For some people, eating can be difficult. There are all manner of reasons why this might be the case, from lactose intolerance to gluten intolerance, nut allergies, even an allergy to citric acid, but for some people, the issue is broader — and therefore much more difficult — than that. It is about eating. Not types of food, or what’s in food, or how food’s been prepared, but eating. They struggle to put a mouthful of food into their mouths, to chew, and to swallow. For anyone who has to deal with this on a regular basis, it’s at best frustrating. Sometimes, it can be downright terrifying. This isn’t being off of your food for a day or two, this isn’t being not very hungry one evening, this is a persistent and prolonged inability to eat.

If you share your life with someone who struggles to eat, you might struggle to know what to do. The advice that I’m able to offer here isn’t a solution, and it certainly isn’t medically ratified. It's a guide. This next bit is really important, though; some people will require professional medical attention. Please, encourage them to seek it. What I’m suggesting is the culmination of years of observation and experience, not medical training. This will help to treat the symptoms, but not the cause of struggling to eat. The cause is a deeper, more complicated issue that needs to be tackled on an individual basis; not eating is the park where it comes out to play.

Struggling to eat can be something that someone battles with for their entire life, or experiences periodically, or experiences as a solitary — but prolonged — episode. I think, though, that whichever form it takes, tackling it requires much the same approach. Aside from addressing the underlying cause, there are six points that can help someone who struggles to eat.

  • Recognise the triggers
  • Don’t make mealtimes a battleground
  • Pay attention to portion size and service
  • Involve people in preparation
  • Identify 'Holy Grail' foods
  • Develop a routine

Even for people who deal with struggling to eat for a life time, there will be periods where things are noticeably worse, usually following some event or incident. For someone who has to tackle not eating periodically, there will, most likely, be a trigger instigating these episodes. If these triggers can be identified, it will help to minimise the impact they might have on not being able to eat. Sometimes, the triggers can’t be avoided entirely, but if you know that it is coming your way, at least you can make adequate preparations.

For most people I know who struggle to eat, the primary trigger is stress. That stress can take different forms, for example being in unfamiliar situations or surroundings or having to deal with something emotionally demanding, but it’s stress all the same. And more often than not it is stress that can be linked back to a lack of control. Subsequently, if they can’t control where they are, they can control what they eat. Recognising the triggers helps to restore an element of control. It’s a very good place to start.

Sometimes, though, those stressful situations will be beyond control. They can be unavoidable or completely unforeseen. In which case, dealing with the fall out of the stress — that is, not eating — will be the next step.

Ah go on! Won't you have a sandwich?

First and foremost, do not turn mealtimes into a battleground. Dealing with mealtimes is probably the most difficult aspect of struggling to eat: it’s uncomfortable for everyone. All the same, it is important to maintain the routine and ritual of mealtimes, because it helps to create stability and propagate the feeling that eating is a healthy and normal activity. But by commenting on things and making them an issue, it only exacerbates the situation. More stress will result in a feeling of less control, which means eating becomes even more problematic. Don’t comment on how little someone has eaten; don’t comment on how much someone has eaten; don’t make references to people’s weight; don’t make suggestions; don’t make 'encouraging' comments; and, if you’ve cooked, don’t feel offended that your food hasn’t been eaten. None of this will help. The fewer stressful associations that can be made with the dinner table and with food, the better. Trust me. In short, don’t push the issue, and definitely not at the dinner table.

You get three; that's a Jewish two.

Which leads us on to what, when, where, how, and how much to serve. We’ve already established that not being able to eat is related to loss of control. If a person loses even more control over mealtimes, for example, how much is served to them, they’ll struggle even more. Allow people to serve themselves. One potato, one slice of chicken, five peas, and a carrot baton is better than nothing.

Dinner plates are large. Dinner plates can be daunting. Dinner plates can make people feel inadequate if they can not either fill it or eat everything that is on it. Use a salad plate. Or even a tea plate. That one potato, one slice of chicken, five peas, and a carrot baton will be suited so much better by a smaller plate. Eating in small quantities will often necessitate eating more frequently, too, so be prepared with left-overs and food that can be made into mini-meals.

The control factor can also mean that if people who struggle to eat are involved in preparing their meals, they will be more likely to eat them. Of course, this isn’t always the case, and in fact the complete opposite can happen, but it is worth remembering. Even people who are hopeless cooks can get involved in the kitchen and the sense of accomplishment at producing a meal can do wonders.

In this house we have chocolate cake for breakfast...

So now the question is what to cook. I wouldn’t necessarily suggest doing anything particularly different, or cooking anything terribly special. I’ve already mentioned that ritual can be important, and so is not making a fuss. Preparing special meals would counter both of those points. However, it is likely that people who struggle to eat will have one or two foods that they are virtually always able to manage. Examples I know of are fruitcake, spaghetti Bolognese, and cheese on toast. It is worth working out what these 'Holy Grail' foods are and having available either a small stock or the required ingredients. Growing overly reliant on these foods could of course become problematic, but never underestimate the power of spaghetti Bolognese for breakfast.

So finally, think about routine. If the little-and-often philosophy works, go with that. If there is one particular time of day when someone is more likely to eat, consider making that the primary meal time. I know quite a few people who can just about always eat breakfast, and although for an entire family sitting down to eat a roast dinner at 7am on a Tuesday is probably unappealing and definitely impractical, there are ways to build it into daily life. And if it means that someone eats at least one full meal each day, then it is worth it.

I'm afraid to give you a hug in case you snap.

None of this is proven, and dealing with the causes of not being able to eat should take priority, but watching someone grow progressively thinner is heartbreaking and hopefully this can help. Remember though, it is about the person who struggles to eat being in control, not anyone else.

I'm going to start with the same disclaimer as The Debutante: this advice isn't medically ratified. A medical professional should identify the underlying cause of any feeding problem, and you should follow the advice they give you.

This is intended to be a list of helpful hints that you may find useful when feeding adults with physical or mental disabilities. My experience is from the viewpoint of speech language pathology (SLP). Feeding is more properly within the scope of practice of an occupational therapist, although SLPs and nurses may also work on feeding issues. Feeding is distinct from swallowing, and refers to the act of getting the food from the plate to the mouth in an appropriate manner. Feeding is ideally something that an individual does for themselves, and the OT will focus on helping a person feed themselves effectively. An SLP is more likely to be focused on the swallow, and if a person has trouble feeding himself the SLP will often feed them without a second thought. Thus, while the advice in this writeup comes from personal and professional experience, it does not constitute as even second-hand medical advice.


Helping With Self-feeding

Even if a person needs hand-over-hand support for feeding, is it best to let them hold the eating utensil. Studies have found that individuals who feed themselves do better than those that are fed by someone else. When a person is fed by someone who guides their hand to their mouth and helps them tip the food off the spoon, they will remain healthier than if they are not part of the feeding process at all. This may be because the action of lifting food to your mouth activates the mental script that guides us through the process of eating. It is admittedly slower and more awkward to help someone hand-over-hand than it is to hold the spoon yourself, and in some cases it may not be practical. Many individuals will loose interest in feeding themselves long before they are full, and in these cases it may also be most effective to take over the feeding.

Modified utensils:

This is usually the last thing that people look at, but in my opinion it should be the first. Often we use bad utensils simply because they are traditional, and while most of us can deal with whatever the table-setter hands us, there's no reason to allow that tyrant to ruin your meal. For example, you can eat almost everything with a spoon. Spoons are generally easier to pick up food with, they will spill less food, and they have fewer sharp points than a fork.

A larger spoon will hold food better than a smaller spoon, but if jaw and lip movement are problematic then small spoons may be easier to get into the mouth. There are also inventions like the spoon and pusher, utensils with twisted handles so that you don't have to bend your wrist to get them into your mouth, weighted utensils that are easier for people with severe tremors to use, utensils with fat handles for individuals with arthritis, and many other modifications. Many of these are hard to come by, but any OT will have catalogs full of them.

Many times a little common sense can go a long way; for example, someone who is having trouble drinking from a cup because they are unable to tilt their head up may benefit from a straw, or even from a glass with a smaller circumference. A confused person who continues to try to eat soup with a knife may benefit from fewer knives. A person who tips over a glass when picking it up may benefit from a mug. Make things as easy and simple as possible!

Modified food:

Obviously, some foods are harder to eat than others. Food is generally easier to eat when it is soft and/or cut into small pieces. This takes some planning on the part of the cook. A hamburger is probably not a good idea (doesn't cut up well), but meatloaf is great. Canned peaches are probably better than fresh, salad is likely to be problem, and boneless chicken is a must. It can be hard to predict what exactly might be a problem, but if you are responsible for feeding someone who has difficulty eating, it is your job to make sure you don't make a mistake more than once. You may want to keep a log/recipe book to remind you of problem foods and successes.

Sometimes more drastic modifications are necessary. Food can be puréed or thickened to make it easier to manipulate and move to the mouth. Generally these types of things are done to aid with swallowing problems, but for someone who cannot get their soup to their mouth, a thickening agent (available at your local drugstore, or add corn starch) may be preferable to drinking it from a cup or a straw. Puréeing food can be very unappetizing; I would not recommend it for most foods except as a last resort, but sometimes is can be both effective and delicious; for example, cauliflower and broccoli work very well mashed with potatoes. Many foods are naturally the texture of purée: apple sauce, pudding, oatmeal, grits, creamed corn, and yogurt, for example.

Finger foods may be a good option. A surprising amount of food can be eaten simply by picking it up. These foods often have downsides; finger foods are usually finger foods because they are hard to eat, and nearly always take multiple bites to finish. Foods that are not generally eaten by hand tend to be messy. But you may find that a person who is hopeless with silverware is fine with their fingers, and this may be worth the mess. Make sure they wash their hands! Keep in mind that eating is, at least on occasion, a social event, so it is important to keep basic table manner skills intact. Practice using a spoon or fork every meal, even if the main dish is apple slices and cheese cubes.

Taste is also an important part of eating. As people age, their taste buds often start to fade. Strongly flavored food and alternating bites of salty and sweet foods can help keep the meal interesting and motivating. Older individuals may wish to add lots of salt or sugar to foods that are not traditionally flavored as such; as long as excessive salt or sugar aren't causing health problems, there's nothing wrong with this.

When feeding is a problem, nutrition is also likely to be a problem. In a hospital there will be a nutritionist to help make sure that dietary needs are meet, but if you are taking care of an individual in your home, you may have to wing it. Monitor the intake of not only vitamins and minerals, but also of calories, protein, and liquids. Malnutrition and dehydration can be serious issues for those who are not eating enough. There are high-calorie and protein foods available, and liquids can be snuck into the diet in the form of jello, soup, applesauce, and other watery foods.


Feeding Others

Posture and Seating:

Generally, it's best to be sitting upright when eating. This helps keep one alert and awake, reduces the risk of choking and silent aspiration, and allows the person being fed to be as aware as possible of what is going on during the feeding. For those with postural instability, it may be necessary to prop them up with cushions or provide them with head/neck cushions for support. It is important for the head and neck to be upright, so for those with a severe forward arch to their spine, a reclining chair may useful.

Your positioning is also important; you should sit so that the person you are feeding can see you and what you are doing. This is particularly important when feeding people with dementia or other mental issues that may cause them be unaware of what is happening, or to forget what's going on in between bites. It may be useful to raise the spoon up to eye level before moving it to their mouth, in order to remind them that a bite is coming, and verbal reminders can also be useful, particularity when changing between food and drink.

The Feeding :

Feeding is often surprisingly easy if you are paying attention to the person being fed. We are very good at seeing what people need and expect, and the act of putting food into mouth is not unfamiliar to us. But you do need to be paying attention. You should not try feeding someone when you are in a rush or distracted. This is an important activity, and it deserves your full attention.

When feeding someone you will probably want to use a spoon and plastic cup. Nothing that will stab or chip a tooth. The hardest part of feeding another person is often helping them drink from a cup, so if they can handle a straw you may prefer to use one; keep in mind that it is easier to choke when using a straw, so be aware of any potential swallowing problems the person you are feeding may have.

When dealing with reluctant eaters it is often necessary to be very firm with the person you are feeding. Eating is a necessary requirement for staying alive, so you are justified in being pushy and stubborn. But it is very literally life threatening to force feed anyone, and moreover you do not want eating to be unpleasant. If you cause the person you are feeding to avoid meals, you are being counterproductive. Be ready to joke, cajole, and bribe, but also know when to stop. Be insistent but not obnoxious or overbearing. By far the best way to learn these skills is by observing someone who has lots of experience (and patience) while they help with a feeding.

When feeding, be reliable. Stay at the table, and don't allow yourself to become distracted. Don't change things just for the sake of change. Don't make the last spoonful extra big. Don't say "two more bites" and then insist of four. Don't give someone a piping hot mouthful without warning "careful, it's hot!". When you see that something isn't working, engage your brain and try to fix what you are doing, not the person you are feeding! You are helping because feeding is already a problem, don't make it worse.

And for God's sake, wash you hands before the meal!

Stimulating Eating:

In some cases you may get the food to your ward's mouth only to find that they are not ready for it, or are unwilling to eat it. I've already written about the importance of texture, taste, and positioning, but there are other factors that may help.

Make sure that you wait for the person you are feeding to have cleared all of the food from the previous bite from their mouth. Stuffing someone's mouth is dangerous, and may lead to choking and aspiration pneumonia; either of these can lead to death. Watch for their swallow, and be aware that in some cases it may take more than one swallow to get all the food down. It may also help to alternate bites and sips, as the sips of liquid will help clear any food residue remaining from the last bite.

Once you put the spoon in their mouth, it may help to press down lightly on their tongue in order to trigger chewing and swallowing. In some cases it may be effective to keep silverware in a cup of ice water; the cold will help provide sensory stimulation and cue chewing. Be careful! If someone does not automatically start chewing when food enters their mouth, you really need to reassess whether or not they are ready to be fed right now. If this is a regular occurrence, you should consult with a medical professional.

Do not push a spoon or straw too far into the mouth. A straw only needs to pass just barely between the lips, and the spoon shouldn't pass mid-tongue. However, touching the lips and tongue may help stimulate eating and swallowing behaviors. When spoon feeding someone, try to get the food past their teeth; it is not good for food to collect in the front of the teeth.

If a person does not automatically swallow, you may be able to cue them to swallow by touching their lips with the spoon, or stroking their throat. Neither of these are particularly reliable, but they are worth a try. In my experience the single most effective cue to swallow is to say "swallow!". In some cases, the person simply does not want to swallow; people with dementia may intentionally store food in their cheeks to avoid swallowing it; in cases like these your best bet may be to alter the diet to foods that are both motivating and hard to pouch (i.e., pudding). Many people find it easier to spit out food residue that remains after the swallow than to try swallowing it again. This is not always appropriate, but consider it as a viable option. Having a good supply of napkins to spit into may save everyone a lot of trouble.

Saving Face:

It is important to keep meal time as positive and stress-free as possible. It is very bad for someone to decide that they don't want to eat because it is too hard or too embarrassing. One thing you have to monitor when feeding someone is how the feeding makes them feel. This is different for everyone.

There are a lot of rules that you may come across: make sure you offer the person you are feeding a chance at everything being served; let them do as much as possible for themselves; avoid trouble foods when eating with company; have them eat with people with the same level of feeding skills as them when possible; and so on and so on. These are only rules of thumb. It may make meals more pleasurable if food choices are limited and simple, if someone takes care of troublesome actions, if a traditional turkey is served at Thanksgiving (and damn the bones!), and if everyone can just eat with whoever they like to eat with. No rule is hard and fast when it comes to making individuals comfortable.

This is the most subjective part of feeding, and you will have to pay close attention and come to know the person you are helping very well. Some people will be mortified when trying to eat messy foods in public, while others will be fine spitting gristle on the floor. The correct actions on your part will involve knowing not only the person you are helping to feed, but also knowing the situation in which they will be eating. This is by far the hardest part of feeding, and also the hardest one to give advice on.

However, you should be aware of the opinions of family members. You should consider carefully what to do with drooled food (with babies we tend to scoop it back up and stick it back in the mouth. This may not be appropriate with adults) and spilled food. You should know how the person you are helping used to eat before they needed help. You should know how the person you are helping feels about you. You should consider how your helping appears to them. And you should be ready to explain, converse, and take feedback whenever possible.




Warning Signs:

Most of the advice above is highly dependent on the individual being fed, and much of it will not apply in your situation. I hope that at least some of it was useful, and that you can use it as a starting point to finding out what works best for you. However, there are certain warning signs that you need to be aware of. Sudden weight loss, or slow weight loss over a long period, are both dangerous and require medical attention. Coughing, choking, and wet or gurgly voice or breathing sounds are not good. You may be able to 'fix' these problems on your own by avoiding foods that cause these problems, but they are a symptom of dysfunction in the throat and need to be evaluated by a professional. Pain may be unavoidable in some cases, but it should never be ignored. See a doctor and find out what is causing the pain and what can be done about it.

Although the account I give above makes feeding sound like a potentially overwhelming task, it should not be a battle or a backbreaking chore. There are many avenues through which you can find help. Eating is medically important, and your doctor can refer you to highly trained and experienced professionals that can give you help and advice. While it may be stressful to think about such things, you may also need to consider home health care, respite care or an assisted living facility or nursing home. Medicare and other government programs will often help pay for help with feeding, as will many insurance plans. 'Feeding' support groups are few and far between, but there are support groups for just about every specific disease and disorder, and they will often talk about feeding problems specific to that population. These groups will often have better information than a general article like this can give you.

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