This study in Scotland set out to explore this question through the use of semi structured questionnaires and focus groups for key stakeholder groups in a day service.
The authors set out to look at how people who sued the service and those who supported them perceived issues of diet and healthy living. They were particularly keen to explore the choices available, the way these were presented and the impact of the social context on choices made.
The researchers were keen to ensure that all participants consented to participating and offered all written materials in easy read format. Participants with learning disabilities had an information session and an ‘illustrated summary letter’ which enabled them to reflect on whether they wished to participate or not.
The researchers collected data through one-to-one semi-structured interviews and two focus groups conducted with service users.
Carers also completed food diaries for a service user in their care, but these were not used in the analysis as they were not completely with sufficient accuracy.
The interviews with people using the service looked at what people had eaten in recent meals and recent exercise and activity.
Interviews with carers went through a typical day describing food and activity of a participant that they supported.
There was a discussion and exploration of healthy eating and activity along with issues around communication about food and activity and potential barriers to healthy eating or exercise.
The researchers used grounded theory to analyse their data, which was coded into segments which were grouped and collapsed into categories. The researchers then identified themes and their results were presented and analysed through these identified themes.
42 people took part in the study
- 10 family carers
- 10 paid carers
- 10 service users
- 12 project leaders
Four themes were explored in the results
i. Informed choice and autonomy
The researchers pointed out that service user choice and autonomy were central principles guiding the way the service was run. Project leaders recognised the potential power they had but were at pains to point out that they were trying always to promote independence through offering inroation upon which to base choices. The researchers reflect however on the need to ensure that the idea of empowerment should not enable services to avoid responsibility to assess and provide appropriate care and support.
At midday, there were food choices available that included some healthy options but also unhealthy foods and staff offered choice. Some staff quotes included suggested
“We give [him] a choice and give him an informed choice . . . he wants stew and tatties then it’s his choice he’s an adult,” and “it’s freedom of choice and it’s their choice. “
ii. The social setting of food choice
The researchers reflect on the difficulties that may be faced when people try to take what is a fairly clear piece of information, e.g ‘food x is healthy’ and ‘food y is unhealthy’ (leaving aside the fact that these statements themselves may be contentious) and use this as a basis for real choices in real life situations where many other variables come into play as facors that might influence that choice.
They point out that meal times are social times for people using the service and so food choice may be influenced by who people sit with. Quotes from paid staff suggested that even if healthy choices were available people did not necessarily choose healthy options for social reasons, with other people influencing their choices.
iii. Staff attitudes to healthy eating
A key point raised through this theme was that people using the service got inconsistent messages from paid carers. Project leaders talked about some people on their team consistently following the agreed programme and others not.
They also identified difficulties with some staff not being able to disentangle their own thoughts about food for themselves and their families from their approach to supporting people using the service.
Project leaders did not expect staff to act as role models in making their own healthy food choices.
Overall, they found staff attitudes to healthy eating varied, with the encouragement of healthy choices at mealtimes but also using food as a treat, for example, by bringing in sweets and biscuits from home.
iv. Diet at home
They found that for family carers, achieving weight loss was perceived as needing to ‘go on a diet’ rather than make changes in lifestyle to encompass healthy eating. Where there had been successes in terms of weight loss, these had often been short term in nature, unsustainable because of a lack of change in lifestyle.
Diets were also often conceived as limiting certain food types, for example only allowing one packet of crisps a day
The researchers also found an underlying assumption people using the service had limited opportunities for pleasure, so unhealthy food choice was acceptable because of this.
One project leader also talked about how food choice was a source of tension between the day centre staff and family carers with some paid carers suggesting that unhealthy eating habits were developed and maintained in the home setting.
Family carers felt that in their experience changing food habits had had negative effects on family/home life. For some, weight management was not the top priority with meals being made with traditional and affordable ingredients, which were not always particularly healthy.
The authors reflect on the impact of social learning in the day services, whereby socially learned behaviour (guided by observing what other people do) was a powerful shaper of the way people made choices. In this context the lack of consistency in messages about healthy eating may have led to what they describe as an “increased propensity to make impulsive food choices”
They draw attention to the fact that inconsistent implementation of healthy eating policies was tolerated in the service. Behaviours such as inclusion of unhealthy choices on the canteen menu, provision of unhealthy foods for treats and the use of treat foods for social bonding between staff and service users were largely unchallenged by project leaders, which contrasted with more directive healthy eating policies in for example schools or hospitals.
The interesting question at the heart of this conclusion is the balance between promotion of autonomy and choice and the duty of care to promote healthy eating and lifestyle choices.
The authors suggest that autonomy and choice should not extend to “tolerating staff promotion of unhealthy choices, either by inappropriate menu planning or by activities involving treats or the preparation of unhealthy food.” P112
They support the view that healthy eating goals should feature in job descriptions and staff supervision.
They also draw attention to the finding that staff felt that eating habits were learned and maintained in the home. However this appeared to leave paid carers feeling powerless to bring about change or maintain it. The authors suggest the need for a shared approach (they suggest using the Care Programme Approach) to work towards a shared agreement about diet and appropriate food choices whilst in the day centre with each person’s care plan included these agreed solutions to personal and situational barriers to healthy eating. This appears a lot easier to write about than to achieve, but ensuring a process to bring this about and embedding it in the planning processes used by a day service may be a good first step.
Strengths and Limitations
The research team appeared to take a thorough approach to ensuring that the people with disabilities involved in this research consented to take part and that their voice was heard consistently and independently throughout.
It would have been good to know a little more about the sample, for example, what percentage of teh total each group represented and a little about paid carers in terms of their qualifications, length of experience to see whether this impacted on their attitudes.
As a qualitative study using questionnaires, this gives a rich picture of staff attitudes and approaches but I did miss some observational data on what actually happened at mealtimes and also some context in terms of the resources available to the service to support choice.
This is an interesting piece of work that touches on some key issues of balance between choice, autonomy and duty of care. Food is a central issue in many services and getting this balance right in relation to food choice is clearly a complex issue, requiring changes in structures, attitudes and processes as well as continued debate and evaluation on whether we are all getting the balance right.
Food choice by people with intellectual disabilities at day centres: A qualitative study Cartwright L, Reid M, Hammersley R, Blackburn C, Glover L, in Journal of Intellectual Disabilities 19(2) 103–115 [abstract]
Biswas A, Vahabzadeh A, Hobbs T, Healy J, Obesity in people with learning disabilities: possible causes and reduction interventions, in Nursing Times, 2010, accessed 10.08.15
NHS Choices, Managing weight with a learning disability, accessed 10.8.15