Malnutrition, which includes undernutrition as well as overweight/obesity, is a common problem among the elderly. The prevalence of undernutrition among home-living elderly people was found to be 14.5% according to the Mini Nutritional Assessment (MNA) [
The consequences of undernutrition in elderly people include functional decline or frailty [
Myriad risk factors are associated with inadequate caloric intake and malnutrition. Risk factors for undernutrition have been identified as higher age, lower self-perceived health, low functional status, diseases, taking several medicines, and symptoms of depression [
Currently in Sweden, fewer elderly people with functional impairment move to nursing homes, and more choose or have to remain in their own homes. Many of these people are disabled and dependent on others for acquiring, preparing and/or consuming their food. The need for help with acquiring food typically occurs before the need for assistance with meal preparation arises [
Considering all the negative effects of malnutrition, it seems of utmost importance to identify elderly people living at home at risk of developing malnutrition, or who have already developed it, so that suitable preventive actions and/or treatment can be provided. To do so we need a deeper understanding of the circumstances of older people living at home, with respect to nutrition, from their perspectives. The aim of the study was to describe home-living elderly people’s views on circumstances that are of importance regarding food and meals.
The study was carried out in a small community in southern Sweden (approximately 12500 inhabitants), containing two smaller towns. Elderly care interventions, such as getting meals from a formal agency (food distribution/meals on wheels), were provided from two different kitchens, one localised in the towns. The meals were distributed to the elderly by home care staff. The elderly person had to pay a subsidised fee for the meal and meal delivery. Even though respondents lived independently they could have access to elderly centres for social activities and restaurants.
This study was a descriptive qualitative study based on semistructured interviews with twelve elderly people living in their own homes in a small municipality in southern Sweden. Criteria for inclusion in the study were elderly people over age 65 living in their own homes (with or without home help service and/or meals from a formal agency) and able to communicate in Swedish. Respondents were recruited by the nutritionally responsible nurse and the unit managers in the municipality. Written information about the aim of the study, that participation was voluntary and who to contact for further information, was distributed to potential respondents by home care staff. It is unknown how many people received this information. Those who agreed to participate were contacted by phone by the first author (E. Edfors); further information about the study was given and the time and place for the interview were set.
Twelve people were interested and actually participated in the study, seven men and five women, aged 82 to 94 (average 87.7 years). Four of them lived as couples and both partners were included in the study. Six of the respondents had no home help service and out of these three had food distribution from a formal agency. Three of the respondents had no food distribution while nine had food distribution that varied from three to seven days a week. Half of the respondents rated their severity of disease as moderate and only one as severe (Table
Characteristics of the respondents.
Interview number | Gender | Age | Cohabitation | Living in town (T) |
Home help service | Food distribution, days/week | Severity of disease(1) |
---|---|---|---|---|---|---|---|
1 | Male | 84 | Alone | CS | No | 7 | Moderate |
2 | Male | 90 | Together | T | Yes | 7 | Mild |
3 | Female | 87 | Together | T | Yes | 7 | Severe |
4 | Female | 94 | Alone | T | Yes | 7 | Moderate |
5 | Male | 82 | Alone | T | No | 7 | None |
6 | Male | 89 | Alone | CS | Yes | 3 | Moderate |
7 | Female | 84 | Alone | T | Yes | 5 | Mild |
8 | Female | 85 | Alone | T | No | 0 | Moderate |
9 | Male | 89 | Alone | T | Yes | 7 | Mild |
10 | Female | 88 | Together | CS | No | 0 | Moderate |
11 | Male | 94 | Together | CS | No | 0 | Moderate |
12 | Male | 86 | Alone | T | No | 7 | Mild |
(1)Self-perceived severity of disease graded as none, mild, moderate, or severe.
The interviews were conducted by the first author (EE) in the respondents’ homes. Before the interview started, the respondent was given clarifying information about the aim of the study, their right to withdraw at any time with no personal consequences, and that participation was voluntary. Written informed consent was obtained. As there could be a risk that the interviews were perceived as an invasion of privacy and cause emotional strain, respondents were offered the opportunity to contact the authors afterwards. All collected materials and personal data relating to respondents were treated confidentially. The study was performed in accordance with the Helsinki declaration of ethical principles [
The interviews were conducted as semistructured interviews [
The interview texts were inductively analysed by using qualitative content analysis [
Three categories, with two-to-five subcategories each, were developed based on the text analysis: habits developed in the past affect the present; getting help from others with food and meals; current food and meals (Table
Categories and subcategories regarding home-living elderly people’s views of food and meals.
Categories | Subcategories |
---|---|
Habits founded in the past affect the present | Food and meals |
Roles | |
| |
To get help from others with food and meals | The breaking point |
Transition from independence to dependence | |
| |
Meals during the day | |
Quality of food | |
Food and meals in present life | Buying and transporting food |
Cooking | |
Eating |
The interviews showed that experiences in childhood and earlier adulthood had a great impact on the respondent’s current feelings and views concerning food and meals. It was evident that the foundations of norms and values regarding food culture, traditions and eating habits were laid early and did not change to any great extent throughout life.
The majority of the respondents had lived their lives in an environment where they were used to cooking for themselves and there was a difference between everyday meals and special occasions. Food and meals had also played an important social role. It was, for instance, important to be generous to the “outside world”.
The respondents had grown up on a diet of home-cooked dishes made from locally produced ingredients. Meals consisted of, for example, porridge, wholemeal bread, potatoes, pork, and fresh fish. At ceremonies and celebrations one might be offered freshly slaughtered meat and more luxurious food.
The diet was based on what the season had to offer and it was vital to “make do with what the house could offer” and seize every opportunity to increase the food supply, for instance, by hunting, fishing, and picking berries.
The interviews showed a division in gender roles regarding the responsibility for the diet. Usually, the woman in the family had the main responsibility for food and meals.
The interviews revealed that in several cases, major changes in the ability to be independently responsible for food and meals were linked to some form of sudden event. It could be that the female partner who was responsible for meals passed away. Other causes could be falls, infections, and other diseases, such as myocardial infarction, conditions that in many cases had led to a hospitalisation. Other factors that affected independence were general frailty and an inability
Becoming dependent on others on a daily basis can be difficult to deal with. One man had a strong desire to get well and return to independence.
Other respondents felt that they had no choice but get used to it and accept the situation.
One man seemed pleased to be dependent and he had strongly questioned the community’s decision to discontinue his food distribution.
Currently, and in the past, respondents’ daily meals were distributed as breakfast, dinner and supper, usually served at the same time every day. The majority had their principal meal at noon, while supper mostly consisted of lighter food, such as tea and sandwiches. However, one male respondent preferred to have a proper cooked meal also for supper. From the interviews it could be discerned that the majority of respondents distributed their meals so that at night there was a long period without eating.
Regular snacks were not common, except when someone occasionally felt hungry and had, for example, a piece of fruit, a cookie, or a sandwich. On the other hand, snacks in the form of coffee breaks were considered a natural and important element in social gatherings with other people, such as when friends came for a visit or when the respondents participated in social activities.
The four respondents who lived as couples ate their meals together, while single respondents mostly ate their meals alone. Two women felt lonesome with no companion at mealtimes. Four men, on the other hand, preferred to eat alone. They found it easier to be able to sit comfortably and eat at any time they wanted at their own pace, without having to consider other people.
Even though respondents lived independently they could have access to elderly centres for social activities and restaurants.
One woman said that eating at the elderly centre demanded suitable clothing, social behaviour and sociability. The noisy environment, caused by young people from a nearby school who also had their lunch there, could be another reason for eating alone at home instead.
Overall, the interviews revealed that the respondents usually did not skip a meal. Their appetite was normally good. Poor appetite and weight loss could be caused by psychological malaise, other illnesses, grief, lack of outdoor activities and bad temper.
Other reasons for a poor appetite or skipping a meal were related to the content of the distributed food, such as food having an unappealing appearance, not tasting good or containing ingredients that the older person did not like or tolerate, such as hot spices, or being difficult to chew and digest.
The interviews revealed different perceptions of the quality of food among respondents who had food distribution. Respondents who got their food from a separate kitchen were very satisfied with the food content and quality. They understood that they would not always be served their favourite dishes. This group of respondents felt that the food consisted of varied and tasty dishes and appreciated the variation in content between weekday and weekend.
Other respondents, who got their food from another kitchen, felt that the food was poor, tasteless, and badly cooked. They also said the food looked unappetising, contained spices that they were not familiar with, and was too influenced by modern food trends, such as pizza. They requested more varied old fashioned food, cooked in the traditional way with well-known spices such as salt, pepper, dill, and bay leaves.
They also wanted certain ingredients in their food, such as fresh fish, veal, lamb, vegetables, fat, and cream. One respondent preferred the restaurant service and seemed to get much better food there than in food distribution. One woman chose to throw away food when it did not taste good or looked unappetising.
Usually it was the home care staff who received the complaints about the food, even though the respondents knew that they not could influence the food content to any significant degree. Several interviews revealed that respondents perceived shortcomings in the municipality’s interest in listening to their views about the food distribution.
The interviews showed that those who lived in urban areas were satisfied with the availability of well-stocked supermarkets. Having more than one shop in the community was believed to promote choice, quality and good prices. The majority of the respondents emphasised the importance of having access to an open-air market that was open one day a week, which gave them the opportunity to buy local products and good quality fresh fish. An important service to one couple that lived outside the urban area was the regular visits of a fish van and a private supplier of food.
One man and one woman, who arranged their shopping independently, said that the premise for this was that they could drive their car to the store themselves. Respondents who were no longer able to buy their food themselves stated different reasons for this, such as the inability to drive and difficulties in mobility. Five of the respondents, who got no help with shopping from the community, got help from children, other relatives and/or friends, usually once a week.
One respondent, who had access to transport service (subsidised transport by taxi) for purchases, did not use this help because he tended to need more than one ride to and between the shops.
Five of the respondents got community assistance with buying and transporting food, usually once a week. They had a strong desire to have control of food planning, such as shopping lists and purchases. Most of them wrote their own shopping list, and the shopping was carried out by the home care staff. Sometimes the respondent would forget to write things down on the list, or the wrong things were purchased by the home care staff. When this happened, the respondent usually had to wait until the next week’s shopping.
One woman requested more than one hour for shopping, since the staff’s short allotment of time for this purpose made it impossible for her to come along to the shop. She wanted to be able to compare what different shops had to offer and make her own decisions.
Cooking was sometimes seen as a meaningful and enjoyable thing to do. One woman liked to cook all the food, both for herself and for others. Four male respondents with food distribution appreciated it and felt it was easier to prepare the morning and evening meals, when they did not have to be responsible for the main meal. Several respondents chose to buy precooked frozen dishes and full meals for the main meal. One reason for this could be that they were frail and did not have enough strength to cook the main meal themselves. Another reason could be that it was boring to cook just for themselves. Prepared dishes were also considered easier to cook, for example, in a microwave, a cheap alternative and sometimes better tasting than the food that was served at the municipality’s elderly centre.
The issues that respondents raised about eating were, in most cases, related to their oral health and dental status. Broken teeth and poorly adapted prostheses could be the causes of difficulties with chewing. Some respondents thought the meat from food distribution was leathery and difficult to chew.
Problems with eating were also linked to the presence of other symptoms, such as fungal infection in the mouth and nausea caused by problems from the oesophagus and stomach. Difficulties in swallowing food were also connected to oral health, dental status, food content, and the cooking method. The respondents emphasised the importance of caring for their teeth and regular dental visits to maintain optimal dental and oral health.
Most respondents had, at some time, choked on something. In two cases the situation had developed to a life-threatening condition. Items the respondents mentioned having choked on included tablets, crumbly bread, large pieces of food, and tough meat.
The aim of the study was to describe home-living elderly people’s views on important circumstances regarding food and meals. The analysis of the interviews showed that respondents’ earlier life had a strong influence on current views of food and meals. Souter and Keller [
The results of the study showed that the respondents’ needs for help to manage their daily food and meals often arose in relation to a sudden life event. Stressful life events also contribute to an increased risk of developing malnutrition. Examples include being widowed or falling ill and requiring hospitalisation. They perceived their dependence on others both positively and negatively. Most respondents stated that the woman in the family had had the main responsibility for meals. Several men in the study reported that their wife’s death had been the breaking point for becoming dependent on food distribution and they thought the food distribution was a good alternative to get nourishing food. However, women who previously had cooked all their food mentioned difficulties in accepting the situation and in reconciling themselves with the conditions of food distribution. This is consistent with a study that showed that being dependent on others was difficult to accept, but dependence on meals from food distribution could also mean better quality of life [
In this study habits founded in past life, and negative life events affected the food and meals in present life. It might be that also the view of the future influences current food intake. Shifflet has studied food habit changes in a couple of studies including elderly patients visiting nutrition sites [
The results of the study are guided by the respondents’ desires to choose and make decisions about shopping, cooking and eating. This could mean access to fresh food of good quality, sitting by yourself and eating in peace or the opportunity to go to the shop with the home care staff. Similar findings are also highlighted in a study by Pajalic et al. [
In planning and implementing qualitative studies, it is important to consider factors such as trustworthiness and transferability. A prerequisite for forming an opinion on trustworthiness is that all steps in the research process are well described [
Meeting the need for optimal nutritional status for older people living at home requires knowledge of individual preferences and habits, from both their earlier and current lives. It is important to pay attention to risk factors that could compromise an individual’s ability to independently manage their diet, such as major life events and hospitalisation. Individual needs of self-determination and involvement should be considered in planning and development efforts for elderly people related to food and meals. Preventive home visits to elderly people, without home help service and/or meals from a formal agency, can be one way to capture difficulties with acquiring, preparing and/or consuming food. This can be done in order to give advice and/or suggest provision of formal help. Another intervention could be to develop a program, promoting eating with other seniors. Elderly people can be picked up at home and driven to an elderly centre restaurant at which they receive nutritious meals and opportunities to socialise with others.
The authors declare that they have no Conflict of interests.
E. Edfors and A. Westergren have contributed equally to this work, that is, to designing and conceiving the study, analysis, coordinating, and drafting the paper. Data collection was made by E. Edfors. Both authors have read and approved the final paper.
The authors wish to thank all the respondents for their participation. They also thank Kerstin Ulander (deceased) for her initial involvement in the study. The study was supported by the Swedish Research Council and the Skåne County Council’s Research and Development Foundation. The study was conducted within the Patient-Reported Outcomes-Clinical Assessment, Research, and Education (PRO-CARE) Group, Kristianstad University.