For the purpose of this assignment, I have used Gibbs’ reflective cycle to reflect on the impact of psychosocial and cultural issues affecting decision making in dietetic practice. For many decades, psychosocial and cultural factors have been researched and recognised as important determinants, which can have serious impact on health and eating behaviour .

In this reflective piece, I have focused on how these factors have the potential to contribute to malnutrition in the elderly. As a consequence, it is imperative that dietitians are able to recognise these issues and consider how they may impact on the negotiated advice (REF).

My subject was a 79 year old lady who had been referred to the dietetic clinic for advice on nutritional support. She had experienced an unintentional weight loss of ten kilograms (‘kg’) over the course of two years, since her husband had passed away. Her drastic weight loss had become a serious concern for her, which led to her referral by her general practitioner (‘GP’).

Description (What happened)

During the consultation, the patient explained that she had lost three kg in one month, which is when she started worrying as she noticed how loose her clothes had become. I examined her food diary and asked a series of questions to find out what she may have been doing differently to account for the weight loss.

She reported her food portions had not changed and that she was eating more in order to gain weight. She seemed to be having a varied diet, although at her last visit to her GP at the beginning of the year, she was informed that she had impaired fasting glucose (‘IFG’). She had therefore decreased her intake of sugary foods as she was afraid of becoming diabetic.

Another major event that had occurred more recently was that she had moved to a smaller place which was more suitable for her since she was now on her own.

Feelings (What were you thinking/feeling)

When she mentioned she was now a widow, I sympathised with her and immediately thought this was the reason for her weight loss. Further questioning revealed that she had battled with loneliness following the loss of her husband of 55 years. . Several psychosocial factors emerged from this initial part of the consultation, which can be regarded as pressures felt by the patient . The first two included bereavement, which is classified as one of life’s stresses, and the state of depression, which she may have endured following this traumatic event ..

A significant attribute of bereavement and depression is appetite loss, which is also accountable for high mortality rates in the first six months of the loss of a loved one. In this case, she no longer had anyone to appreciate her cooking efforts and the deprivation of companionship at mealtimes becomes a reminder of her loss. A time intended for communication, joy and bonding had become a painful experience, leading to lack of interest in any activity related to food or eating. The reduced enjoyment of the social aspect of mealtimes had made eating more of a chore .

It is important to remember eating as a social variable and recognise that it is part of our self and social identity, which also makes it a cultural variable. It is a structured part of one’s everyday life and a valued social activity for most married people. Food habits developed throughout life are an important component of culture and strongly influences food decisions. Therefore, the stress of bereavement has the power to alter the social, psychological and cultural significance of food during this difficult time .

These issues were sensitively addressed in the consultation. The patient reported that the support of her son had helped her through the grieving process and that she had accepted the loss and was moving on.

Other social determinants which impact eating behaviour include access to food, and ability to cook food and share meals with others . The patient reported she was doing her own weekly shopping and that she had started consuming more ready-meals as she still struggled cooking just for herself. Therefore, she only cooked when her son and family came to visit at the weekend . I suggested joining a social club in the area where they regularly meet for lunch and other social gatherings, which could help improve her moral , but she was reluctant to do so. She explained that she suffered from urinary incontinence and found it embarrassing having to urinate so frequently when around people.

I thought it would be ideal if she could have that kind of social interaction as it can have a great impact on appetite and meal size. Meal ambiance which incorporates factors such as acquaintance, conversation and pleasantness, have been shown to improve levels of ingestion and is an important stimulus modulated to help stimulate appetite in places such as nursing homes .

The mechanisms by which a person is affected by social support varies depending on the individual, however, the potential support that can be provided from social structures has been shown to aid in maintaining nutrition in certain elderly people .

Relocation and change of environment can also yield negative outcomes in terms of psychosocial disturbances such as, confusion, anxiety, depression and loneliness associated with transferring from one place to another and leaving behind treasured memories or souvenirs of a loved .

Two months prior, she moved to a smaller house, which had been a very stressful time for her. She had settled into the place but she reported having had a hard time adjusting. This is an area I should have explored. For example, had she made any friends in the surroundings or whether she was still able to meet her old friends, was she getting familiar with the new neighbourhood she was in, were there any safety issues that needed addressing which we could help support her with, and so forth. These issues would have a heavy impact on her intake and weight if they were causing her anxiety or depression .

Financial constraint is another psychosocial factor to consider when giving dietary advice, as unaffordability affects intake . The patient reported she drove to do her weekly shopping from a reputable supplier in town. According to her food diary, she did not appear to be restricting herself. However, as research suggests, misreporting of food diaries is common where patients try to present themselves more favourably .

Decline in cognitive function is

Another psychosocial issue I had to consider was the food anxiety which had been created following the IFG test. Her GP had told her she was in the pre-diabetic stage and so she had eliminated most fruit and all high sugar foods from her diet as she was worried about becoming diabetic. The burden of disease caused her to change the way she felt about certain foods . She was now anxious about eating any foods with sugar. I explained that she did not have to exclude sugar from her diet completely. This in turn created confusion as my advice was conflicting that of her GP’s. I explained about glucose absorption and that she could add sugar to her puddings, cereal and so forth, which would slow down absorption of the sugar and help with better blood glucose control but to still avoid pure forms of sugar e.g. sweets. She was relieved to discover that and it seemed to make her happier that she could relax her diet.

From there is an exploration of psychobehavioral models of appetite, and address

issues of depression, bereavement, and social interaction before examination of personality and

anxiety disorders. These issues are then considered as related to cognition and memory.

Cultural factors:

access to appropriate foods

Communication

Attitude, values, beliefs, behaviours – shared by society/population

Psychosocial factors:

Attitude

Peer pressure

Cultural, religious and regional factors: cultural

origins, religious background, beliefs and traditions

of culture and race, geographical region.

DeCultural factors

Food habits are a component of culture that make an important contribution to

the food decisions consumers make

“Food habits are seen as the culturally standardized set of

behaviors in regard to food manifested by individuals who have been reared within

a given cultural tradition.

Although

some view culture and food habits as static and unchanging, it is now recognized

that they are continually changing as they adapt to travel, immigration, and the socioeconomic

environment (Jerome, 1982; Lowenberg et al., 1974; Senauer et al., 1991;

Kittler and Sucher, 1995). When modifying food intakes to meet dietary recommendations

there are certain aspects of food habits that are difficult to change, such as

the concept of meals, meal patterns, the number of meals eaten in a day, when to

eat what during the day, how food is acquired and prepared, the etiquette of eating

and what is considered edible as food.

(Lowenberg et al., 1974; Kittler and Sucher, 1995). Food is always used to satisfy

hunger and to meet nutritional needs. Food is used to promote family unity when

members eat together. It can denote ethnic, regional and national identity. It is used

socially to develop friendships, provide hospitality, as a gift, and as an important

part of holidays, celebrations and special family occasions. In religious rituals and

beliefs certain foods have specific symbolic meanings, or there may be prohibited

foods or food taboos. Food can be used to show status or prestige, make one feel

secure, express feelings and emotions, and to relieve tension, stress or boredom. Food

controls the behavior of others when used as reward, punishment or as a political tool

in protests and hunger strikes.

Evaluation (What was good and bad about the experience)

Why decided to go down that route?

Behavioural change model

Analysis (What sense can you make of the situation)

Conclusion (What else could you have done)

Action plan (If it arose again what would you do)

What have I learnt from this experience

What was the outcome of this experience