Diet and nutrition in palliative care

The importance of nutrition

Good nutrition that is right for your stage of life can:

• provide strength to help you cope with the physical and mental demands of illness and treatment
• improve overall wellbeing and quality of life
• help to maintain a strong immune system and reduce the risk of infection
• increase tissue repair and wound healing

Nutrition in palliative care

In palliative care the focus of nutrition should be on improving quality of life and reducing any anxieties around food and eating. Illness, disease and associated treatments can make huge demands on the body and, as a result, the recommendations for healthy eating may be different to those for a person who is well.

Thinking about nutrition should begin as early as possible to have the greatest benefit. You may need to be flexible around food and meals depending on how you feel at different times.

Common concerns

Weight loss

Weight loss is very common in serious illness and is not only due to loss of appetite. In most life-limiting conditions, the body changes the way it uses food and nutrients which can lead to an increase in the amount of energy the body uses. Treatment demands can also add to this, which can make it difficult to stop weight loss, regardless of how much is eaten. It is still important to try to eat well as it will give you strength and add to your quality of life and sense of ‘normality’. Improving the way you eat can help you to feel better and enjoy life more.

Loss of appetite

It is common to lose your appetite when you feel unwell. Loss of appetite can be caused by physical factors, such as pain or constipation or emotional factors such as anxiety and depression. It’s important to consider which factors might be affecting your appetite as there may be options such as relaxation techniques, therapy or medications which could help. Some medication can also reduce your appetite or make symptoms such as constipation worse so it’s important to discuss this with your doctor or another member of the palliative care team if you feel this is affecting you.

While providing food can be an important way for people to show love and care, it is important that the person who is unwell does not feel they have to eat to protect the feelings of their family and friends. Eating and drinking should be led by the person themselves and how they feel, with support from family and friends.

Anxiety and low mood can have a negative effect on appetite. It can be worth exploring strategies that may help you to relax such as having a massage, listening to music or trying guided meditation.

Anxiety and conflict around food and expectations

When a person is not able to eat or does not want to eat as they previously have, it can cause stress and anxiety. This can be a particularly difficult adjustment for family or carers and can leave them feeling helpless. It is vital that the needs and wishes of the person who is unwell are always considered first, even if they differ from that of the care giver. The benefits of eating and drinking should always outweigh any risk or burden to the person who is unwell.

Symptoms that affect appetite

Loss of appetite

Make everything you eat and drink count by trying to ensure everything you consume contains maximum calories or energy (see Foods high in calories).

Eat little and often rather than waiting until a ‘usual’ meal time to eat, when you may not feel like it. Do not wait for hunger signals if you are able to manage something. A small glass of wine can sometimes help to stimulate appetite (if appropriate).

Have small portions on small plates to avoid feeling overwhelmed.

Drink nourishing drinks throughout the day if you do not feel able to eat: fruit juice, milk, hot chocolate, malt drink.

Try to avoid filling up on low calorie foods and drinks such as diet drinks and foods, fruit and vegetables, clear soups.

Try and drink after meals rather than before to avoid feeling full.

Nausea and vomiting

Take any anti-nausea medication as prescribed by your doctor or nurse.

Cold foods can be better tolerated than hot.

Avoid strong smelling or tasting foods.

Try to have small amounts or sips of nourishing drinks throughout the day as being hungry can make nausea worse.

Some people find that ginger can help. Try drinking ginger tea (hot or cold) or eating ginger biscuits.

Open the window to get some fresh air.

Taste changes

If a food or drink does not taste nice then avoid it until taste returns to normal to avoid developing an aversion.

Suck hard sweets or mints.

Experiment with different temperatures and textures as some may be better tolerated than others.

Tart or sharp foods such as those containing lemon may improve taste Metal cutlery can exacerbate metallic tastes in mouth so try using plastic or wooden cutlery or use your fingers.

Rinsing the mouth with a salt and bicarbonate of soda solution before meals can help neutralise bad tastes (1/2 tsp salt + ½ tsp bicarbonate of soda in 1 cup of warm water).

Swallowing difficulties

If you are having difficulty swallowing you may need to be assessed by a speech and language therapist.

They can advise whether texture modified foods and drinks may make it easier for you to swallow safely.

Diarrhoea

Keep hydrated by sipping fluids throughout the day.

Try eating little and often rather than having large amounts at once.

Limit high fibre foods such as wholemeal bread, rice and pasta and try to eat fruit and vegetables without skins, seeds or pith Avoid foods that are high in fat.

Sometimes some medications can cause a short term sensitivity to milk containing products such as milk, ice cream and custard. It may be worth trialling a short period without these but if it does not improve, continue having them as they can be an important source of nutrients.

Dry mouth

Frequent mouth rinse, water spray (or artificial saliva if prescribed).

Suck on hard sweets, mints or ice lollies.

Use lip balm or moisturiser.

Moisten foods with sauce, gravy or butter.

Sip nourishing fluids throughout the day– milk, juice, hot chocolate.

Consider a humidifier (or bowl of water on the radiator).

Practice good oral hygiene with a soft toothbrush several times a day.

Sore mouth

Discuss pain with your doctor or nurse.

Choose soft bland foods such as mashed potato and porridge.

Avoid:

• rough foods, e.g toast and crisps
• acidic foods, e.g vinegar or lemon
• spicy foods, e.g containing chilli
• salty foods, e.g olives or crisps
• fizzy drinks
• very hot foods – eat foods at room temperature

Constipation

Discuss with your doctor or nurse as some medications can cause constipation.

Try to increase your intake of fluid (unless you have been advised to restrict fluids).

Increase fibre and foods high in natural laxatives such as prunes, prune juice, figs, beetroot.

Add some linseeds to your diet – can be added to cereal or porridge.

Optimising nutrition

If you are losing weight or are struggling to eat enough due to a lack of appetite it is important to make everything you eat ‘count’.

Try to have more foods that are high in protein and calories and limit foods that are low in protein and calories such as diet foods, fruit, vegetables, watery drinks and clear soups.

Protein

Needed for growth and repair, as well as sparing muscle mass and maintaining a healthy immune system.

High protein foods include:

• Meat
• Fish
• Meat alternatives (Quorn, tofu, soya protein products)
• Beans and pulses
• Dairy products
• Nuts and seeds
• Grains such as porridge and wheat containing products e.g. bread and pasta

Foods high in calories (energy)

Eating higher calorie foods means boosting energy intake without increasing the volume eaten.

People can often feel anxiety around high calorie foods due to usual healthy eating messages, particularly around fats. In palliative care these usual health messages become less important as the focus switches to one of maintaining strength and limiting weight loss.

Please speak to your healthcare professional if you have any concerns regarding this.

High calorie foods include:

• cheese
• oil
• butter
• cream
• avocado
• nuts and seeds
• peanut butter or other nut butters
• mayonnaise
• full fat yoghurt
• cake
• biscuits
• chocolate
• ice cream

Fortified milk

Consider making fortified milk to use in drinks and foods. This can be made by adding dried skimmed milk powder to standard milk (semi or full fat). The fortified milk can then be used as ordinary milk in drinks or cooking.

Add 2-4 tablespoons of dried milk powder to 1 litre of milk and mix well.

How can we help?

Contact your Dorothy House professional if you have any further questions or concerns.