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Nutrition,support,nudging and learning disabilities

Understanding how people with learning disabilities (LD) might be able to change their dietary patterns and make healthier choices around food could be a game changer in order to keep them healthier and increase their lifespan.

People with Learning disabilities are more likely to be overweight (compared to the general population), often due to poorly balanced diets and low levels of physical activity.

In response to this extra weight and inactivity they may suffer from health conditions such as:

  • heart disease

  • high blood pressure

  • strokes

  • diabetes

  • several types of cancer

  • mobility difficulties

Life expectancy for women is 27% and for men 22% shorter than the general population. Obesity is also higher than average at 37% compared to 26% in the general population.

Public Health England (PHE) reported that a mixture of poor diets and excess weight are associated with premature death,illness and mortality. Links to social issues such as poverty, poor housing and social isolation are all key factors and all of which are experienced disproportionately by people with learning disabilities. Data collected from GP’s across the UK showed that people with LD were more likely to be obese (37%) than the general population (30%).

Difficulty of Change

Changing dietary behaviour is not easy, especially since eating habits and dietary practices are often well established.

Around 60 to 70% of people who are on the autistic spectrum will have a learning disability. This is important to be aware of as autistic people often have sensory issues that could affect not only food choices but also the environment where they are happy to eat.

People with learning disabilities or their families and care services often mention issues about capacity and choice around diet and physical activity as being difficult, this can include:

  • supporters such as family or staff struggling to contribute to best interest decisions

  • dilemmas about balancing choice and the duty of care and balancing different risks and benefits

  • paid supporters can feel limited in their capacity to influence food choices

Dangers of Poor Diets

Eating unhealthy diets that are high in processed foods can lead to high levels of sodium, which causes high blood pressure. These foods also lack important essential nutrients that are vital for good health.

Eating such a diet can and often does lead to malnutrition. The reason for this may well be out of the individual’s control: for instance having oral motor difficulties; food allergies; medication effects; suffering from choking; gastro problems and suffering with dental issues.

Overall there is a lack of knowledge around nutrition and what foods to eat. Fussy eating is a key element, often leading to processed food being consumed.

Annual health checks

PHE together with Voluntary Organisations Disability Group have developed a health charter for social care providers offering support promoting health and access to healthcare. This is accompanied by guidance for commissioners and providers

To support and encourage progress, a tool kit is provided as part of the charter, to allow ways to encourage discussion to help ascertain the current situation and where changes can be made. There is an opportunity to evidence base these findings which will help to support findings. Team meetings and supervision sessions are a good time to talk about areas that need change, try and include clients with LD and their families into discussion as they will have thoughts and opinions. The aim is to be able to support clients with LD with opportunities to improve their health and wellbeing.

It is important for people with LD to have an annual health check as an opportunity to review:

  • Health

  • LIfestyle

  • Medication

  • Risks associated with health and wellbeing

After a health check, it is a requirement that a health action plan is produced. This will look at actions to support the results of the health check.

If weight gain is observed, the GP might recommend actions that can be supported by family and support workers.

GP’s might also review medication that is associated with weight gain, and if diabetes is present, look at ways to support and manage this.

The individual themselves should be encouraged to eat healthily and do more exercise where this is feasible. Of course this may be challenging, so ways to support this are what the rest of this article focuses on.

Importance of Family and Support Staff

There is a wide variety of capability amongst those with LD. Some are able to cook for themselves. Some have a reliance on caregivers to make their meals. For the latter group, food offered might well be not their first choice since caregivers will often cook meals that they themselves are comfortable with and know how to make. Cooking healthy meals for clients with LD is not easy as preferences are hard to change.

The benefits of having family and/or support workers supporting change are huge as they offer both motivation and practical support.

  • Motivation to make changes and eat more healthily

  • Help plan healthy meals and support cooking

  • Encourage increased activity

  • Look at the best interests

  • Act as role models

However there are barriers too.

  • A lack of knowledge around nutrition, wha food to buy, and how to cook it

  • Time - often in short supply resulting in less healthy ready meals and fast food options.

  • Food and drink benign used a means of reward

The role of support staff who look after clients is vital in terms of promoting healthy diets and supporting behavioural change. Provider organisations have a duty of care to their clients to provide them with a health optimising environment, as defined within the Health and Social Care Act.27 and the Mental Capacity Act. They have a responsibility to meet individuals’ health needs and should ensure that staff are competent to meet these needs by providing training in health promotion, specific to this population group.

Role of Organisations

Organisations have a responsibility to ensure that appropriate staffing levels and infrastructure are in place to enable individuals to meet physical activity and dietary recommendations, and their policies should provide guidance around the expectations of the organisation in terms of consistent promotion of healthy diet and physical activity.

However clients are encouraged to make their own independent choices around food and have the capacity to make this decision to look after themselves where diet is concerned. This leaves the care sector in a difficult position where diet is concerned.

Staff supporting clients with LD is key to promoting dietary change and supporting weight loss. Often clients will not have the motivation to make change and the support from staff is essential to help to facilitate change.

Training staff around diet and nutrition is then paramount to assist staff to help support clients to make changes. This can cover the following areas:

  • Basic cooking skills

  • Diet and healthy eating

  • Sensory impairments

Public Health England Research

In order to look at how interventions could be beneficial and help changes to be made, Public health England carried out some research. [Public Health England (2020) Obesity and Weight Management for People with Learning Disabilities]

This looked at how Interventions were carried out with both clients with learning disabilities and their carers.

The overall results were that online cooking videos worked well, especially if the cooking was facilitated by people with learning difficulties themselves.

Video Tutorials

Clients were encouraged to showcase recipes that they liked and were then were videoed in the process of making the meal. Clients were filmed cooking and explaining what they were doing at each stage. One example involved cooking a Christmas dinner, showing that people with LD are able to be independent. This encourages learning the safe use of knives, ovens and other equipment.

The videos were initially supported with a recipe sheet, with photos depicting each step. This was found to pose problems as the picture was taken too literally. For instance in the example of zesting of a lemon, the whole lemon was grated rather than simply grating some zest. In response to this, realtime visual examples, broken down into bite-size clips are needed.

Safe Cooking Times

The length of time food is cooked is vital to ensure that it is cooked properly, neither overcooked nor raw. This is especially true where chicken is concerned, being such a high risk for food poisoning. This can be a difficult concept. One solution was for colour-coded timers to be used, where colours matched recipes.

Hand Hygiene

Handwashing presented a major challenge where raw meat,especially chicken, was being handled. Recipe books, videos and easy to read leaflets failed to address these problems.

There might have been a prompt to wash hands at the start of the recipe book, but the instruction was never repeated, so became forgotten by the time the meal was prepared. Therefore hand washing needs to be added as a step within recipes immediately after any step where raw meat is handled.

Training for Clients.

In order to help clients with learning disabilities make changes it is important to support behavioural change and diet preferences. That means training, ideally to nudge participants in the direction of better diets.

Clients with LD reported that they loved taking part in the cooking videos. They enjoyed the food, but reported the following deterrents to healthy eating:

  • Not liking the consistency of uncooked fruit.

  • Wanting to eat junk food when they were feeling sad;

  • Being tempted by unhealthy options in shops

Training was also offered to support staff, nurses, GPs and others who interacted with clients with LD.

Training for Support staff and Carers

The research concluded that people with LD often have diets that lack essential nutrients. In order to support this group it is vital that carers and other professionals think imaginatively as to how they can best help and support them to promote healthy lifestyles.

Training should be offered for staff to understand not only healthy eating but how to work with their clients to help them to make changes overall that will helpfully facilitate long lasting change.

Some simple initiatives that training can introduce are:

  • Using smaller plates for meals

  • Smaller portion sizes

  • Linking healthy snacks with activities

  • Learning about healthy eating from childhood so that good routine are established early in life

  • Motivating clients by recognising success such as losing weight or choosing healthy options

  • Setting achievable goals to adopt healthier eating

  • Instigating behavioural change

Nudge Effects

The nudge effect was promoted as a way to encourage behaviour change. This is the concept of using positive reinforcement and indirect suggestion to influence people’s behaviour and decisions to encourage them to make healthy choices.

Where diet is concerned, the approach uses a combination of food availability, positive reinforcement and subtle suggestions to influence decision making. There is a growing body of evidence that it can improve lifestyle behaviours in both institutional work and school settings (Williamson et al, 2013).”

The nudge was broken into three different methods

Cognitive nudges

  • Using symbols to indicate healthy options on menu boards and the sheets clients use to choose their meal options;

  • Placing healthy foods at eye level

Affective nudges

  • Describing foods using appetising terminology to draw attention to healthy options

Behavioural nudges

  • Placing healthy vegetables at the start of a buffet

  • Using smaller plates to encourage people to eat less

  • Using larger glasses so individuals stay hydrated

  • Making healthy options more convenient; for example by placing chopped veggie sticks and fruit in easy reach, and chocolate at the back


The importance of diet for people with LD cannot be overstated. It not only contributes to their quality of life but the extent of their life too. Carers and support staff owe it to their clients to prioritise this issue.

The excellent research by Public Health England shows a way forward through training for staff and for learning materials for clients that can nudge towards better outcomes for all concerned.


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