Appetite 43 (2004) 269–276 www.elsevier.com/locate/appet Research Report Old and alone: barriers to healthy eating in older men living on their own Georgina Hughes, Kate M. Bennett, Marion M. Hetherington* Department of Psychology, University of Liverpool, Eleanor Rathbone Building, Liverpool, L69 7ZA, UK Received 10 December 2003; revised 29 March 2004; accepted 11 June 2004 Abstract Ageing is associated with reduced energy intake and loss of appetite. Older men tend to have poorer dietary intakes including consumption of fewer fruits and vegetables in comparison to older women. Living and eating alone further diminishes food consumption and dietary quality. Nutrition and Eating Behaviours of Aging People
The aim of the present study was to explore food choice and energy intake in older men living alone using both quantitative and qualitative methods. 39 older men were interviewed and completed questionnaires on health, food choice, dietary patterns and appetite. Few men managed to consume recommended levels of energy, essential trace elements or vitamins A and D. Age and BMI failed to predict patterns of intake, but men with good cooking skills reported better physical health and higher intake of vegetables. Nutrition & Eating Behaviors of Aging People
However, cooking skills were negatively correlated with energy intake. Men who managed to consume at least 4 portions of fruits and vegetables each day had significantly higher vitamin C levels, a greater percentage of energy as protein and generally more adequate diets. Interviews revealed that poor cooking skills and low motivation to change eating habits may constitute barriers to improving energy intake, healthy eating and appetite in older men (193). q 2004 Elsevier Ltd. All rights reserved. Keywords: Ageing; Food intake; Cooking; Fruits and vegetables; 5-a-day; Appetite Ageing is characterized by a decrease in activity (Drewnowski & Warren-Mears, 2001), a decline in lean body mass (Morley, Baumgartner, Roubenoff, Mayer, & Nair, 2001) and loss of appetite (Hetherington, 1999). Nutrition and Eating Behaviours of Aging People
Poor nutritional status and low energy intake may increase the risk of diet-related illnesses (Drewnowski & Shultz, 2001) and affect cognitive performance (Ortega et al., 1997). Taken together, poor diet impacts upon quality of life through compromised health outcomes and lower general functioning. Evidence of lower energy intakes is derived from largescale USA nutritional surveys (NHANES, 1994) and in Europe (Sjogren, Osterberg, & Steen, 1994). Nutrition and Eating Behaviours of Aging People
These suggest that many older adults do not meet daily energy requirements. Indeed low energy intake is often coupled with nutrient deficiency in both free-living older adults and those in care settings (Vellas et al., 2001). Inadequate nutrition is linked to the anorexia of ageing and to changes in social status. In addition to the characteristic loss of sensory acuity * Corresponding author. E-mail address: firstname.lastname@example.org (M.M. Hetherington). 0195-6663/$ – see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2004.06.002 and desire to eat with old age (Hetherington, 1999), widowhood and bereavement may compromise nutrition and health (Bennett, 1998). Nutrition and Eating Behaviours of Aging People
A key element of the general trend to eat less with ageing is that quantity and quality of food intake are affected by a number of modifiable factors including cooking skills (for a discussion see Caraher, Dixon, Lang, & Carr-Hill, 1999), nutritional knowledge (Baker & Wardle, 2003) and social engagement (Donini, Savina, & Cannella, 2003). Thus, although appetite tends to diminish with old age, there are nevertheless several potential routes available to delay or reduce these changes. It has been well established in younger adults, that eating in social groups enhances food intake by as much as 40% (de Castro, 1994). Nutrition and Eating Behaviours of Aging People
When older adults were invited to a laboratory to eat with familiar others intake was enhanced by 60% (McAlpine, Harper, McMurdo, Bolton-Smith, & Hetherington, 2003). Healthy older adults therefore respond to social contexts in the same way as younger adults, but opportunities to eat meals with family and friends may diminish. During the Nottingham Longitudinal Study of Activity and Ageing (NLSAA) older adults were asked who did 270 G. Hughes et al. / Appetite 43 (2004) 269–276 the cooking. There were significant gender differences in who cooked, with women cooking significantly more than men. Nutrition and Eating Behaviours of Aging People
These gender differences were reduced but not eradicated when controlling for marital status. Men living alone cooked more than married men but still significantly less than women who lived alone. There is also evidence that as the respondents aged they cooked less, with relatives, friends and formal support agencies cooking on behalf of the respondent (see Bennett, 1998, for a discussion of gender and domestic activities). Similarly, a more recent study (Bennett, Hughes & Smith, 2003) revealed that a small, but nonetheless significant issue in the experience of widowhood is that of cooking and nutrition more generally. Nutrition and Eating Behaviours of Aging People
Many widowed men rely on luncheon clubs, family and ‘ready meals’ to provide dietary intake. A small minority of the men interviewed prepared substantial meals and enjoyed cooking. Indeed, these men were predominantly those men widowed at a younger age with a family to raise. During interviews participants suggested that women are better able to deal with widowhood, largely because of their perceived greater domestic experience (e.g. cooking and shopping). Nutrition and Eating Behaviours of Aging People
Healthy eating is both desirable and achievable in old age despite changes in appetite regulation. Women appear to fare better than men in valuing and achieving a healthy diet. Studies have now shown that older women consume more fruit and vegetables than men (Baker & Wardle, 2003; Donkin et al., 1998; Johnson et al., 1998) and this seems to be due, in part, to a better awareness of dietary recommendations in women (Baker & Wardle). Overall, a significant pattern has emerged from the literature. Nutrition and Eating Behaviours of Aging People
This indicates that barriers to eating sufficient energy and choosing healthy foods in older adults include both the consequences of normal ageing for the control of appetite, and changes in psychosocial circumstances which may exacerbate diminished appetite such as fewer social eating occasions, poor cooking skills, bereavement and loss. The aim of this study was to investigate barriers to healthy eating, focusing on energy intake, food choice (specifically fruits and vegetables), cooking skills and well-being in a group of older men living alone. Nutrition and Eating Behaviours of Aging People
To date, most studies on appetite in older adults have applied quantitative methods and many have focused on women. Therefore, the approach adopted was to apply both quantitative and qualitative research methods to further our understanding of the experience of older men living alone in relation to appetite, food choice and diet quality. This approach permits a deeper analysis of attitudes, beliefs and feelings, which lie behind data taken from diet records and questionnaires. Nutrition and Eating Behaviours of Aging People
Interviews were used to complement and extend quantitative analyses. In particular, intake of fruits and vegetables was quantified using recall, interview and food frequency questionnaires, and then characteristics of those achieving the recommended five portions of fruits and vegetables each day were profiled. Methods Participants Older men were recruited from the Merseyside area, a largely urban region of the north west of England. Nutrition and Eating Behaviours of Aging People
The aims of the project were communicated to a wide range of formal and informal groups of older people. Contact was made with welfare organisations, social services and sheltered housing schemes, who then circulated details of the study within their groups. Flyers were posted in libraries, drop-in centres and other public spaces known to be used by older people. An ‘expression of interest’ form was completed and returned by those people interested in taking part in the study.
A suitable time and venue for interview was then arranged. All who volunteered were recruited to the study. Thirty-nine men aged between 62 and 94 years (MZ74) living alone were interviewed and completed questionnaires on health, food frequency, and dietary intake (one participant did not complete the questionnaire data as he was unwell on the day of testing). Nutrition & Eating Behaviors of Aging People
Characteristics of the sample are summarised in Table 1. Eighteen were widowed (46%), 14 were single and had never married (36%), 6 were divorced (15%) and one man was married but his wife was in care. 92% of participants were retired and 8% currently unemployed.
Former employment of the participants, classified traditionally, were professional (2.5%), managerial (21%), skilled (31%), partly skilled (15%) and unskilled (28%) with 1 unknown occupation (2.5%). All participants had kitchen facilities where they could prepare their own meals. No-one was totally reliant on others for meal provision or preparation. Procedure The men were interviewed at home (nZ12), at a day centre (nZ3), sheltered housing office (nZ1) or in the laboratory (nZ23) according to preference. Questionnaires were administered in the same place.
Body weight Table 1 Mean (SD) and range of characteristics and data from the sample Variable Mean SD Range Age in years BMI Daily Energy Intake (Mcal) Daily fruit and vegetables portions Daily vitamin C (g) Daily alcohol (g) Physical healtha Self-assessed healtha Symptoms of anxietya Symptoms of depressiona Life satisfactionb Social engagementb 74.8 26.5 1.87 2.79 72 10.6 5.53 25.64 1.95 1.45 17.24 16.16 8.21 3.55 0.52 1.82 49.4 18.1 2.27 4.61 2.34 2.41 4.16 3.62 62–94 21.2–34.9 1–3.13 0–6.75 4–225 0–89 1–11 16–37 0–8 0–10 5–26 8–23 a b Higher scores indicate poorer outcomes.
Higher scores indicate better outcomes. G. Hughes et al. / Appetite 43 (2004) 269–276 and height were calculated using a stadiometer (Leicester Height Measure distributed by Seca Limited, Birmingham) and portable scales (Seca 770, Hamburg, Germany). Body mass index was calculated as weight (kg)/[height(m)]2. Two 24-h food recall questionnaires were conducted, one on a weekday (Monday, nZ12, Tuesday, nZ14, Wednesday, nZ8, Thursday, nZ3, Friday, nZ1) and the other on a day during the weekend (Sunday).
Both recalls were completed within two weeks and collected by the same, trained individual (GH). Materials To assess physical and mental health, general well-being and mood, questionnaires used in the Nottingham Longitudinal Study of Activity and Ageing (Morgan, 1998) were utilised. The questionnaires enquired about physical and mental health, self assessed levels of health (subjective health); symptoms of anxiety and depression, life satisfaction and social engagement. Details of smoking and alcohol consumption were also recorded. Interviews All interviews were tape-recorded (Sanyo Compact Cassette Recorder TRC-960C and Sanyo MM01 Conference Microphone) and then transcribed. Nutrition and Eating Behaviours of Aging People
The interview began by asking respondents general questions about family, living circumstances, previous occupation and then set questions relating to diet and activity (what constitutes a healthy diet; how important it is; how easy or difficult it is to maintain); appetite (changes in appetite or weight; skipping meals/forgetting to eat); shopping and dietary choices (meal planning; access to shops; food purchases; eating out; eating fast food); circumstances of eating (eating alone or not; meal patterns and timing); domestic skills (cooking; home help; domestic assistance; growing own food). Nutrition and Eating Behaviours of Aging People
Finally, the interviewer invited the respondent to discuss any strategies they thought might assist other men living alone to achieve a healthy diet. Food intake To determine typical dietary intake two methods were employed. Nutrition & Eating Behaviors of Aging People
First was a Food Frequency Questionnaire (FFQ: Margetts, Cade, & Osmond, 1989) which asks respondents to indicate how often they eat particular types of food. Second respondents were asked to report food intake over two 24-h periods, adapting the multiple pass technique (Conway, Ingwerson, Vinyard, & Moshfegh, 2003) for 24-h dietary recall.
Two members of the team were trained in use of multiple-pass dietary recalls, which were conducted face to face or over the phone and randomized across condition and day of recall. ‘Multiplepass’ refers to the method of extracting dietary information 271 via a series of prompts in order to obtain as accurate recall as possible. For the purposes of this report, daily energy intake, percentage of energy from protein, fat and carbohydrate, vitamin C and alcohol intake will be reported alongside fruit and vegetable intake from recall and the FFQ. Data analysis The interviews were analysed using grounded theory and content analysis (see Bennett & Vidal-Hall, 2000, for a detailed description of the analytical technique).
Four members of the team coded the interviews and inter-rater reliability was 80%. QSR NUD*IST revision 4 (QSR International Pty Ltd) software was used to assist in this process. Statistical analysis of questionnaires was carried out by SPSS (v11). The multiple-pass 24-h food recalls were analysed using WISPw (V2.00, Tinuviel, Warrington) nutritional analysis
software. Energy and nutrient intakes are compared against UK reference nutrient intakes (RNI) (Department of Health, 1991). Nutrition and Eating Behaviours of Aging People
These are calculated on the basis of the age, sex, BMI and physical activity level of each participant. It was assumed that the men were relatively sedentary and so low levels of physical activity were used as the standard for all participants for dietary analyses. Results In order to investigate possible barriers to healthy eating the data was examined under four themes investigating the following areas: health and well-being, energy and nutrient intakes, cooking skills, and fruit and vegetable intake. Nutrition and Eating Behaviours of Aging People
The questionnaires provided numerical data on health
and well-being, energy and nutrient intakes, and fruit and vegetable intake, whilst cooking skills were extracted from the interview data. The interviews were also used to provide clarification relating to these themes, as illustrated later. All data are presented as mean GSD, unless otherwise stated. Nutrition and Eating Behaviours of Aging People
Health and well-being Ages ranged from ‘young old’ (62 years) to ‘very old’ (94 years). Health status varied across the sample, but chronological age did not correlate with self-assessed health, physical health, life satisfaction, mood or social engagement. Body mass index also varied across the sample, with 21 normal weight, 8 overweight (BMIR27!30) and 8 men classified as obese (BMIR30). A comparison of variables by weight status revealed no significant differences in health and well-being. There were 8 smokers and 31 non-smokers in the sample.
Analysis of variance revealed no significant differences in any of the health and well-being variables although smokers were significantly younger (68.2G6 years) than non-smokers (76.5G8 years, p!0.01). 272 G. Hughes et al. / Appetite 43 (2004) 269–276 Overall, reported levels of subjective health correlated positively with physical health, r(35)Z0.346, p!0.05, and negatively with life satisfaction, r(35)ZK0.408, p!0.01. Thus better subjective health corresponded with better physical well-being, and poor subjective health was related to a lower life satisfaction.
Nutrition & Eating Behaviors of Aging People
Life satisfaction was also highly correlated with social engagement, r(37)Z0.555, p!0.001. As expected, scores of depression and anxiety were closely linked, r(37)Z0.805, p!0.0001, but these mood variables did not correlate significantly with any of the health and well-being questionnaires. Energy and nutrient intakes Energy intake was calculated from 24-h recalls for each day then averaged across the two days for all dietary reference values. Most men (nZ25, 64%) consumed less energy on average than recommended (adjusted for BMI, physical activity and age). Only 4 of the men (10%) managed to consume at or above the RNI on at least one day. Considering diet quality, most of the men had low intakes from sources of potassium, calcium, magnesium, copper and zinc.
All of the men had below the RNI for Vitamin D and almost half of the sample failed to meet the RNI for Vitamin A. In contrast most of the men (65%) consumed above the RNI for Vitamin C and around half of the men (47%) did not drink any alcohol on either of the dietary recall days. Energy intake was positively correlated with amount (g) of alcohol consumed, r(37)Z0.406, p!0.01, thus for those consuming alcohol on the days of the dietary recall, energy from alcohol boosted overall intake, although on average energy from alcohol constituted only 6.7G5.7% of total energy intake (i.e. an amount within recommended guidelines). Nutrition and Eating Behaviours of Aging People
Normal weight men (87G57 g) consumed more Vitamin C than overweight and obese men (54.8G30 g; pZ0.05). However, the most significant differences between members of the sample were observed when the men were categorized by their cooking skills. Cooking skills The data has been shaped by a combination of participants’ interpretations of cooking skills and the researcher’s understanding of the meanings attributed to these skills. Participants were asked if they cooked, if someone else cooked for them, if they heated food and how they described their cooking skills. Nutrition and Eating Behaviours of Aging People
This question was subsequently coded as 1 ‘no, poor or basic’, 2 ‘adequate’ or 3 ‘good’. Coding was based on the participants’ descriptions, using their exact words. Therefore ‘no, poor or basic skills’ were stated as such by the participants. Basic skills differed from our coding of ‘adequate’ because from reading the interviews ‘basic’ skills appeared to imply a lack of necessary skills, whereas ‘adequate’ was specifically referred to by participants as being adequate for their needs.
For example Participant 28, age 86 years, described his cooking skills: “They’re adequate for what I need.” ‘Good’ skills were identified from the answer to this question where participants said they were good cooks and/or they offered a list of skills. This is illustrated as follows: Q. How would you describe your cooking skills? “Above average. (laughs) I can cook a joint, I can cook fish, I can poach a salmon, I can make me sauces, I can do er it’s hard to describe this—seems like boasting (laughs). Nutrition & Eating Behaviors of Aging People
I can cook pastry, I can cook cake, I can cook bread. Q. Nutrition and Eating Behaviours of Aging People
Do you use a pressure cooker? Yes. Very fond of it. (laughs) Q. What do you use it for? “I use that to make soups, stuff like that.” [Participant 33, age 76 years] Good cooking skills are also illustrated by this participant, in the following way: “Good. I’m a good cook. I watch it, I don’t go away and leave it. Nutrition and Eating Behaviours of Aging People. Nutrition and Eating Behaviours of Aging People
If I’m cooking vegetables broccoli and stuff like that—tri minuto—huh OK. Only soon as it’s done three minutes off. Because it’s just nice for chewing it’s crisp, they’re not soft, They’re not boiled, you haven’t boiled all the goodness out of them. Three minutes dead.” [Participant 30, age 94 years]. Using these categories, the men were compared on a number of different parameters (see Fig. 1). Nutrition and Eating Behaviours of Aging People
Men with good cooking skills reported better physical health, F(2,34)Z 7.077, p!0.01, and consumed more vegetables than men with poorer cooking skills, F(2,34)Z3.545, p!0.05, which then contributed to a significant overall effect on fruit and vegetable intake. Energy intake was negatively correlated with cooking skills, r(34)ZK0.336, p!0.05, suggesting that men with better cooking skills consumed less energy than men with poor or adequate skills. Nutrition and Eating Behaviours
of Aging People. Nutrition and Eating Behaviours of Aging People
This relationship Fig. 1. Cooking skills, physical health and intake of fruits and vegetables. G. Hughes et al. / Appetite 43 (2004) 269–276 may, in part, be explained by the observation that men with good cooking skills consumed more vegetables and these foods tend to be low in energy density thus contributing to a lower overall energy intake. Those eating more fruit and vegetables did not just eat more of ev … Nutrition & Eating Behaviors of Aging People