Why won’t they eat?

This leaflet aims to answer frequently asked questions about appetite and weight loss when the person you are caring for is very ill. It accompanies the one on fluids and the use of artifical hydration in advanced disease and is aimed mainly at carers. However, some patients may also find this information helpful.

1 Why have they stopped eating? I keep cooking tempting dishes and they just push them away

Many people with serious illnesses such as cancer or heart failure lose their appetite as they become less well. Sometimes there is an obvious cause like feeling sick or having a sore mouth which medication can help. However, very often the illness itself causes the loss of appetite. It can feel very hurtful when the person you are caring for pushes food away, especially when you have taken trouble to make something they like, but it is important to remember that it is not meant to upset you. They just don’t feel like eating, and often feel bad about that themselves. It may help to talk to the nurse or doctor about how it makes you both feel.

2 Why does this happen?

Many cancers and some other illnesses make the body produce chemicals which break down muscle and fat faster than it should. These chemicals also ‘trick’ the part of the brain that controls appetite into thinking that the person is full after only a few mouthfuls or even after no food at all. These chemical changes will only go away if the underlying illness is successfully treated.

3 But won’t they starve to death if they don’t eat?

The answer is no. Changes that occur in the human body during severe illnesses such as advanced cancer or heart failure are completely different from those that happen in healthy people who have been forced to go short of food.* In advanced illness, people can start to lose weight even when their appetite is still fairly normal because the body is no longer able to use the food it is given to build itself up. This is why the appetite gets smaller – the body seems to recognise that it can no longer cope with food. Surprisingly, people with advanced illness often live for some time after they have stopped eating completely, although it is often one of the signs that the person is beginning to get less well.

4 Are there alternative feeding methods? What about ‘drip’ or ‘tube’ feeding?

We know from research** that neither drip nor tube feeding will make most people with advanced cancer put on weight or live any longer. Feeding via a tube through the nose into the stomach (nasogastric tube) or directly through a hole into the stomach (gastrostomy) is provided for some people who have an appetite but are not able to eat properly, but this is only done in certain specific circumstances. Drip-feeding (given into a vein, called TPN or total parenteral nutrition) is done very rarely and usually for just a short time, for example after some types of bowel surgery. It is not helpful to people with advanced illnesses.***

5 What will happen to someone who is already being fed through a tube? Will their food be stopped?

At any time an ill person has the right to say that they want to stop being artificially fed and to have the tube removed.*** If they get less well, their appetite may also get smaller, and decisions may then have to be made about whether artificial feeding should be stopped.

If they become too ill to make that decision, the doctors and nurses will make a careful assessment and discuss fully with the patient’s family the right thing to do. The ultimate responsibility for decisions about starting and stopping artificial feeding rests with the senior doctor caring for the patient.

Sometimes it can do more harm than good to carry on feeding. The sort of harmful effects that could happen when someone is in the last few days of their life and very weak include regurgitation, sickness and food spilling over into the lungs (‘aspiration’).

6 Things that may help

  • Offer small meals or snacks spread out over the day rather than large meals that can be off-putting.
  • Don’t worry too much about balanced meals, ‘a little of what you fancy does you good’.
  • You might find it helpful to talk to a dietician about different sorts of meals and foods. Ask the nurse or doctor if this would help.
  • Food supplements such as Ensure® and Fortisip® can be obtained on prescription. These can help if the person you are caring for likes them.
  • Alcohol can sometimes help to stimulate appetite and will not usually interfere with medication (but please check first with the doctor or nurse).
  • Gentle exercise can help and slow up muscle loss; a physiotherapist may be able to advise you further, ask your nurse.
  • As the ill person becomes weaker, you may notice that food begins to go down the ‘wrong way’ causing them to cough and splutter. This may be a problem that can be solved by changing the texture of the food and by ensuring as upright a position as possible while eating. It could also be a sign that they are getting less well.

7 Are there any medications that can help with appetite or weight gain?

Some medications, such as steroids and progestogens, can help boost appetite. Often the effect is only temporary. However, any weight gained in this way is only fat or fluid and not muscle (which is the most useful).

*Esper DH, Harb WA. The cancer cachexia syndrome: a review of metabolic and clinical manifestations. Nutr Clin Pract. 2005 Aug;20(4):369-76.
**Inui A. Cancer Anorexia-Cachexia Syndrome. CA Cancer J Clin 2002; 52: 72 – 91
***Partridge R, Campbell C, (2007) Artificial Nutrition and Hydration – Guidance in End of Life Care for Adults. A joint publication between National Council for Palliative Care and The Association of Palliative Medicine. ISBN: 978-1-898915-53-9