Care home staff's experiences and views of supporting the dietary management and choices of older residents with obesity.

BACKGROUND
Rising numbers of older people with obesity living in care homes is an international phenomenon. Addressing dietary management of residents with obesity is a cause of debate and controversy. On one hand, the 'obesity paradox' suggests obesity protects against morbidity in frail older people. On the other hand, obesity reduces functional status and restricts activity for this group. This paper considers care home staff's experience and views of supporting dietary management and choice for residents with obesity within the context of this controversy.


DESIGN
In this qualitative study, 33 staff from seven care homes in the North East England participated in focus groups, and data were analysed using Braun and Clarkes's (2006) six-phase thematic analysis approach.


FINDINGS
Findings indicate that participants' support of dietary management and choice for residents with obesity may be strongly influenced by the care home environment. Care priorities, dietary management approaches, care home life and family involvement in residents' dietary intake facilitate and encourage weight gain, and as such, pose challenges for staff attempting to support weight management of residents with obesity.


CONCLUSION
Findings suggest that in the care home setting, nutrition policy, guidelines and service commissioning processes and staff nutrition education should include management of obesity. Furthermore, families should be supported to understand the implications of their own caring behaviours on residents' nutritional status.


| BACKG ROU N D
The provision of nutrition support and the management of nutrition are highly relevant to the nursing care of older people. In contemporary society, the increase of obesity has become a major public health priority, and as the population ages, obesity is a significant and increasing phenomena in the older population (Peralta, Ramos, Lipert, Martins, & Marques, 2018). Research focusing on the prevalence of obesity in care homes, primarily USA-based, show prevalence in these care facilities is increasing significantly (Felix, Bradway, Chisholm, Pradhan, & Weech-Maldonado, 2015;Zhang et al., 2019).
The prevalence of older residents with obesity in European care homes is difficult to estimate as data are limited, although a study of residents' body mass index (BMI) data in Germany and Austria reported that 16% of residents were obese in those countries (Valentini et al., 2009). In the United Kingdom (UK), the British Association for Parenteral and Enteral Nutrition (BAPEN) have completed nutrition screening surveys in care homes, and the most recent, undertaken in 2011, found 11% of the 522 residents surveyed had a BMI of 30 or greater, compared with 9% of 584 residents in 2008. BMI between 25 and 29 also increased from 25% to 32% in that period (Russell & Elia, 2015).
Addressing the increase in obesity in the care home population is a cause of debate and controversy. A number of studies suggest an 'obesity paradox' occurs in the older care home population in that resident body mass indices (BMI) demonstrating obesity are associated with lower mortality (Grabowski, Campbell, & Ellis, 2005;Kaiser et al., 2010;Lee et al., 2014;Souto Barreto, Cadroy, Kelaiditi, Vellas, & Rolland, 2017). Other studies refute this, proposing multi-morbidity associated with older age, and life style-related conditions prohibit research from making meaningful conclusions about the association between obesity and mortality in this age group (Wei Zanandrea, de Souto Bareto, Cesari, Vellas, & Rolland, 2013;Zhou et al., 2017). Nevertheless, 'obesity paradox' findings have resulted in weight loss interventions in older adults being perceived as controversial, and therefore not generally implemented.
Even if a relationship between obesity and mortality is established, a number of studies have found the negative impact of obesity on residents' health quality of life and health status is a reality.
For example, obesity in the care home older population is related to several conditions such as diabetes, hypertension, coronary heart disease and heart failure (Zanandrea et al., 2013), dementia (Atti et al., 2007), skin infections, incontinence and osteoporosis (Folsom et al., 2000;Henderson, Sadlier, & Currie, 2006), falls (Mitchell, Lord, Harvey, & Close, 2015) and depression (Hamer, Batty, & Kivimaki, 2015). Research has also shown a positive relationship between obesity and reduced functional ability in older people, requiring increased support with activities of daily living (Coker & Wolfe, 2017).
The few studies that have explored the care management of residents with obesity (RWO) residing in care homes have revealed a number of care challenges. For example, care home premises are not always adequate to accommodate the care of RWO (Felix, Bradway, Ali, & Li, 2016;Miles et al., 2012). There is a lack of specialist equipment, resources and training to enable staff to provide effective care (Bradway, Miller, Heivly, & Fleshner, 2010;Dimant, 2005;Felix et al., 2016;Marihart, Brunt, & Geraci, 2015).
Also, management of RWO requires more intensive assistance with personal care from staff (Harris, Engberg, & Castle, 2018;Kosar, Thomas, Gozalo, & Mor, 2018) and may increase the risk of work-related injury (Bradway, DiResta, Fleshner, & Polomano, 2008 suggest that these factors are barriers to care home admission for RWO, which result in longer or inappropriate hospital stays. According to studies by Yang andZhang (2014) andMarihart et al. (2015), financial costs of caring for RWO is significantly higher than for non-obese residents.
Finding a solution that accounts for both the 'obesity paradox', and supporting quality of life and health status for care home RWO is problematic. A number of studies propose that weight management interventions should be considered despite the 'obesity paradox' as they can improve function, cognition and mental health (Chau, Cho, Jani, & St Jeor, 2008;Napoli et al., 2014;Payne et al., 2018).
It should be noted that all these authors stress weight management What does this research add to existing knowledge in gerontology?
• Despite increasing numbers of older people with obesity residing in care homes, nutrition policy, management and education focus only on reducing risk of weight loss and malnutrition.
• In care homes, care priorities, dietary management approaches, care home life and family involvement in residents' dietary intake predispose high-calorie food choices for residents.
What are the implications of this new knowledge for nursing care with older people?
• As environmental and contextual factors in care homes for older people facilitate and encourage weight gain, the risk of obesity increases.
• As nutrition policy, management and education focus on reducing risk of weight loss and malnutrition, this poses a challenge for staff attempting to support weight management of residents with obesity.
How could the findings be used to influence policy or practice or research or education?
• In care homes for older people, nutrition policy, guidelines and service commissioning processes and staff nutrition education should include management of obesity.
• In care homes for older people, both staff and families should be supported to understand the implications of their own caring behaviours on residents' nutritional status.
programmes for older people should be developed by experts in nutrition to maximise safe practice.
Within the context of this controversy, care home staff are attempting to balance the provision of high-quality care for RWO. This involves promoting choice and preferences, supporting maintenance of health and mortality status, managing complex co-morbidities and supporting residents to access social activity and interaction.
Given that obesity impacts on all these care activities, it is important to explore how staff support RWO with dietary management and choices. To-date, few studies have considered this area. The aim of this paper was therefore to explore this dilemma.
This paper reports on one aspect of a wider study which aimed to describe the prevalence of obesity in the care home population in North East England; explore care home staff's experiences of caring for RWO, facilitators and barriers to care provision and approaches to weight management; and use insights gained to inform recommendations for the care of older RWO. This article does not represent the study's findings in entirety, but presents one identified theme: supporting the dietary management and choices of older RWO.

| ME THODOLOGY
This study was undertaken by two academic researchers with expertise in gerontological research, based at a North East England university. As this study aimed to explore care home staff's experiences and views of caring for RWO, a qualitative methodology was adopted within a constructivist paradigm. The research team felt that explorations of shared meanings and understandings within organisational, policy and cultural contexts reflected Crotty's (1998, p.42) view 'that all knowledge, and therefore all meaningful reality as such, is contingent upon human practices, being constructed in and out of interaction between human beings and their world, and developed and transmitted within an essentially social context'. COREQ guidelines were used in reporting this study.
Approval to undertake this study was granted by the Faculty of Health and Life Science Ethics Committee, Northumbria University.

| Sample
For convenience, all care homes offering nursing student placements to the university were invited via email to participate in the study (n = 78). The inclusion criterion for care homes was that they provided care for older people. The response rate was low as only seven care homes replied, all seven agreeing to participate. This was considered to reflect judgements that potential participants made about the commitment that focus group participation would require in the context of busy care home environments. Care home managers agreeing to participation were invited to indicate convenient dates/times for focus group interviews. Managers contacted all staff due to be working on those dates/times, providing them with study information sheets and details of how interested parties could contact the research team. The inclusion criterion for staff was that they must have supported residents with dietary management. The aim was to include staff with a variety of roles regarding dietary management in order to capture the views and experiences of staff ordering and preparing food (chefs), supporting residents to eat (health care assistants, registered nurses and students nurses), monitoring nutritional status (registered nurses and student nurses), assessing residents needs prior to admission and providing appropriate facilities and equipment for residents' changing needs (managers and deputy managers). Older person's specialist nurses were included as these staff have particular expertise in the comprehensive assessment and care of older people. Registered mental health nurses were included as in the care home setting, these staff manage the care of older people with mental health conditions and dementia. Recruiting participants with a range of responsibilities and input during the dietary care process maximised discussion about all aspects of dietary care.
In total, 33 staff members consented to participate (Table 1). All participants were assigned pseudonyms to preserve their anonymity.

| Data collection
Data were collected via focus group interviews conducted at each care home. Both researchers were involved in data collection. Focus group size ranged from two to eight participants. In two focus groups, some participants joined after the start of the focus group, or left prior to the end of the focus group. This flexible approach was facilitated to ensure individuals could participate while not detracting from resident care. Focus group interviews lasted no longer than one hour. Focus groups provided an opportunity for participants to give in-depth descriptions of their experiences and views of caring for RWO. In relation to RWO, participants were invited to discuss their experiences and views of caring, challenges and facilitators of managing care, policies and practice guidelines, approaches to care, weight management strategies, access to resources and access to support from external agencies.

| Data analysis
Audio recordings were made of the interviews. Audio recorded data were transcribed verbatim. Thematic analysis was chosen as it is 'a method for organising, analysing and reporting patterns (themes) within data. It minimally organises and describes data set in (rich) detail' (Braun & Clarke, 2006, p.79). The approach taken was inductive; in other words, the analysis was data-driven, rather than theory-driven. The six-phase guide to conducting thematic analysis, as outlined by Braun and Clarke (2006) was used.
During this process, each team member independently coded all transcripts then searched for themes. Outcomes were reviewed and compared by the team in order to validate and define the themes. This allowed elucidation and description of participants' experiences, while creating meaningful themes. A number of themes were identified from the analysis. This paper reports on one of the identified themes: supporting the dietary management and choices of older RWO.

| Findings
All participants stated that they do care for RWO. Some said that lack of appropriate resources and equipment limited admissions of individuals with obesity to their care homes, but nevertheless, they come to care for RWO because older people who are admitted with low or normal weights risk becoming obese while living in the care home environment: G5: We encourage eating because we don't want people to lose weight. As professionals, do we do that.
We try and not let them lose weight, so we go too far the other way.
All participants agreed that supporting residents' choice with regard to diet is of paramount importance, regardless whether choices contribute to excessive weight gain: E2: It's their choice and if they want to make that choice, then who are we to take it away from them?
The four sub-themes within the theme of supporting the dietary management and choices of older RWO suggested that this support may be strongly influenced by living in the care home environment.
These sub-themes were as follows: care priorities; dietary management; care home life and family involvement.

| Care priorities
Participants suggested that the primary focus of nutrition care in care homes is the minimisation of the risk of weight loss and malnutrition for residents: E1: Everything is focused on weight loss and malnutrition and not about weight gain and obesity All participants recognised that weight loss was a sign of deterioration in residents' health, and some proposed that being overweight afforded residents a level of health protection, in that it constitutes a 'reserve': G3: When I think they've got a bit of flesh on them, they're more comfortable…because they've got weight they can lose…so I think the weight's not always bad.
They indicated that this focus is reflected in care homes' nutrition policies, which provide directives about supporting residents to maintain a healthy weight, but omit guidance about management of obesity:

| Family involvement
Participants proposed that family involvement in residents' diets may predispose residents to consume foods with high sugar content.
Some participants suggested that families fear that weight loss sig-  for RWO, in many instances both management approaches and residents' choices are biased. This is because the environment and context in which they live predisposes high-calorie food choices. This is not a unique challenge, as it is widely recognised that context and environment strongly influence and prejudice lifestyle management and choice (Elliston, Ferguson, Schüz, & Schüz, 2017;Mackenbacj, Lakerveld, & Brug, 2018;Suglia et al., 2016). In this case, findings and Payne et al. (2018), weight loss interventions for older people should be individualised and supported by nutrition experts in order to ensure safety and effectiveness. However, expert dietitian input is difficult to access because CCGs do not commission and fund dietetic services to support care home RWO unless they have diabetes or are malnourished due to acute weight loss. Lack of acknowledgement of obesity as a challenge by policy, training programmes and service commissioners may contribute to the 'one fits all' practice followed by some of the care homes in the study of fortifying all meals on the menu. This practice ensures residents at risk of weight loss are nutritionally supported, but does not cater for RWO, as according to participants in this study, the main strategy to address obesity-offering smaller portions to this group of residents, does not work.

| D ISCUSS I ON
Food is not simply a means of gaining nutrition, but a cultural and social activity (Higgs & Thomas, 2016 people's feelings and behaviours towards that group (Finkelstein, King, & Voyles, 2015). According to Finkelstein and colleagues, where perceptions of older people as frail are dominant, feelings of pity result in ageist behaviours.
Participants said that most food brought in by families is by way of a gift, so tends to be 'treat' foods such as chocolate, cake and biscuits. Some participants said that where a resident has obesity, staff discourage families from bringing in these foodstuffs, but their recommendations often go unheeded. Some felt that families require education to support their understanding of nutrition. Other participants acknowledged that education may not suffice as a means of behaviour change, as families' actions may be driven by emotive reasons rather than lack of understanding about nutrition. These participants said families use food gifts to demonstrate kindness, or to alleviate the guilt they feel that may arise from 'putting their relative in a home'. According to Pearson, Nay, and Taylor (2004) and Wilkes, Jackson, and Vallido (2008) having a relative residing in a care home can result in family members feeling guilt and distress due to perceiving themselves as having failed to take care of their relative, or feeling uncertain about what their role in the caring process is now.
In this study, a number of participants also commented on the significance of food as the gift of choice. They proposed that families bring food because this is the traditional gift given to patients in hospital. people's quality of life within the care home context (Cooney, 2012;Eyers, Arber, Luff, Young, & Ellmers, 2012). In this study, however, findings suggest that for some residents, lack of access to meaningful activity, including meaningful physical activity, reduces their motivation to exercise and may even contribute to eating to excess.

| Limitations
This study's findings are based upon the responses of a small number of participants located in one region of England.

| CON CLUS IONS/RECOMMENDATIONS
Findings suggest that the care management of obesity is not prioritised in care homes for older people. This seems to be because precedence is given to minimising the risk of weight loss and the associated deterioration in health and mortality. Despite the requirement to address weight loss, effective support and management of obesity is required to ensure residents have the opportunities to enjoy their later years unimpeded by the restrictions that having obesity may impose.
Of course, residents' choice about their dietary habits should be tantamount, but findings of this study suggest that choices are biased because context and environmental factors make high-calorie foods abundantly available, easily accessible and tempting, while healthier alternatives such as lower calorie foods or activities on offer may be less appealing. To address these challenges, health and social care policy makers, service commissioners and care home operational and clinical managers should consider the following:

| Policies, guidelines and service commissioning
Policies and guidelines regarding nutrition support for older people should include management of obesity as well as weight loss and malnutrition prevention and treatment. Dietetic services to support obesity management as well as malnutrition prevention should be commissioned and funded to ensure such services are able to provide support that is specific to the needs of individual care homes and individual residents.

| Staff training/education
Training and education on nutrition should include the management of obesity. Staff need to know how to devise and implement individual nutrition plans that safely support weight management and create meals and snacks that are culturally acceptable and tempting regardless of calorific content, and how to educate and support residents and families with regard to nutrition. Staff training should also highlight links between eating habits and boredom, and the use of meaningful activity, including meaningful physical activity, as an alternative pastime to eating for RWO.

| Resident and family support
Residents and their families need further support to understand the implications of residency in a care home on the whole family. This might include support to: understand that residents can still benefit from health promotion despite age and infirmity; to reflect upon families' role in the caring process; negotiate the complexity of their perceptions of care homes ('homes' and/or healthcare provision facilities); and consider alternative gifts to food where the resident has obesity. • As environmental and contextual factors in care homes for older people facilitate and encourage weight gain, the risk of obesity increases.

CONTRIBUTI ON
• In care homes for older people, nutrition policy, guidelines and service commissioning processes and staff nutrition education should include management of obesity.