Stopping Eating and Drinking by Advance Directives (SED by AD) in Assisted Living and Nursing Homes.

The Ethics Subcommittee of AMDA-The Society for Post-Acute and Long-Term Care Medicine ("The Society") presents arguments for and against Stopping Eating and Drinking by Advance Directives (SED by AD). SED by AD is a type of advance directive in which a proxy is instructed to stop offering food and fluids to a person when they reach a certain stage of dementia. Although most conversations regarding SED by AD focus on patient autonomy and the right to determine one's care, we propose that the ethical principle of justice-the obligation to treat all individuals equally regardless of race, gender, and physical or cognitive ability-is the decisive principle in this controversy. We also suggest that implementing SED by AD can violate a physician's obligation to beneficence and nonmaleficence. On the other hand, we identify with the families of our patients who see the refusal to follow an advance directive as an injustice of the highest order. In the end, The Society is convinced that no choice can be made here without practicing an injustice: if one refuses to implement SED by AD, one violates the autonomy of the person who drew up the advance directive. If, on the other hand, one refuses food and fluid to a resident who still accepts food, one risks practicing an injustice against that person as they are now. Recognizing that we have the greatest responsibility to our patients as they present to us in the residential setting, The Society recommends against implementing SED by AD in residents who still accept food and fluids, implementing instead, a policy of comfort feeding for those with advanced dementia.

Negative prompts aimed at maintaining eating independence.

BACKGROUND: Psychological abuse of older people is difficult to recognise; specifically, nursing home residents have been documented to be at higher risk of psychological abuse during daily care, such as during feeding. Healthcare professionals adopt positive and negative verbal prompts to maintain residents' eating independence; however, negative prompts' purposes and implications have never been discussed to date. RESEARCH AIMS: To critically analyse negative verbal prompts given during mealtimes as forms of abuse of older individuals and violation of ethical principles. RESEARCH DESIGN: This is a secondary analysis of three cases of negative prompts that emerged in a large descriptive study based upon focus group methodology and involving 13 nursing homes and 54 healthcare professionals. PARTICIPANTS AND RESEARCH CONTEXT: This study included 3 out of 13 nursing homes caring for residents with moderate/severe functional dependence in self-feeding mainly due to dementia; in these nursing homes, we conducted three focus groups and 13 healthcare professionals participated. ETHICAL CONSIDERATIONS: This study was conducted in accordance with the Human Subject Research Ethics Committee guidelines after being approved by the Review Board of the Trust. FINDINGS: With the intent of maintaining self-feeding independence, negative verbal prompts have been reported as being used by nursing home teams. By critically analysing these negative prompts, it turned out they could trigger intimidation, depression and anxiety and thus could be considered as forms of abuse; moreover, negative prompts can threaten the ethical principles of (1) autonomy using a paternalist approach, (2) beneficence and non-maleficence as with the intent to act in the best interests of residents (to maintain self-feeding independence) they are harmed in their dignity and (3) justice, given that residents who received negative prompts are treated differently from those who received positive prompts. DISCUSSION: Eating should be a pleasant experience with a positive impact on physiological, psychological and social well-being. However, negative prompting can lead to abuse and violation of basic ethical principles, destroying the healthcare professional resident and relative relationships strongly dependent on trust. CONCLUSION: Negative verbal prompting must be avoided.

Cap a una alimentació ètica. Aproximació teòrico-pràctica a les dietes vegetarianes / Hacia una alimentación ética. Aproximación teórico-práctica a las dietas vegetarianas / Towards an ethical food. Theoretical and practical approaches to a vegetarian diet

Des que tenia cinc anys en Tom Watkins s'alimentava seguint exclusivament una dieta crudivegana. L'any 2008 nombroses veus es van alçar en contra de la seva mare per la manera com aquesta l'alimentava, ja que consideraven tenia conseqüències negatives per la salut del menor. L'estudi d'aquest cas ens permetrà, prenent com a referència els principis de la bioètica i la deontologia professional, discutir quines són les possibilitats de les que disposem per abordar conflictes com aquest. Debatrem les característiques del model alimentari actual, i veurem com d'allunyat n'està de poder-se considerar saludable i respectuós tant amb el medi ambient com amb els animals. I finalment ens preguntarem sobre quin ha de ser el paper del dietista-nutricionista a l'hora de tractar qüestions com aquestes

Desde que tenía cinco años, Tom Watkins se alimentaba siguiendo exclusivamente una dieta crudivegana. El año 2008, numerosas voces se alzaron en contra de su madre por la manera en que lo alimentaba, ya que consideraban que tenía consecuencias negativas para la salud del menor. El estudio de este caso nos permitirá, tomando como referencia los principios de la bioética y la deontología profesional, discutir cuáles son las posibilidades de las que disponemos para abordar conflictos como este. Debatiremos las características del modelo alimentario actual y veremos cuán alejado está de poder considerarlo saludable y respetuoso tanto con el medio ambiente como con los animales. Finalmente nos preguntaremos cuál debe ser el papel del dietista-nutricionista a la hora de tratar cuestiones como éstas

Since he was five years old, Tom Watkins was exclusively fed following a raw vegan diet. In 2008, many people started criticizing his mother for the way she was feeding her son, as they considered this diet had negative consequences for the minor's health. Analysing this case will allow us, taking as a point of reference the principles of bioethics and professional ethics, to discuss the available possibilities to tackle such conflicts. We will also discuss the characteristics of the current food model and we will see how distant it is from being healthy and respectful with the environment and the other animals. Finally, we will analyse the role of the dietician-nutritionists in dealing with this type of issues

Adolescents' lived experiences of making health choices: an ethical point of view.

This study describes and interprets adolescents' lived experiences of their rights, duties and responsibilities in relation to their health choices. Fourteen focus group interviews with 67 adolescents aged 15 and 16 were conducted and analysed using the phenomenological hermeneutical method. Adolescents' lived experiences of their rights in relation to their health choices were described as things that were allowed. Duties and responsibilities were perceived as something that they were required to carry out for their own health or other people's health. Although their experiences of rights, duties and responsibilities overlapped, they referred to different aspects of their health choices. Adolescents viewed their rights, duties and responsibilities in the wider context, with parents and society defining their opportunities to make independent choices. We found that ethical considerations influenced adolescents' choices and, the opportunities to exercise their rights, duties and responsibilities varied. Further consideration and recognition of these issues are needed.

The Impact of Trained Volunteer Mealtime Assistants on Dietary Intake and Satisfaction with Mealtime Care in Adult Hospital Inpatients: A Systematic Review.

BACKGROUND: Malnutrition is common in hospital inpatients and is associated with increased morbidity and mortality. Insufficient assistance at mealtimes can contribute to this and therefore trained volunteer mealtime assistants may be of benefit. OBJECTIVES: To identify and review the current evidence for the impact of trained volunteer mealtime assistants on dietary intake and satisfaction with mealtime care in adult hospital inpatients. METHODS: A systematic search of Medline, Embase and CINAHL was conducted to identify relevant articles. Articles of any methodology were considered. Quality assessment and data extraction were carried out by two reviewers independently. PARTICIPANTS: Participants were inpatients in a hospital setting, including rehabilitation units. Participants in long term care facilities were excluded. INTERVENTION: Articles that examined the effect of trained volunteer mealtime assistants on nutritional outcomes or satisfaction with mealtime care were included. RESULTS: 5576 articles were identified, of which 14 were included in the review. Nine were small research studies and five were quality improvement initiatives. The quality of eight studies was moderate, with one study being of lower quality. Eight articles reported dietary intake and seven demonstrated an improvement, with protein intakes at volunteer mealtimes increasing by 4.3g-10.1g and energy intakes by 44-105kcal. Ten articles reported positive staff, patient and volunteer feedback. No adverse events were reported. CONCLUSION: There is evidence from small studies and improvement projects that trained volunteer mealtime assistants are safe and improve satisfaction with mealtime care in hospital inpatients, although evidence for an effect on dietary intake was less consistent. Larger studies with robust methodology are required to confirm this.

Coping with unpleasant knowledge: Meat eating among students of environmental studies.

This paper presents qualitative research on the attitudes and behaviors of environmental studies graduate students toward meat eating, and their strategies for coping with the cognitive dissonance induced by the issues related to meat eating and production. The research draws on theoretical and empirical research on the issue of meat eating and the psychological processes involved in it, and by analyzing in-depth interviews it reveals that these students exhibit partially different coping strategies than what studies on general population show, as a result of their awareness and their social circle. The results show that even though these people do not usually regard meat eating as wrong or undesirable in principle, they are well aware of the ethical and environmental issues related to it. In their attitudes and behavior the students are significantly influenced by their friends and fellow students amongst whom they perceive avoiding meat as a social norm. A generalization of the results suggests that the psychological dynamics of meat eating among environmentally informed and engaged people in general may be different than in general population. Further research into this group of people is proposed, most importantly from a socio-cultural point of view.

Understanding Urban Demand for Wild Meat in Vietnam: Implications for Conservation Actions.

Vietnam is a significant consumer of wildlife, particularly wild meat, in urban restaurant settings. To meet this demand, poaching of wildlife is widespread, threatening regional and international biodiversity. Previous interventions to tackle illegal and potentially unsustainable consumption of wild meat in Vietnam have generally focused on limiting supply. While critical, they have been impeded by a lack of resources, the presence of increasingly organised criminal networks and corruption. Attention is, therefore, turning to the consumer, but a paucity of research investigating consumer demand for wild meat will impede the creation of effective consumer-centred interventions. Here we used a mixed-methods research approach comprising a hypothetical choice modelling survey and qualitative interviews to explore the drivers of wild meat consumption and consumer preferences among residents of Ho Chi Minh City, Vietnam. Our findings indicate that demand for wild meat is heterogeneous and highly context specific. Wild-sourced, rare, and expensive wild meat-types are eaten by those situated towards the top of the societal hierarchy to convey wealth and status and are commonly consumed in lucrative business contexts. Cheaper, legal and farmed substitutes for wild-sourced meats are also consumed, but typically in more casual consumption or social drinking settings. We explore the implications of our results for current conservation interventions in Vietnam that attempt to tackle illegal and potentially unsustainable trade in and consumption of wild meat and detail how our research informs future consumer-centric conservation actions.

'You can't be forcing food down 'em': Nursing home carers' perceptions of residents' dining needs.

Malnutrition is a life-threatening condition among older people living in nursing care homes. This qualitative analysis of interview data from five care staff aimed to understand their perceptions of 'caring for' residents' nutritional needs. Tensions in the delivery of care and institutionalisation and disempowerment were identified. Despite carers' good intentions, they often failed to recognise the importance of the psychosocial aspects of mealtimes. Staff shortages, routine-driven, medically based working practices and residents' resistance to institutionalisation emerged as barriers to quality caregiving. The findings indicate that the relational aspects of care are constrained by social, structural and ideological contexts.

Translation and Validation of the Food Neophobia Scale (FNS) to the Brazilian Portuguese / Traducción y validación de la escala de neofobia alimentaria (ena) para el Portugués de Brasil

Introduction: The Food Neophobia Scale (FNS), originally developed in English, has been widely used in different studies to assess the individual’s willingness to try new foods. However, a process of translation and cultural adaptation is required to enable the use of FNS in other countries. Objective: to translate and to validate the FNS into Brazilian Portuguese. Methods: the FNS was translated into Brazilian Portuguese by three English teachers independently and back-translated into English by other three professionals. After that, both the English and Brazilian Portuguese FNS versions were administered to a sample of 40 graduate students of the University of Campinas, São Paulo, Brazil, between September and October 2014. The reproducibility between the instruments was assessed by the intra-class correlation coefficient (ICC). The internal reliability of the scale was evaluated by Cronbach’s Alpha coefficient. The FNS total score ranged from 10-70 and the respondents were classified as food neophilic (≤16.4), neutral (16.5-38.5) and food neophobic (≥38.6). Results: the ICC between the items of the original FNS and the Brazilian FNS ranged between 0.266 and 0.815 (P< 0.05). The total score of the FNS was 0.903 (p< 0.001). Cronbach’s alpha coefficient was 0.916. Most respondents were classified as neutral (72.5%), other 10% as neophilics, and only 17.5% as neophobics. Conclusion: the Brazilian version of the FNS proved to be an adequate and reliable tool to measure food neophobia. Yet, further research is required to investigate the presence of food neophobia in Brazilian population and to analyse its impact on food behavior (AU)

Introducción: La Escala de Neofobia Alimentaria (ENA), desarrollada originalmente en lengua inglesa, ha sido ampliamente utilizada en diferentes estudios para evaluar el deseo individual de probar nuevos alimentos. Sin embargo, es necesario un proceso de traducción y adaptación cultural para permitir su uso en otros países. Objetivo: traducir y validar la ENA en portugués brasileño. Métodos: la escala fue traducida al portugués, de forma independiente, por tres profesores de inglés, siendo traducido al revés al inglés por otros tres profesionales del sector. Se entregaron estas traduciones a una muestra de 40 estudiantes de posgrado de la Universidad de Campinas, São Paulo (Brasil), entre septiembre y octubre de 2014. La reproducibilidad entre los instrumentos se evaluó por medio del coeficiente de correlación intraclase (CCI). La confiabilidad interna de la escala se evaluó por medio del coeficiente alfa de Cronbach. La puntuación total de la ENA varió 10-70 y los individuos fueron clasificados con neofilia alimentaria (≤16,4), neutralidad (16,5-38,5) y neofobia alimentaria (≥38,6). Resultados: el CCI entre los ítems de la versión original y traducida se situó entre 0,266 y 0,815 (p< 0,05) y la puntuación total de la ENA fue 0,903 (p< 0,001). El coeficiente alfa de Cronbach fue 0,916. La mayoría de los encuestados fueron clasificados como neutrales (72,5%), el otro 10% como neofilia y solo el 17,5% con neofobia alimentaria. Conclusiones: la versión brasileña de la ENA resultó ser una herramienta adecuada y confiable para medir la neofobia alimentaria. No obstante, se necesitan investigaciones futuras para evaluar la presencia de neofobia alimentaria en la población brasileña y para analizar su impacto en la conducta alimentaria (AU)

Development of the HELIUS food frequency questionnaires: ethnic-specific questionnaires to assess the diet of a multiethnic population in The Netherlands.

OBJECTIVES: Ethnic minorities are often not included in studies of diet and health because of a lack of validated instruments to assess their habitual diets. Given the increased ethnic diversity in many high-income countries, insight into the diets of ethnic minorities is needed for the development of nutritional policies and interventions. In this paper, we describe the development of ethnic-specific food frequency questionnaires (FFQs) to study the diets of Surinamese (African and South Asian), Turkish, Moroccan and ethnic Dutch residents of The Netherlands. METHODS: An existing Dutch FFQ was adapted and formed the basis for three new FFQs. Information on food intake was obtained from single 24 h recalls. Food items were selected according to their percentage contribution to and variance in absolute nutrient intake of the respective ethnic groups. A nutrient database for each FFQ was constructed, consisting of data from the Dutch Food Composition table; data on ethnic foods were based on new chemical analyses and available international data. RESULTS: We developed four ethnic-specific FFQs using a standardised approach that included ~200 food items each and that covered more than 90% of the intake of the main nutrients of interest. CONCLUSIONS: The developed FFQs will enable standardised and comparable assessment of the diet of five different ethnic groups and provide insight into the role of diet in differences in health between ethnic groups. The methodology described in this paper and the choices made during the development phase may be useful in developing similar FFQs in other settings.

Underlying differences between conscientious omnivores and vegetarians in the evaluation of meat and animals.

As criticisms of factory farming continue to mount, an increasing number of individuals have changed their existing dietary practices. Perhaps the two most important options for those reacting against industrial farming are (1) vegetarianism/veganism (i.e., veg*nism), the avoidance of animal flesh/all animal products; and (2) conscientious omnivorism (CO), the consumption of meat or fish only when it satisfies certain ethical standards. While the former group has recently received much attention in the social science literature, studies specifically examining those who identify themselves as COs have been virtually nonexistent. The present research sought to investigate possible underlying attitudinal differences between the two groups. Results indicated that relative to veg*ns, COs evaluated animals less favorably, meat more favorably, and were lower in idealism, misanthropy, and ingroup identification. Mediation analysis demonstrated that differences between COs and veg*ns in the perceived acceptability of killing animals for food were mediated by beliefs about animals and meat. The discussion largely speculates on the causal direction of these effects.

Efforts to overcome vegetarian-induced dissonance among meat eaters.

Meat eaters face dissonance whether it results from inconsistency ("I eat meat; I don't like to hurt animals"), aversive consequences ("I eat meat; eating meat harms animals"), or threats to self image ("I eat meat; compassionate people don't hurt animals"). The present work proposes that there are a number of strategies that omnivores adopt to reduce this dissonance including avoidance, dissociation, perceived behavioral change, denial of animal pain, denial of animal mind, pro-meat justifications, reducing perceived choice, and actual behavioral change. The presence of vegetarians was speculated to cause meat eating to be a scrutinized behavior, remind meat eaters of their discomfort, and undermine the effectiveness of these strategies. It was therefore hypothesized that exposure to a description of a vegetarian would lead omnivores to embrace dissonance-reducing strategies. Supporting this hypothesis, participants who read a vignette about a vegetarian denied animal mind more than participants who read about a gluten-free individual. It was also hypothesized that omnivores would be sensitive to individual differences between vegetarians and would demonstrate using dissonance-reducing strategies more when the situation failed to provide cognitions consonant with eating meat or to reduce dissonant cognitions. Four experiments supported this prediction and found that authentic vegetarians, vegetarians freely making the decision to abandon meat, consistent vegetarians, and anticipating moral reproach from vegetarians produced greater endorsement of dissonance-reducing strategies than their counterpart conditions.

Differences between health and ethical vegetarians. Strength of conviction, nutrition knowledge, dietary restriction, and duration of adherence.

Little research has been published concerning the differences between health oriented and ethically oriented vegetarians. The present study compared differences in conviction, nutrition knowledge, dietary restriction, and duration of adherence to vegetarianism between the two groups. Subjects completed an online survey and were grouped by original reason for becoming vegetarian (n=292, 58 health, 234 ethical), and current reason for remaining vegetarian (n=281, 49 health, 232 ethical). Whether grouped by current or original motivation, ethical vegetarians scored higher on the conviction instrument than health vegetarians and exhibited somewhat greater dietary restriction (significant when grouped by current motivation) and had been vegetarian for longer (significant when grouped by original motivation). Nutrition knowledge did not differ between the two groups. The results suggest that ethical vegetarians could experience stronger feelings of conviction and consume fewer animal products than health vegetarians, and may remain vegetarian longer. More research is necessary to understand how vegetarians' eating behaviors are influenced by their motivational profiles.

Prácticas, hábitos y conductas vs educación y cultura alimentarias / Practices, habits and behaviors vs food education and culture

Pretender establecer un discurso desde la filosofía en aspectos tan complejos en el mundo de hoy, como lo son la educación y la cultura alimentarias, requiere de un análisis desprejuiciado de la realidad externa e interna, precisamente porque sus componentes por naturaleza apuntan a la discusión, filosófica o no, dependiendo de los saberes de quienes se inserten en los debates. Por regla general, visualizar las complejidades de esta temática, debe hacerse desde las actuaciones en las comunidades e intervenir en ellas. De lo contrario se corre el riesgo de acuñar determinados presupuestos, sean educativos o culturales, que en el mejor de los casos, establece un reduccionismo en el que se lacera la esencia de estos conceptos (AU)

To try to establish a discourse from philosophy in such complex aspects in today?s world as food education and culture, requires an analysis without prejudices of the external and internal reality, since their components by nature point to the discussion, philosophical or not, depending on the knowledge of those who are inserted in the debates. As a general rule, the complexities of this theme should be visualized from the performances in the communities and to intervene in them. Otherwise, certain assumption may be established, either educational or cultural, that at best oversimplifies the essence of these concepts (AU)

Hábitos y Trastornos Alimenticios asociados a factores Socio-demográficos, Físicos y Conductuales en Universitarios de Cartagena, Colombia / Eating habits and disorders associated to socio-demographic, physical and behavioural factors in university students, Cartagena Colombia

Objetivo. Describir la prevalencia de hábitos y desórdenes alimenticios en universitarios y relacionarlos con factores socio-demográficos, físicos y conductuales. Diseño. Estudio de corte transversal. Emplazamiento. Municipio de Cartagena de Indias, Colombia. Participantes. Un total de 1.040 estudiantes de los programas diurnos y nocturnos de la Universidad de Cartagena. Mediciones principales. Se utilizó una encuesta estructurada para evaluar hábitos alimenticios y aspectos socio-demográficos, EAT-26 y SCOFF para trastornos alimenticios y escala de Holmes and Rahe para la susceptibilidad de enfermar. Se estimó la ocurrencia a través de prevalencias, las relaciones entre variables a través de razones de disparidad y el análisis multivariable mediante regresión logística nominal. Resultados. El motivo más frecuente para no alimentarse bien fue la falta de costumbre y tiempo. La susceptibilidad de enfermar fue del 23,1% y el riesgo de anorexia y bulimia del 14,2%. En el análisis multivariable el mejor modelo con el SCOFF mostró significación estadística con edad (OR: 1,86), susceptibilidad de enfermar (OR: 1,77), dieta (OR: 2,81), problemas de colon (OR: 1,8) y no realizar actividad física (OR: 3,04). Conclusiones. Los hábitos y trastornos de alimentación en estudiantes universitarios están influidos por factores relacionados con el quehacer universitario, siendo necesario considerar este comportamiento alimentario como un problema relevante que interactúa con el buen desarrollo de las actividades académicas (AU)

Objective. To describe the prevalence of eating habits and disorders in university students and their relationship with socio-demographic, physical and behavioural factors. Design. Cross-sectional study Setting. Municipality of Cartagena de Indias, Colombia. Participants. 1040 students in day and evening programmes at the University of Cartagena. Main measurements. A structured questionnaire was used to assess eating habits and socio-demographic factors; EAT-26 and SCOFF for eating disorders and the Holmes and Rahe scale for the susceptibility to disease. Occurrence was estimated by prevalence, assuming confidence 95% intervals. Relationships between variables were evaluated using odds ratios and multivariate analysis using nominal logistic regression. Results. The most common reason for not eating well was the lack of habit and time. Susceptibility to disease was 23.1% and the risk of anorexia and bulimia 14.2%. The best model for logistic regression with SCOFF showed statistical significance with age (OR: 1.86), susceptibility to disease (OR: 1.77), diet (OR: 2.81), colon problems (OR: 1.8), and lack of physical activity (OR: 3.04). Conclusions. Eating habits and disorders in university students are influenced by factors related to university life. This behavior should be considered as a serious problem that one that interferes with the smooth running of academic activities (AU)