly referred to as acid reflux, is a condition in which stomach liquids regurgitate into the esophagus and, over time cause damage to it. Many people, who are constantly hurried during eating, develop GERD.
It is common for older people to require a protracted time to eat even a small meal. However, in many institutional settings they are required to eat quickly (generally due to staff shortages at mealtimes), and the result is indigestion following a meal, and over time, the development of GERD. The long term consequence is that the person is reluctant to eat because their stomach is upset and they are in pain. This can cause a downward health spiral with weight loss and undernutrition as the result.
Undernutrition and malnutrition exist at epidemic proportions in nursing homes in the U.S. The American Geriatric Society and the Nutrition Screening Initiative identified that approximately 40% of all nursing home residents are under nourished. A report titled Malnutrition and Dehydration in Nursing Homes: Key Issues in Prevention and Treatment5 established the key reasons as being: residents must be fed, or need help eating; the need for additional time to eat; cognitive impairments; and, chronic understaffing in nursing homes.
The benefits of independent eating are considerable and diverse. The safety and health issues that relate to the benefits of independent eating were discussed above. In the remaining discussion, we will expand upon the topic to include the social aspects of independent eating and the impact of independence at mealtimes on people.
Socialization: Mealtimes are generally a social time with family or friends together sharing food and talking. However, if you are being fed, you are unlikely to fully participate in the ongoing conversation because you must always anticipate receiving a bite of food. If you open your mouth to speak, your feeding partner could easily (unintentionally) put a bite of food in your mouth when you are not ready, not knowing that you are about to talk. The result of this situation is that those being fed are usually not able to fully participate in the social interactions surrounding a meal. They are more likely to be passive participants listening to the conversation rather than fully participating. When feeding yourself you choose when to talk and when to eat.
For residents of institutions mealtime conversations are unlikely. While they are being fed, usually quickly (because staff have several people to feed at each meal), staff will talk to one another but typically interact only briefly with the person they are feeding. The interactions are mostly related to eating. In this situation the person being fed is deprived of the normal mealtime social experience. (It should be noted, however, that people who have swallowing difficulties should refrain from talking and eating at the same time. A speech language pathologist should advise them about the best practices to follow at mealtimes. The training should always be adhered to until the swallowing problems abate.)
When empowered to feed themselves using assistive technology (AT), verbal interactions have been observed to change. For children, who have never experienced mealtime independence, the change is gradual. As they realize that they can choose when to speak and when to eat, they are more likely to join in the conversation. For those regaining independence through the use of AT, conversation returns to a normal pattern almost immediately.
Independence. Food selection for those being fed is a difficult issue for a feeding partner. Either they must choose what food is fed for each bite or they must ask the person being fed what they want for every bite. Most commonly the person providing food makes all of the decisions about what will be offered and the pace at which it is provided. Even the very best feeding partners have difficulty matching how they provide each bite of food with what the person they are feeding might like. A good example of this is a wife who fed her husband and carefully provided him each bite with a mixture of food on the utensil (e.g., potatoes and meat, or green beans and tomato). When her husband was able to eat independently by using an assistive dining device, he ate all of his potatoes, next all of his green beans, and finally the meat. His wife was astonished and felt that he was still having difficulty with feeding himself. When the couple discussed this, the husband explained that he was so appreciative of her care that he could not possibly impose upon her further to change how she selected the food that she was feeding him, but that he really preferred that his food not be mixed.
Many children who have never experienced independence at mealtimes, eat whatever is offered to them showing little regard for the flavor. Either they do not realize that they have a choice, or they simply accept that some food doesn’t taste as good as other food, but they believe that they should eat it, regardless. (No clinical explanation of this behavior has been established.) What has been observed is that if independence is gained, food selection and the pace of eating often changes dramatically. On many occasions, it has been observed that a child who has always eaten all of his or her vegetables, for example, when using a Mealtime Partner Dining Device (and can therefore make his/her own food selection), suddenly rejects (i.e., never selects) a specific vegetable, even though all of the family members and caregivers were adamant that the child liked that particular food item. Additionally, the pace at which people eat will change when they are able to control the pace through the use of AT. People diagnosed with gastroesophageal reflux disease have been observed to dramatically slow their pace of eating, in some cases doubling the time spent eating. It should also be noted that they experienced less discomfort after their meal when they ate at a slower pace.
Conclusion. Eisemann Shimizu6, et. al., concluded that for people who are totally dependent on a caregiver to feed them, “the joys of eating and being able to eat by oneself are taken away from him/her. This can lead to feelings of shame, discomfort, loss of appetite, decreased self-esteem and panic or fear”. For those living in a supportive family environment, these findings may not be applicable. Nevertheless, for those who lack the ability to feed themselves, the goal should be to have them participate as fully as possible in eating, not only for reasons defined by Shimizu, but for the many other reasons discussed above.
- Gustafsson B. The Experiential Meaning of Eating, Handicap, Adaptedness, and Confirmation in Living With Esophageal Dysphagia. Dysphagia, Spring, 1995, 10(2):68-85.
- Hermann, R. P., Phalangas, A. C., Mahoney, R. M. Powered feeding devices: an evaluation of three models. Arch Phys Med Rehabil, 1999, 80: 1237-1242.
- Calhoun, K. H., Wax, M., Eibling, D. E., Expert Guide to Otolaryngology. American College of Physicians, American Society of Internal Medicine. Publishe ACP Press, 2001.
- DeLegge, M. H., Aspiration pneumonia: Incidence, mortality, and at-risk populations. Journal of Parenteral and Enteral Nutrition, Nov/Dec, 2002.
- Greene Burger, S., Kayser-Jones, J., Prince Bell, J. Malnutrition and Dehydration in Nursing Homes: Key Issues in Prevention and Treatment. Published by: National Citizens’ Coalition for Nursing Home Reform, June 2000.
- Eisemann Shimizu, M., Otsuka, A., Kania, S., Oki, S. The Therapeutic Effects of Independent Eating for the Severely Physically Disabled. Journal of Phys. Therapy Sci. 16: 73-79, 2004.