Hunger is an urge that needs to be satisfied every day, but food is so much more than sustenance. It is also an expression of our identity and autonomy, of what to eat, when to eat, and whom to eat with.

This urge does not diminish with age or disease. On the contrary, towards the end of life, food becomes a form of comfort and a fulfilment of one’s last wishes and desires.

Food also represents legacy – as beautifully captured in an installation titled Remember, To Eat by artist Shirley Soh with Telok Blangah residents as part of a collaborative programme called Both Sides, Now.

And yet, in our research studies on ageing, we discovered a sad but often overlooked reality in this “foodie” nation: the eating options available to many of our older folk, especially those who require food to be modified in line with the state of their health, are often bland, tepid or unpalatable.

This is not because the caregivers don’t realise how much food means to an ageing person. In the course of our research, we met family caregivers who go to great lengths to prepare their loved one’s favourite dish. We also met community carers who go beyond the call of duty to help satisfy their home-bound elderly clients’ cravings for hawker fare – often at their own expense. This can ease the suffering of those with life-limiting illnesses and mobility issues.

So why hasn’t more attention been paid to this important issue in a nation that is both ageing rapidly and for which eating is a national pastime?
 

We are what we eat, or we eat what we are?

It all comes down to a simple question: Does one eat for pleasure or sustenance?

Sadly, even with many well-meaning carers, the focus seems to be mainly on providing sustenance to the elderly while pleasure gets overlooked.

It’s true that food plays a key role in determining the state of one’s health. Some older people may not eat enough because they have issues with salivation, dry mouth, chewing and swallowing, which can affect their appetite. Some may suffer from depression, while others may simply not be able to afford the food they want.

And yet, giving the elderly access to the food they’d like to eat is critical.

Across our research studies, older Singaporeans have pointed out the importance of eating “heartily and healthily”. Eating healthily should not mean they have to compromise on the pleasure that food gives.

Good food equals good mood. One participant shared: “When you cannot eat well, you got no strength. When you have no strength, you don’t feel like talking to people.”

Another said: “Sometimes people end up hating that they are alive, when your options for food become so limited, when it becomes painful to eat.”

Someone else who survived stomach cancer had suicidal thoughts when he was tube-fed. Being deprived of the pleasure and sensations from eating despite meeting nutritional needs made it hard to feel alive.

Dysphagia, or difficulty in swallowing, becomes more prevalent with age. An estimated 15 per cent of older Singaporeans suffer from dysphagia and are at risk of aspirating or getting food into the lungs. To prevent aspiration, thickeners are added to food and beverages.

But this can have its own knock-on effects and our experience with food in the intermediate and long-term care sector has been, to put it mildly, underwhelming. 

In 2017, television host Anita Kapoor spent two weeks at a nursing home and documented her experience in a 70-minute documentary commissioned by the Lien Foundation. In one memorable scene, she was served a bowl of “slop”, or thick-consistency functional food meant for residents with dysphagia. According to Ms Kapoor, functional food smells like medicine, tastes like vomit, dulls tastebuds, and actually makes you feel sick.

Older residents were captured on camera refusing and spitting out food but were coaxed to eat to fulfil their nutritional intake. “We need to pause to ask our elderly what they want, what their feelings are. We need to stop treating the elderly and eldercare simply as beds and bodies,” Ms Kapoor lamented.

At restaurants, meals are served and intended to enhance pleasure. In contrast, meals served at aged-care facilities and healthcare institutions primarily focus on nourishing and giving energy. The wishes of older adults are not taken into account. The result is that while nutrition is provided, pleasure is lost.

We understand that it would be a tall order to meet the diverse and individualised needs of a large group of patients. Still, the lack of variety, colour, texture and taste in some cases was disheartening.

 
Importance of serving pleasure

We must recognise the crucial role that food plays in the lives of the elderly. If we can focus more on providing them the food they want and need, we can make the lives of older persons happier.

In Singapore, programmes and services geared towards enhancing eating pleasure for persons with dysphagia are gaining traction, but they still lag behind countries like Japan. There are companies providing texture-modified foods that cater to the local palate, including culturally attuned dishes such as chicken rice, hor fun, mee soto and chicken curry. Such offerings bring back a measure of the joy that loved ones associate with meal times.

The Smaller Bites to Swallow Right campaign led by speech therapists at Alexandra Hospital aims to allow individuals with swallowing difficulties to continue enjoying the food they love safely at no extra charge. Participating hawker stalls offer options for food to be chopped, minced or pureed. Yet, in the wider context, meal options continue to be limited for individuals with more advanced swallowing difficulties.

In Japan, elder-friendly restaurants cater to people with dysphagia so generations can dine together. They can eat out in style, interact with loved ones, and savour a range of dishes catered especially for them that vary in choice and flavour.

Meals provide the elderly with a reason to leave the house, a pause in between routines, and an opportunity to interact with others. Meals trigger strong memories of love, comfort, belonging and familiarity. In a care facility, such emotions can enhance the well-being of older persons. The ability to choose where one can sit in the dining space, decide on the menu, when to have the meal, size of portions, and when to finish the meal makes it more enjoyable.

Offering a variety of menu options and accommodating individual preferences provide seniors with control over their dining experience. Involving them in planning and decision-making processes related to food services can create a sense of ownership and has been associated with overall well-being.

These elements are present at Goodlife! Makan, a social initiative driven by Montfort Care to support ageing-in-place and address issues of social isolation and loneliness. The void deck is transformed into an open kitchen and living room where older residents plan, shop, prepare and cook meals together.

It is important we recognise that, for seniors, the importance of food goes beyond its nutritional value. Let’s focus on this to allow them to enjoy what makes life worth living.

• Ad Maulod is a senior research fellow at the Centre for Ageing Research and Education (Care) at Duke-NUS Medical School, Singapore.
• Siti Hazirah Mohamad is a former Care staff member and current public health PhD student at the University of Toronto. She is also a long-term caregiver of a family member with dysphagia.