Older adults' attitudes to food and nutrition: a qualitative study

AUTHOR(S)

Jane Winter, Sarah McNaughton, Caryl Nowson

PUBLICATION DATE

01-12-2016

HANDLE

10536/DRO/DU:30086136

Downloaded from Deakin University’s Figshare repository

Deakin University CRICOS Provider Code: 00113B

Winter, J.E., McNaughton, S.A. and Nowson, C.A. 2016, Older adults' attitudes to food and nutrition:
a qualitative study, The journal of aging research and clinical practice, vol. 5, no. 2, pp. 114-119.

DOI: 10.14283/jarcp.2016.100

This is the published version.

©2016, Journal of Aging Research and Clinical Practice

Reproduced with the kind permission of the copyright owner.

Available from Deakin Research Online:

http://hdl.handle.net/10536/DRO/DU:30086136
Journal of Aging Research & Clinical Practice© J Aging Res Clin Practice 2016;5(2):114-119
Volume 5, Number 2, 2016 Published online May 30, 2016, http://dx.doi.org/10.14283/jarcp.2016.100

ORIGINAL RESEARCH

OLDER ADULTS’ ATTITUDES TO FOOD AND NUTRITION:

A QUALITATIVE STUDY
J.E. Winter, S.A. McNaughton, C.A. Nowson

Abstract: Objective: To explore the factors that influence food choices of older adults and identify potential sources of dietary
advice. Design: A qualitative research design using semi-structured, one on one interviews. Setting: A general medical practice in
Victoria, Australia. Participants: Twelve community dwelling adults aged 75 to 89 (mean 82.8 ± 4.4) years, 92% living alone and 92%
female. Measurements: Interview questions addressed usual daily food pattern, shopping routines, appetite, importance of diet and
potential sources of dietary advice or assistance. Results: Thematic analysis identified key themes influencing food choices were
maintaining independence; value of nutrition; childhood patterns; and health factors. Dietary restrictions and concerns with weight
gain were expressed, and although these were managed independently, the GP was identified as the first source of information
if required. Conclusion: This sample of older adults placed high value on eating well as they age, however a number followed
self-imposed dietary restrictions which have the potential to compromise their nutritional status as dietary requirements change.
Further research is needed into how to communicate changing nutritional needs to this group.

Key words: Elderly, attitudes, nutrition, interviews.

Introduction that early identification of nutritional issues is important

in preventing nutritional decline, (14) older adults can be
Older adults are at risk of under-nutrition due to resistant to dietary interventions. For example, studies
normal physiological changes combined with alterations in community-based seniors in Australia has shown
in food choice, food access and health conditions (1, 2). low uptake of dietetic referrals and resistance to a home
Nutritional studies have shown that older adults tend delivered meal intervention (15, 16), however it is not
towards consuming a lower energy intake (3), smaller clear what sources of information older adults do use, if
meals, slower eating and reduced physical activity (4). any, to make decisions regarding diet or food choice.
Australian data indicate that adults aged over 70 years General practitioners (GPs) and other primary health
consume less energy than younger adults and are less staff such as nurses, have been identified as preferred
likely to meet requirements for protein, riboflavin and providers of nutritional care providing trustworthy and
vitamin B6 (5). personalised care (17), however a study of older adults
Factors that impact on food choice and meal patterns aged 75 years and over suggested some scepticism about
have reported to include social isolation (6), presence of dietary advice provided by GPs (18).
chronic disease resulting in dietary restrictions (7), and This qualitative study aimed to build on current
difficulties with activities of daily living (ADLs) (8, 9). understanding of food choices of community living
Changes to food intake and the consequent impact on older adults and explore potential acceptable sources of
nutritional status can result in increased risk of frailty nutritional advice and support.
and reduced functional capabilities (10, 11).
Prevalence of malnutrition or nutritional risk amongst
Methods
older adults in the community has been reported at
between 16% and 43% (12, 13). Although it is recognised
Participants were community dwelling adults aged
Centre for Physical Activity and Nutrition, School of Exercise and Nutrition 75 years or older who had a health assessment (“75+
Sciences, Deakin University, Burwood, Victoria, Australia health assessment”) within the previous three months
Corresponding Author: J. E. Winter, Centre for Physical Activity and Nutrition,
and were recruited from a general medical practice in
School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Victoria, Australia. The 75+ health assessment is an
Australia, [email protected] annual government funded health assessment offered
Received October 26, 2015
114
Accepted for publication December 18, 2015
JOURNAL OF AGING RESEARCH AND CLINICAL PRACTICE©

Table 1
Interview questions and inquiry logic

Inquiry Logic Interview Question

Understand general social & health situation Living arrangements (where, alone, with spouse, with family)
Any assistance with meals
How would you rate your health
Height / weight
Understand influences of health status on food choices Tell me about any health conditions that influence your diet.
Explore perception of weight on health Can you tell me about your current weight?
Explore food choices and meal patterns What would you usually eat in a typical day:
- Frequency
- Location
- Preparation techniques
Understand whether appetite has affected dietary intake How would you rate your appetite compared with 10 years
ago? Describe changes
Identify issues associated with food access Tell me about how you do your food shopping.
Relative importance or changing role of diet with age. How do you think dietary needs change with age?

Determine sources of advice regarding diet / nutrition Any dietary advice in the past?

to adults aged 75 years or older. Sixty patients who had used to identify emergent themes from the data, coding
most recently attended the practice in May 2014 were sent it without trying to fit it into a pre-existing frame (21).
a letter from the practice inviting them to participate in Transcripts were read through several times and notes
the study. made on general themes and related categories of data.
One on one, semi-structured interviews were Interviews and analyses were conducted by a single
conducted by an experienced dietitian (JW). Qualitative investigator, and a second researcher coded 25% of the
inquiry was used as it is well placed to answer complex transcripts to verify the coding. Any differences were
questions about food behaviours by investigating how discussed until agreement was reached. The transcripts
and why individuals act in certain ways (19). Open- were imported into NVIVO 9 (QSR International Pty Ltd),
ended questions were developed using an inquiry coded according to the initial notes and then categories
logic that reflected the study aims (Table 1). Interview were collapsed to generate themes for each of the four
questions addressed usual daily food pattern, shopping areas of interest: dietary patterns; influences on food
routines, appetite, perceived importance of diet and choices; dietary changes with ageing; and sources of
potential sources of dietary advice. Information was dietary advice.
also collected on age, living situation, weight, and
height. The Mini Nutritional Assessment (MNA®-SF), Results
a validated nutritional screening tool for adults aged
65 years and older, was used to determine nutritional Of the 60 people invited to participate in the study,
risk of the participants. The MNA®-SF comprises six 16 contacted the surgery to arrange an interview time.
questions about food intake, weight loss, mobility, recent Four later withdrew due to illness (three) or confusion
acute illness, cognitive function and body mass index over appointment times (one). Twelve interviews were
(BMI).The study protocol was approved by Faculty of included in the analysis, at which point data saturation
Health Human Ethics Advisory Group on behalf of the was considered to be reached with no new concepts
Deakin University Human Research Advisory Committee emerging. Eleven interviews were conducted in a private
(HEAG-H 48_2014). All participants provided written room at the medical practice, one was conducted at the
informed consent. participant’s home at their request. The average interview
Interviews were audio-recorded and transcribed duration was 33 minutes.
verbatim. Notes were also taken during the interview The age of the participants ranged from 75 to 89 years
and compared with the transcripts. Thematic content (mean 82.8 ± 4.4 years). Eleven participants were female
analysis was used to categorise and codify the interview (92%), and 11 (92%) lived alone. Three participants
transcripts (20, 21). An inductive thematic analysis was
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 OLDER ADULTS’ ATTITUDES TO FOOD AND NUTRITION

(25%) were classified as being at risk of malnutrition had started using packaged frozen foods from the
according to the MNA®-SF, all three had suffered supermarket or at least having some in the freezer in case
acute illness or psychological stress within the previous they didn’t feel like cooking or had unexpected guests.
three months, however all reported that the issues had, “Well, sometimes, I always keep a couple of supermarket,
or were resolving. No participants were classified as McCain meals in the freezer, in case I’m sick and I can’t be
malnourished. bothered by the... I heat up one of those.” (Female #9, 89 years)
Overall participants felt that they had good, healthy
diets and that nutrition was important to their overall Influences on food choices
health and well-being.
“Very important [diet]. I think particularly when you live
on your own, you can get in to really bad habits....but oh yes, Independence and positive attitude
it’s fundamental isn’t it? It’s very important.” (Female #11,
75yrs) Participants expressed pride in their ability to remain
“I cook every day. I don’t eat junk food. I don’t like it.” independent and self-sufficient in all facets of their lives,
(Female #2, 83years) including shopping and preparing food. They felt that
Key themes identified in the analysis are described staying active either at home, within their family or with
below under the topics of dietary patterns, food choices, social groups was an important factor in their general
age related change and dietary advice. health. Even when faced with health issues, they felt that
‘just getting on with it’ was important.
“I can’t do very much. I try, but... and I keep trying til I’m
Dietary Patterns exhausted.” (Female #10, 86 years)
“actually, sometimes I think, when you’ve got a bit of
The usual dietary pattern described involved three responsibility, it makes you get up and get going. You can’t
meals per day, with skipping meals a rare occurrence. As say, ‘Oh, I’ll just sit in all day today’.” (Female #8, 78 years).
nearly all participants lived alone, most meals were eaten
alone in their own homes. Eating out occasions were rare,
but more commonly involved meeting friends for ‘coffee’ Value of eating well
or having a cup of tea or coffee, with or without a snack
when at the shops. Diet and nutrition was considered to be important to
their overall health, and therefore participants felt it was
worth the effort to continue with food preparation.
Routine “I still prepare and cook my own meals…..But, I eat well.
I’m a healthy eater.” (Female #9, 89 years)
Days tended to be fairly structured with similar meal It was acknowledged that it could be easy to slip into
times each day. There was usually a standard time that bad habits such as missing meals but the value they
participants arose each morning and meals were then placed on diet, prevented this. They often felt that they
organised according to the activities of the day. When were doing better than others of their age who appeared
describing their meals, it was common to qualify their to place a lower value on their own well-being.
statements with “every day” or “always”. Sometimes “always good meals, you know? Yeah, I think it is, because
these routines reflected long-standing habits. some people say, ‘oh, we never cook, eat sandwich’. I don’t like
“I’ve been doing it for a long time, same old routine so I that.” (Female #2, 83 years)
can’t change it” (Female #5, 86years) “But she [friend] tells me what she’s eating, and she’s
“I still got used to when I worked in the factory 12 o’clock it not eating like I am eating, and you know sometimes, “Oh,
must be lunch.” (Male #4, 86yrs) I couldn’t be bothered making a meal,” I would never be like
that.” (Female #1, 84 years)
Food Preparation
Childhood patterns
As the majority of respondents were female, they had
been responsible for food preparation for most of their Participants talked about their current food patterns
adult lives, and continued to cook for themselves even as similar to those they were brought up on and that
when they were living alone. All reported consuming at their parents provided for them. Some food choices were
least one hot meal each day, but often cooked sufficient unchanged over many years. The provision of regular
quantity to last for a few days. ‘good’ meals as children appeared to set the standard for
“I’m all for cooking up, you know, larger quantities like that. dietary practices over the course of their adult life.
If I cook a couple of cutlets I’ll cook say four, it’s two for one “well, we were brought up to, on a farm. And my mum and,
night, and an alternate night you have the other two.” (Female and dad always made sure we were well fed. And you know we
#7, 86years) just eat the same. Meat and three veg.” (Female #9, 89 years)
Despite a desire to prepare their own food, many
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JOURNAL OF AGING RESEARCH AND CLINICAL PRACTICE©

Health Conditions the media were also sources of dietary information.

In terms of receiving assistance with services such
Food choices were commonly restricted or influenced as home delivered meals (only one participant was
by health conditions or previous dietary advice. Six of the occasionally using a home delivered meal service), they
female participants were conscious of their weight and were considered a possibility but the preference was
did restrict food intake to try and reduce their weight. In to have home prepared meals. There was a focus on
some instances, this was even in the presence of recent consuming fresh or home-made meals.
weight loss due to illness or emotional distress. “But any food that had to have been cooked and frozen and
“I have lost a bit of weight in the last six months, which then delivered, it’s just not like fresh food.” (Female #8, 78
is part of this [illness] but this is more my natural weight” years)
(Female #7, 86 years)
Specific foods were often chosen to meet the perceived Discussion
personal dietary needs or restrictions of participants.
Food restrictions included full fat dairy products,
This study aimed to build on our understanding of
artificial preservatives, lactose, fructose and artificial
what influences food choices and dietary patterns of
sweeteners. These choices appeared to be self-imposed
adults over 75 years of age in Australia. We found that
with little guidance from any health care professionals.
participants placed a high value on eating well and their
food choices were driven by childhood eating patterns,
Changes with age and their specific health conditions which frequently
resulted in self-imposed dietary restrictions. Age related
Inevitability changes were seen as inevitable and could be divided
into physiological changes such as reduced appetite
Changes associated with age were seen as inevitable or social changes such as living alone. The first option
and something to be accepted and managed. Participants for seeking dietary advice was the GP, and while
associated changes to their food intake or nutritional services such as home delivered meals were considered
requirements with advancing age with either social acceptable, freshly prepared meals were the preferred
factors (e.g. loss of a partner) or physiological changes. option.
The social change was most commonly the adjustment The participants in this study were living
to living alone and cooking for one, which impacted on independently with very few support services, and the
quantity of food consumed. There was also recognition majority were still able to drive. Although all but one
that a reduced appetite was associated with lower activity were living alone they placed a high value on continuing
levels and that keeping physically active could improve to eat well and preparing meals for themselves. Vesnaver
appetite. and colleagues described a model of ‘dietary resilience’
“And the fact that you live on your own and you’re not based on interviews with 30 Canadian adults aged
cooking. My husband had an enormous appetite, and of course between 73 and 87 years (22). One of the features of
you know you’re cooking for two, and you sit down and you’re dietary resilience was prioritizing eating well, enabling
talking, you do eat more.” (Female #7, 86 years) individuals to adapt and overcome dietary obstacles.
Physiological changes included alterations in taste, This notion of resilience is consistent with the themes
appetite or metabolic changes resulting in smaller food we identified of independence and value of eating well
portions consumed. Although participants often reported where, despite being faced with challenges, food intake
that their appetite was good, it was generally felt that it was maintained.
had declined with age. Routine and childhood meal patterns were
“We’ve cut down ..... we used to have a piece of steak you contributing factors to current dietary practices and this
know oh it’d be bigger than that but we, now we would only has also been identified in other older populations. A
have half a scotch fillet each.” (Female #2, 83 years) study of Scottish adults aged 75 years and older used
24 hour food recall in conjunction with interviews to
Dietary advice or assistance understand dietary beliefs and practices (18). They found
routine was seen as an important way of overcoming
fluctuations in appetite, and the establishment of dietary
GP first point of contact beliefs and habits in childhood carried over into old age.
The issue of weight management and dietary
Most participants identified their general practitioner restriction is an important area to explore further. We
(GP) as the first point of contact if they had any dietary found that management of weight was a common area
concerns. They trusted the doctor to tell them if there was of concern for participants, as it had been a main focus of
any need to alter their diet and to answer any questions their diet during adulthood. However, in older adults, a
they had. Two participants felt that their doctor would higher BMI is associated with lower mortality (23), and
refer them to a dietitian if required. Family, friends and
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 OLDER ADULTS’ ATTITUDES TO FOOD AND NUTRITION

weight change is associated with greater mortality (24). compromise their nutrition as dietary requirements
In addition to weight concerns, a number of other dietary change. Further research is needed into how to
restrictions had been adopted without any specific communicate changing nutritional needs to this group
guidance, including reduced fat, reduced lactose, reduced and to determine whether primary care staff are
fructose and avoidance of certain additives. Dietary equipped to provide appropriate nutrition information.
restrictions in older people are considered to have an
Acknowledgements: The authors would like to thank Kate Wingrove for her
unfavourable benefit / risk ratio with the potential to invaluable assistance in coding a sample of the interviews. We would also like
result in deficiencies and contribute to under-nutrition to thank the staff at the medical centre for their role in recruiting participants,
(7, 25). Further investigation is required to determine co-ordinating interview times and providing interview facilities. And finally, we
would like to thank the participants for their willingness to provide their time for
whether these restrictive practices have an impact on the project.
nutritional adequacy in this population.
Age-related changes impacting on food intake such Conflict of interest: Ms Winter reports other from Nestle Health Science
(employee of the company), outside the submitted work. Dr. McNaughton has
as reduced appetite, social isolation, altered capacity to nothing to disclose. Dr. Nowson reports grants from Nestle Health Science, grants
shop and prepare food have been well described in the and personal fees from Meat and Livestock Australia, personal fees from Dairy
Health Nutrition Consortium outside the submitted work and is a member of
literature (26). Although the participants in this study AWASH and WASH (Australian Division of World Action on Salt and Health) but
did identify changes in appetite, reduced serve sizes, does not receive any financial support from these organisations..
and issues associated with living alone and cooking
for one they tended to downplay these factors and felt Ethical Standards: Study protocol approved by Deakin University Human
Research Advisory Committee.
that they were inevitable part of aging that weren’t
impacting on their overall nutritional intake. Ramic and
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