Yesterday I mentioned that I had recently lost a little weight – part of a fitness regime with some alterations to my diet.
Our society has a strange relationship with weight.
If you are too heavy, existing beyond a certain idealised body mass index (obesity), it is considered bad, too little, skinny below that ideal (anorexia), also bad.
Most, like everything in nature hovers around a norm.
There are certain parts of the UK where normal is larger than other places. I won’t call-out those towns or cities.
Weight gain is considered bad, as is weight loss, particularly if it impacts or is related to your health.
We talk about a ‘healthy weight’.
Weight is of course dependent on many factors – your height, your frame, the size of your bones, adiposity and so on.
I won’t say I have a fixation with weight although it is quite important to me, from a professional rather than personal perspective.
I use it as a marker of the health of my patients.
Most very old people tend to be on the light side of normal.
It is a fact that those who are very overweight tend not to live into their 90’s. usually strokes, heart attacks or cancer get them long before. You can of course be unlucky, faulty genetics perhaps or too many cigarettes and die young with an ideal body weight, although statistics would be against that.
I saw a man last week who weights 50Kg.
For some that might be OK, for others a little too low. A decade before he had weighed almost 100Kg.
In those ten years had has lost half his body weight, half his mass has disappeared.
He is ill, he has dementia and other conditions.
Each week as I travel round the nursing homes a key indicator of health is a person’s weight. Losing too much and there is usually something going on.
People living with dementia often lose weight, particularly as the disease progresses. Loss of interest in food, forgetting to eat, distractibility and broken sleep patterns all contribute.
And here I am getting to the point.
I’ll add a little caveat first.
You see, weight-gain, perhaps through exercise, gaining muscle mass, is probably the ideal, although if you are in your late 80’s and crippled by arthritis, keep-fit is a struggle.
Weight gain and loss can be due to other factors, one of the most common is the movement of water into and out of the tissues.
People walking about with swollen, oedematous legs are often carrying extra unnecessary kilos.
Equally, prescribing water tablets, diuretics can result in an overall loss of fluid and a drop in weight.
So, weight is complicated. It is, as Hemingway might have said, a moveable feast.
Within the world of health and social care lurk the Safeguarders.
These are teams of men and women, who are employed by healthcare providers and councils to police the safety of those in the system.
You will have heard more often of failures of safeguarding, like the events in Rotherham between the 1980s to the early 2000’s, the Rotherham Child Sex Exploitation Scandal, an example close to home. Or the many instances of Baby P, S, A, Child G, and so on, where safeguards failed and children died or were harmed.
The Safeguarders are custodians. Intent on keeping people safe.
Most of this is good. It is likely an indicator of an advanced society. No doubt they have been banned or abolished in America.
And yet, there is an inherent risk with safety as a driving force. It can limit possibilities. It can stifle creativity.
Would Baby P rather be alive or witness creativity? Yes, the former.
And yet, if you work within a system that sees every possibility as a threat it can grind you down, it can freeze you in your tracks.
This stops innovation. It prevents people from taking calculated risks or living outside the protocols and guidelines. It can become draconian and restrictive.
And this, I feel has happened within some of the Safeguarding teams that support older people.
Narrowly, weight loss, as I have been discussing is considered bad.
It is a system based on my mum’s philosophy of ‘another gefilte fish won’t hurt’.
And this is the point.
If care homes have residents who are losing weight, they are considered, unless they tick the right boxes (which are mostly, inform the family, inform the doctor, refer to dietetics) causing neglect.
A safeguarding concern will be raised.
Investigations will happen.
Records will be scrutinised, multi-agency meetings will be arranged.
Reports will be written.
And, even with the family, the doctor and the dietician, if the weight continues to fall, that is a double-bad.
Some of my patients are tiny.
They are small of stature, mostly old women. Weighing 45Kg is not unusual. That is over half my weight. Two of them for one of me.
As I said, dementia in particular is associated with weight loss.
Over the past decade there has been a shift in the requirements for entry to a nursing or residential home. (My Papa who in the late 80’s lived in a Care Home in Glasgow and was fit enough to act as a runner for the bookies two miles away, wouldn’t have stood a chance of getting into a home today).
To receive funding from health (NHS) or social care, you must have failed, and often failed repeatedly at home before this is considered.
People progress from one carer a day to two, then three and four, to two carers four times a day, to repeated hospital admission before it is considered appropriate to allow the move to care.
Most of this emphasis is good – people want to remain at home, not move into a home and yet, some very old people, realise that they can’t manage and ask for the move only to be told they do not meet the criteria.
Consequently the average care home resident in the UK is very frail, mostly quite old, the average age in the late 80s (probably older if you are in the South of England), most will have life-limiting conditions – cancer, advanced arthritis, frailty, dementia, Parkinson’s disease.
The ‘average length of stay’ in a nursing home is about a year. This means, that the majority of people within a year of moving to a care home will die, frequently from dementia.
And this is the conundrum.
To gain entry to a care home you have to be old and severely frail.
Old and very frail and in the last year of life often results in weight loss, cognitive and physical decline. It is often part of the natural life course.
And yes, it intersects with the safeguarding machine that sees weight as absolute and misses the person.
Family-doctor-dietician and still losing weight; you must be failing the person, not meeting their needs, not creating innovative or adequately tasty food, not supporting mealtimes, not doing your job.
It is an exhausting treadmill that takes away focus from what matters to the people to what matters to the system. It is a regime that misses the point and focuses on the number of grammes gained or lost from one month to the next. It is easy. It is far easier to focus on this than look at the wider system – the plight of people unnecessarily admitted to hospital, the fractures in primary care as described in this Guardian article by Jacqui Wakefield.
It’s almost lunchtime, maybe I need to eat something.