g...‘ 0--...00 CHANGES IN FOOD BEHAWOR WUH AGE Thesis for the Degree of M. S. MICHlGAN STATE UNlVERSlTY 0L JEAN WRUBLE 1976 . . .0. ‘ _. - . - A~ . - '- a a — . . . ’ . - . - -. .. .. . , . e - . . ., 7". . . - u - . IHI“WI\Mlll“H““INHHHMHIIHLHNUHIIWI 3 1293 105283 nEsLs as: Y95 ABSTRACT CHANGES IN FOOD BEHAVIOR WITH AGE BY Carol Jean Wruble Perceived changes in food behavior with age were assessed for fifty-one main meal preparers who were sixty years and older. Data were collected during the fall of 1975 as part of a North Central Region Experiment Station Study (NC 108), "Changes in Food Practices for Better Nutrition." Respondents indicated a perceived change in food behavior with age. In over half the sample the change in food behavior experienced was a decrease in food intake, an adaptive change in View of the decreased caloric needs of the aged. The reasons cited for changes in food behavior were attributed to retirement, health, death of family members, and loneliness. Changes in food behavior included: follow- ing special diets and decreasing the quantity and variety of foods prepared and eaten. Diets of the elderly sampled generally provided two-thirds of the Recommended Dietary Allowance (RDA) for six nutrients (protein, calcium, thiamin, iron, vitamin A and C) as calculated from food Carol Jean Wruble frequency estimates and food quantity data. Food portion size data were collected using food models. Males living alone, participants in nutrition pro- grams and respondents citing loneliness and health as reasons for perceived changes in food behavior were among those not meeting two-thirds of the RDA. Environmental factors which may affect the nutrient intakes of an elderly pOpulation were identified. CHANGES IN FOOD BEHAVIOR WITH AGE BY Carol Jean Wruble A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE Department of Food Science and Human Nutrition 1976 Fc Re di th ACKNOWLEDGMENTS A most sincere thank you to Drs. Jenny Bond and Bea Paolucci for their advice and direction in the completion of this thesis. Special thanks to Dr. Kathryn Kolasa for her insight, support and personal encouragement throughout the research. The financial support from both the Department of Food Science and Human Nutrition and from the North Central Region Experiment Station is gratefully acknowledged. To those persons interviewed in Huron County, Michigan, a warm thank you for giving of themselves. Special thanks to all those persons providing the diversions which helped me keep the proper perspective of this "matter of great consequence." ii TABLE OF CONTENTS ACKNOWLEDGMENTS . . . . . . . . . . . . . LIST OF TABLES . . . . . . . . . . . . . INTRODUCTION . . . . . . . . . . . . . . OPERATIONAL DEFINITIONS . . . . . . . . . . REVIEW OF LITERATURE . . . . . . . . . . . Food Behavior . . . . . . . . . . . Need to Study Food Behavior . . . . . . Need for an Instrument to Document Food Behavior . . . . . . . . . . Aging Population . . . . . . . . . . Environmental Factors of Aging . . . . . Effect of Environmental Change on Food Behavior . . . . . . . . Nutrient Needs of the Elderly . . . . . Nutrient Intake Studies of Elderly . . . . Studies of Food Behavior of the Elderly . Nutrition Programs for the Elderly in Michigan Nutritional Status of the Elderly in Michigan Summary . . . . . . . . . . . . . MTnomLOGY O O O O O O O O O I O O O 0 Regional Research Project NC 108 . . . . Michigan Research . . . . . . Participant Observation . . . . Field Notes . . . . . . . . . . . .Geographical Area . . . . . . Purposive Sample . . . . . . Goal Statements . . . . . . . . . . Interview Process . . . . . . . . . Food Models . . . . . . . . . . . Interview Schedule . . . . . . . . . Data Analysis . . . . . . . . . . . iii Page ii \Omfl mm m 12 12 14 16 19 20 21 21 22 23 24 25 25 26 27 27 28 28 Page RESULTS . . . . . . . . . . . . . . . . 30 Sample Characteristics . . . . . . . . 30 Use of Special Diets and Vitamin Supplementation . . . . . . . . . . 32 Change in Food Behavior with Age . . . . . 34 Adjustments Made in Food Purchasing Behavior . 34 Nutrient Intake of Main Meal Preparers . . . 35 Importance of Goal Statements to Main Meal Preparers . . . . . . . . 37 Outstanding Event and Effects on Food Behavior . . . . . . . . . . . . . 38 Changes in Food Preparation Practices . . . . 39 Food Preparation for Guests . . . . . . . 41 Food Considered a Treat . . . . . . . . 41 Profile of Typical Respondent . . . . . . 42 Nutrition Program Case Studies . . . . . . 43 DISCUSSION, SUMMARY, CONCLUSIONS . . . . . . . . 47 Demographic Data . . . . . . . . . . . 47 Use of Special Diets and Vitamin Supplements . 48 Change in Food Behavior . . . . . . . . 49 Adjustments Made in Food Purchasing . . . . 51 RDA . . . . . . . . . . . . . . . 52 Nutrient Intake . . . . . . . . . . . 53 Importance of Goals . . . . . . . . . . 56 Outstanding Events and Effects on Food Behavior . . . . . . . . . . . 56 Food for Guests and Food Considered Treats . . 57 Case Studies . . . . . . . . . . . . 58 Other Nutrition Program Participants . . . . 58 General Summary . . . . . . . . . . 60 Limitations of the Research and Needs for Future Research . . . . . . . . . . 62 REFEMNCES O O O O O O O O O O O O O O O 64 APPENDIX 0 O O O O O O O O O O O O O O O 69 iv LIST OF TABLES Table 1. Demographic Characteristics of Respondents . . 2. Use of Special Diets and Vitamin and/or Mineral Supplements by Main Meal Preparers . 3. Food Purchasing Behavior of Main Meal Preparers . . . . . . . . . . . . 4. Percent of Main Meal Preparers with Dietary Intakes Less than 66 Percent RDA, 66-100 Percent or Greater than RDA for Selected Nutrients O O O O I O O O O O O O 5. Mean Rating Given by Main Meal Preparers for Selected Goal Statements . . . . . . . 6. Events and Effects Described by Main Meal Preparers as Instrumental in Changing Life StYle O O O O O O O O O O O O 7. Main Meal Preparer's Change in Practices with Age Toward Cooking . . . . . . . . Page 31 33 35 36 38 39 40 INTRODUCTION Complicating environmental factors that are associated with aging such as decreased income, mobility, motivation, and loss of job, family, friends, and status have stereotyped the aged. The "typical elderly" person has been described as chronically ill, poor, isolated and generally regarded as unimportant due to loss of his/her productivity in society. These same complicating factors associated with aging may cause a change in food behavior. What effect these factors may have on the nutritional status of the elderly has not been documented. Nutritionists have become aware within recent years of the importance of economic, social, and cultural factors which influence dietary patterns, food intake, and the nutri- tional status of a population. The study of food behavior has been defined as the determination of the ways in which individuals or groups in response to social and cultural pressures select, consume and utilize portions of the avail- able food supply (National Research Council, 1945). The Committee on Food Habits of the National Research Council recognized that improving nutritional practices in the United States depends as much on knowledge of culture, behavior and personal traits of the pepulation in relation to food as on biochemical and physiological knowledge of nutrient requirements and metabolism. Few studies have described change in food behavior, that is, the change in how a person relates to food. Ameri- cans are eating differently than they did a number of years ago for an assortment of reasons including an increase in the number of food products from which to choose, the -increase in food advertising, a shift from rural to urban society, and the growth in population. The change in eating behavior associated with these environmental changes has caused a decline in the nutritional status of the American diet (Henderson, 1972). An analysis of the trends of change in food behavior and the resulting nutritional problems may result in develOpment of corrective measures (McKenzie, 1964). The assessment of environmental factors which induce change in food consumption will be useful to nutritionists and intervention program planners. It is necessary to know the food history and the effects of chronic illness, decreased physical activity, dentition problems, limited incomes, social isolation, and the lackof motivation of the aged in attempting to meet nutritional needs. Yet, there is little information on the socio-cultural, economic and dietary aspects of the aged as associated with their nutritional status and health (Rao, 1973). Several studies of nutrient intake that have been completed (Fry, §E_al., 1963; Emerson, 1964; and Steinkamp,g§_al., 1965) have indicated that the elderly often consume inadequate amounts of calcium, iron, and vitamins A, D, C, and B complex. Studies of food intake of the aged have indicated that with change in traditional food intake patterns the nutritional adequacy of the diet decreases (Clarke and Wakefield, 1975 and Stanton and Exton-Smith, 1970). The environmental factors which induce change in food behavior may cause decreased nutritional adequacy of the diet. As a greater percentage of the American population is comprised of elderly, the need for reliable data of the effect of environmental factors on food behavior of the elderly increases. There is a need to establish then, what the food patterns of the elderly are, and how they can be effectively modified to insure optimal health. The objectives of this research were to: (a) describe the food behavior of a selected rural elderly population in Michigan, and (b) determine the influence of environmental factors on food behavior of a selected group. OPERATIONAL DEFINITIONS Elderly Nutrition Program (Title VII): is a program authorized under Title VII of the Older Americans Act of 1965, to supply low cost, nutritionally sound meals in a congregate setting to people over the age of sixty years and their spouses. The Title VII Program also provides additional suppor- tive services, such as nutrition education and transportation. Food Behavior: is the way in which an individual or group of people in response to social and cultural pres— sures, select, prepare and consume portions of the available food supply (National Research Council, 1945). Food Models: are polyurethane shaped into mounds of differ- ent sizes, not suggestive of any particular food (Christensen, 1973). Food models were used to estimate food portion size. Home-Delivered Meals Program (HDMP): is a program funded through a combination of public and private monies, providing well—balanced meals to the aged who are homebound, and/or physically handicapped in an attempt to enable the individual to live indepen- dently in his/her own home. Independent: is a person maintaining their own household in a non-institutionalized setting. Main Meal Preparer: is a person who does the majority of the food preparation in the home. Participant Observer: is an adult engaged in the process of studying a culture or group of people different from his own. Recommended Dietary Allowances (RDA): are established by the Food and Nutrition Board of the National Research Council, revised in 1974. The RDA are recommenda- tions for levels of intake of nutrients sufficiently in excess of average nutritional requirements to meet the nutritional needs of most people. REVIEW OF LI TERATURE Food Behavior Few studies have been conducted to describe the food behavior of a selected group. A study of food behavior of a p0pu1ation must not be isolated from the social and economic setting of the group. The myriad of factors, social, economical, medical and psychological, which con— currently influence the nutritional well-being of a group must be considered when describing food behavior (Sims, §£;gl., 1972). Current eating patterns reflect the physi- cal, economical, social, technological and ideological aspects of the culture (Gifft, §t_§l., 1972). A cultural definition of food includes the attitudes, habits and customs acquired by learning which are subject to change (Fathauer, 1960). The complexity of the study of food behavior is evident. Need to Study Food Behavior To realize the full social benefits from the find- ings of biochemistry, physiology, agriculture and economics there must be research in the field of food behavior (National Research Council, 1945). The discoveries made in the laboratory need to be translated into applicable terms for the layman to effect the improvement of the quality of life (National Research Council, 1943). With the knowledge of what people are eating one may determine what to preserve or change in order to make better use of the available food supply. Gordon (1973) indicated there was a need for a system of surveillance of nutritional status of people on which to base the remedial action of nutrition programs. In order to establish methods to strengthen the forces which lead to dietary improvement through nutrition programs, it is necessary to research behavioral aspects for food patterns (Aldrich, 1965). The data collected may be used to design programs which focus on directing change for improvement in nutritional status. Need for an Instrument to Document Food Behavior One major problem in conducting research on change in food behavior is the lack of appropriate methodology. Madden and coworkers (1976) stated: such research methodology is long overdue and should receive rather high priority in view of the important policy decisions that are made partly on the basis of dietary impact. These policy decisions determine the types of pro- grams available, the allocation of public monies, and ultimately, the well-being of the elderly, the poor and needy populations. Securing, with a valid instrument data on the food behavior of a target population is the first step in designing an effective intervention method which would provide optimal health and nutritional conditions. Identification of food sources, typical foods, food terminology, methods of food preparation, storage and the meaning given to food in a particular culture are important steps in the development of instruments for collecting information and interpreting data about food behavior (Kolasa and Bass, 1974). However, no valid instrument has been developed to determine food behavior and food intake of specific populations. Campbell and Cuthbertson (1963) described the limitations of tools used for collecting and interpreting dietary data pertinent to the elderly as a group. Young and Scrimshaw (1975) compared the accuracy of the twenty- four hour recall of young and old groups of people and concluded that the older people remembered less about their food intake than did younger people. They also ascertained that women of any age remembered better than men of any age due to their lifelong practices of dealing with food. Young and Scrimshaw (1975) established that the twenty-four hour recall was a valid instrument to determine food intake of a group when used with fifty or more people. AginggPopulation In the Hearings before the Select Committee on Nutrition and Human Needs (Senate Select Committee, 1969) Senator McGovern stated that ten percent of the American population, the elderly, represented the most uniformly malnourished segment of the population. Youland (1961) found that three of four persons over sixty-five years were afflicted with chronic conditions in which nutrition played the single most important role. Wood (1975) suggested that half of the health problems of the elderly were related to their nutritional status. Although the elderly represent fourteen percent of the United State's population, they require more than half the money spent for health services in this country (Watkin, 1975). The elderly live in a social system which gives them little importance and renders low priority to disease prevention at older ages (Wylie, 1975). Nutrition is one environmental factor directly under man's control. Since proper nutrition can be effective in the maintenance of health, prevention of disease and dis- ability and the deceleration of aging (Watkin, 1973), it becomes increasingly important to establish what factors contribute to suboptimal nutritional status exhibited by many aged. Environmental Factors of Aging The aged are a group of individuals Who have experi- enced a variety of physical and emotional insults which may influence their nutritional status. The elderly in America face social isolation as "aged in a youth oriented 10 society, economically and culturally deprived of a rightful place in society" (Watkin, 1973). Psychologically, the elderly may experience loss of their economic role, friends, family, home and social responsibility. Each loss neces- sitates a rearrangement of equilibrium which had been set up for comfortable functioning (Weinberg, 1972). The sense of loss associated with the aging process may influence both the nutritional intake and nutritional status of the elderly. Many situations inherent to the elderly person have handicapped their attempts to obtain an adequate diet. The economic deprivation associated with the elderly fre- quently leads to inadequate food purchase and food intakes since food is the easiest item to adjust on a fixed income (Watkin, 1975). The elderly population, in general, has a greater frequency of illness than the rest of the pOpula- tion which require medication that may interfere with appetite for food and/or absorption of nutrients. In addi- tion, the elderly may lack the motivation to prepare a meal, especially if alone. The specific personal and situational factors of the aged must be considered when evaluating nutritional status.. It is necessary to evaluate also the effects of related environmental factors on food intake and the subsequent nutritional status of the elderly. 11 Effect of Environmental Change on Food Behavior Any change in the usual pattern of living is likely to result in a change in food behavior. The elderly are often in a state of transition relative to their pattern in living. The effects of change on food behavior have not been examined. A Clark and Wakefield (1975) indicated the need for research especially in the field of food behavior of older people as they experience change in their environment. Howell and Loeb (1969) stated that, "Seniors are vulnerable to the uncompromising aspects of environmental change; the consequent effect on food behavior and nutritional status is unknown." The psychological and emotional reaction to change in the lives of the elderly may exert a real and potent effect on their pattern of eating (Swanson, 1964). However, it is neither known what these effects are nor the extent to which they interfere with nutritional health in the elderly. Longitudinal studies of man's development may serve to define the optimal environment for the individual to realize his full biologic and psychologic potential (Berrien, 1973). Specific to the aged pOpulation, such studies would define the factors which promote Optimal nutrition in the midst of the change experienced with aging. 12 Nutrient Needs of the Elderly The physiological implications of aging on nutrient requirements have not been established. In addition, the nutrient requirements of this age group have not been thoroughly studied to date. Evidence would indicate that the only change in nutrient requirement with age is energy calories. The need for caloric decrease with aging is due to changes in physical activity and in body metabolism (due to a decrease in the number of cells in the body). With a decrease in caloric needs, food choices become more critical for the aged to meet nutritional requirements. The elderly often lack the nutrition knowledge to make the necessary critical food choices which would provide recom- mended levels of protein, vitamins and minerals along with decreased calories. Nutrient Intake Studies of Elderly Fry and coworkers (1963) found that mean nutrient intakes of females over sixty-five years met or exceeded the 1958 RDA except for iron, and with the exception of calcium and riboflavin, nutrient intake declined with age. Emerson (1964) attributed low nutrient levels in vitamin A and C of the elderly studied to their omission of yellow and green vegetables, citrus fruit from the diet and the low calcium to their omission of milk in the diet. re: de 9X 8‘] f. 13 In assessing the nutritional status of ten male residents in a home for the aged, Brin and coworkers (1964) determined that clinical deficiencies may exist without expression; supplementation should be based on biochemical evaluation. The lack of protein and possibly iron and the B complex may cause fatigue and lassitude in subjects. Steinkamp and coworkers (1965) found in~a longitu- dinal study of elderly people that mean intakes of nutrients met the RDA except for calories of men and calcium for women. In the same study, twenty-five percent of the respondents had low intakes of vitamin A and C. Ascorbic acid and calcium intakes did not meet two-thirds RDA in a food consumption study conducted by Le Bovit (1965). Huntanen (1971) used the twenty-four hour recall as an instrument to collect food intake data of elderly resi- dents in rural Benzie County, Michigan, to determine dietary patterns and food behavior. Thirty-one percent of those interviewed met one-third of the Recommended Dietary Allowance for all nutrients. In addition, Huntanen (1971) found that those on special diets had a balanced diet (met two-thirds RDA). An unbalanced diet was associated with eating alone, regular intake of medicine and low income. Guthrie and coworkers (1972) evaluated, with the twenty-four hour recall, diets of elderly eligible for food stamps and compared with elderly not eligible for food stamps. Those interviewed who had incomes below the poverty 14 line had inadequate (less than two—thirds RDA) intakes of iron, protein and riboflavin. The diets of 633 elderly subjects as determined with twenty-four hour food recall by Pao and Burk (1972) provided twenty-five percent fewer calories than the RDA, and less calcium and iron than that of the 1968 RDA. Schlenker (1976) in a longitudinal study of elderly women in Lansing, Michigan, found that mean intakes of all nutrients except calcium were adequate in the diets of those sampled. In individual cases, calories, calcium, thiamin and vitamin A intakes were low. Schlenker (1976) also found that the decrease in caloric intake of her sample was not related necessarily to poor nutrition. Studies of Food Behavior of the Elderly There are limited research data describing the food behavior attitudes and practices which are influencing factors in the health and enjoyment of people in the later years of life. Few studies have been conducted with rural populations to describe dietary changes occurring when people become older. What changes an older person will make in food intake as a result of change in environment and what impact that change will have on food intake has not been established. In a study of food acceptance and attitudes of the aged (Todhunter et al., 1974), forty percent of the IE be f. 15 respondents in their sixth decade had changed their food behavior. Thirty-five percent in their seventh decade had changed their food behavior because of health reasons. Huntanen (1971) concluded that the food patterns of the rural elderly population she interviewed were stable. The food patterns of Huntanen's sample tended to become perma- nent and changed little with age. Both Todhunter and coworkers (1974) and Howell and Loeb (1969) suggested that the elderly tended to follow the food habits of their childhood. The implications of an economically deprived childhood may imply an establishment of inadequate food patterns due to the scarcity of food . before, during and after the Depression. The effects of affluence also may affect food patterns. Henderson (1972) suggested that the constant increase in use of snack foods is an emerging pattern in food consumption, potentially imposing new nutritional problems. Several studies have ascertained that a nutritionally "elite" group exists among the aged whose nutritional intake is high and changes little with age (Huntanen, 1971; Tod- hunter gt_al., 1974; and Clarke and Wakefield, 1975). Clarke and Wakefield (1975) compared independently living elderly with nursing home residents and determined that the more respondents had changed their traditional eating behavior, the lower their nutritional intakes. Clarke and Wakefield (1975) concluded that good nutritional status could be l6 maintained by independents with adequate nutrient intakes if they simply ate their usual diet. A longitudinal study in London, England (Stanton and Exton-Smith, 1970) conducted in 1962 and again in 1969 utilized seven days weighed food samples and food records to determine nutrient intake. The respondents were grouped with respect to their dietary intake changes over seven years. The group whose protein and caloric intake had decreased more than ten percent was identified as having deteriorating health. However, the group that had changed food intake minimally maintained a similar state of height and weight between 1962 and 1969. Nutrition Programs for the Elderly in Michigan The food behavior of the aged may be affected by participation in programs which provide food and/or social interaction. A review of the literature describing these nutrition programs and their effects on food behavior and nutritional status is appropriate to this discussion of factors affecting change in food behavior. Title VII Nutrition Program.--A variety of programs (are designed to assist elderly independently living persons to cope with health problems, mobility and environmental problems which otherwise may lead to institutionalization and/or confinement in a nursing home. The Nutrition Program f0 19 nu p1 17 for elderly authorized under the Older Americans Act of 1965 (Title VII) is one program designed to meet the nutritional needs of the aged pOpulation. The Title VII program is the major nutritional supplement program for older people in Michigan (Havel, 1975). The Title VII National Nutrition Program is a formula grant program operated by State Agencies on Aging. The program is designed to serve peOple who do not eat properly, cannot afford to eat, lack the mobility to shop, lack the skill to cook, lack the incentive to eat (Wells, 1973). The major objectives of the Title VII program are to: supply low cost, nutritionally sound meals in congre— gate settings for people over the age of sixty years and their spouses, and provide additional supportive services to the elderly such as transportation, information and referral, shopping assistance, health and welfare counsel- ing, recreation, and nutrition education (Wells, 1973). The social component of the program may be as impor- tant as the food. The Title VII program provides more than just a meal by capitalizing on the importance of food to basic feelings of security (Sherwood, 1973). The multiple facets of the nutrition program which provide social involvement and food are equally important in improving the well-being of the elderly (Troll, 1971). The social life of the adult is built to a great extent around the psychological meaning of food and drink, the nutrition program for the elderly supports this concept. 18 Pilot programs were authorized in 1971 before national implementation of elderly nutrition programs. Senior citizens, in a free pilot meals program, valued the program and wanted to pay for it (Holmes, 1972). Evalua- tion of the program was continuous and showed that eating habits and the general feeling of well—being of the parti- cipants improved with participation in program. Rankine and Taylor (1975) surveyed the food attitudes of Title VII and home-delivered meals program participants and compared them with the food attitudes of nursing home residents. The data supported the hypothesis that the meals served in the socialized setting of the Title VII program provided participants with more than just basic nutritional require- ments. The program also provided social and psychological involvement. Home-Delivered Meals Program.-—The home-delivered meals program (HDMP) is another program in operation in various communities in Michigan. It is designed to meet the nutritional needs of the elderly pOpulation who experi- ence physiological, social and economic change in living patterns which may lead to malnutrition. The HDMP in ‘Michigan currently is funded by a combination of private and public monies and is serving approximately 1500 meals each day to the elderly in Michigan. The HDMP provides, "an adequate, well-balanced, medically appropriate meal to the aged who are homebound, l9 handicapped or otherwise unable to prepare their own meals, in an attempt to prevent physical and psychological dete- rioration and to enable the individual to live independently in his/her own home" (Buchholtz, 1971). No studies des- cribing the impact of the home-delivered meals program on food behavior and nutritional status of recipients have been reported. Nutritional Status of the Elderly in Michigan The aged have been defined as a population group at nutritional risk in Michigan. As a result of the Survey of Needs sponsored by the Office of Services to the Aging, 3 Comprehensive Plan on Aging (Kivi, §E_§l., 1974) was formulated and included recommendations to investigate and promote additional funding sources for home-delivered meals programs. A national evaluation of the impact of the Title VII Senior Nutrition Program on the nutritional status and food behavior of participants has been planned by the Department of Health, Education and Welfare. The evaluation is in the implementation process at this time. Title VII participants in four geographical areas in Michigan are being interviewed as a part of the national evaluation. I As a result of the hearings conducted by Represen- tative Hood in Michigan in 1975, a recommendation was made. that the State of Michigan double its financial commitment 20 to nutrition programs for the elderly to include a greater proportion of the population in need of nutritional services (Havel, 1975). The recommendations of "A Matter of Justice," also called for a nutritional assessment as part of medicaid screening to monitor longitudinal changes in nutritional status of the aged pOpulation. With the docu- mentation of nutritional problems through ongoing nutri- tional status assessment adequate intervention programs may be developed. Summary A review of the literature indicates that there is little data available describing the food behavior of the older adult. Because a reliable tool for the collection of food behavior data does not exist, the data secured to date has not been collected in a consistent manner. There is growing concern within Michigan for the nutritionally at risk elderly population. The nutrition programs designed and implemented both in Michigan and across the U.S. to improve the nutritional status of this vulnerable group have not been evaluated for their effec- tiveness. The combination of a lack of information on the food behavior of the elderly as a group, and the lack of evalua- tion of nutrition programs has stimulated a need for investi- gating the food behavior of a selected rural population in Michigan including those participating in nutrition programs. METHODOLOGY Regional Research Project NC 108 In 1975, data for the North Central Region Experi- ment Station (NC 108) were collected in Michigan describing changes in food practices of fifty-one people over the age of sixty years. Demographic and food intake data were collected in eight other states participating in the NC 108 study: Georgia, Illinois, Indiana, Iowa, Kansas, Minnesota, Missouri and Nebraska, the results of which have not been made available. Data on food practices of elderly persons were collected in Kansas and Illinois. The five year plan for the NC 108 study involved: 1. obtaining food intake, demographic and attitudinal information from a group (to be defined in each state) of fifty main meal preparers. 2. analyzing and evaluating of data collected to determine the need for nutritional intervention. 21 22 3. designing intervention tools or programs which would meet the defined needs of the selected group. This researcher completed only the first objective. Michigan Research In addition to obtaining food intake, demographic and attitudinal information from a group of main meal pre- parers over sixty years, the researcher secured data on environmental factors that influence food behavior of a selected elderly population in Michigan. The method used to collect data was a personal interview. "Changes in Food Behavior with Age" (Appendix) was the interview schedule used to obtain nutrient intake and food behavior data, to describe food behavior change with age in a selected Michigan population and to describe social factors involved in the food selection of main meal preparers over the age of sixty years. Main meal preparers were defined by both the researcher and respondents as those persons who do the majority of the cooking in the home. The procedure followed by this researcher included: A. Complete an experience in participant observation. B. AdOpt the NC 108 interview schedule and expand interview schedule to include questions about the changes experienced 23 with age in food behavior, attitudes and practices of main meal preparers over sixty years of age. C. Select a geographic area and sample population. D. Interview using an interview schedule and food models to ascertain portion size of foods consumed. E. Analyze the data. A more detailed description of the methodology follows. Participant Observation The researcher spent three months prior to inter— viewing as a participant-observer. A participant-observer is an adult engaged in the process of studying a culture or group of people different from his own. The participant- observer's role for a foods and nutrition professional provides the opportunity to study the behavior of a selected group related to food production, selection, procurement, consumption and disposal (Kolasa and Bass, 1974). The experience in participant observation was planned to pre- _pare the researcher for constructing questions to add to NC 108 interview schedule and to prepare the researcher for the role of interviewer. The experience in participant observation was com- pleted through visits to the Senior Nutrition Programs 24 (Title VII) in Ingham, Grand Traverse, Manistee, Kalkaska, Antrim, and Huron Counties. These programs are authorized through the Title VII of the Older Americans Act of 1965. Through visits to the Title VII program, contacts were made with Indian, Black, White and Latino elderly populations in both rural and urban settings. Following interview training with faculty supervision, the thirteen original questions were developed by the researcher and were pre- tested with Title VII participants, including the groups mentioned above. To further clarify the meaning of selected questions minor modifications were necessary, after the pretest. The interview schedule "Changes in Food Behavior with Age" was approved for use with human subjects by the Michigan State University Human Rights Committee. Field Notes Field notes were recorded by the researcher both during the participant observation experience and throughout the interview process. The field notes included additional information that may have been overlooked if data available were limited to that collected with the interview schedule. The additional information recorded included observations and information about interviewees. The field notes were used in construction of case studies and in discussion of the results. 25 Geographical Area Huron County, Michigan was chosen as the research site for the following reasons: more than ten percent of the county pOpulation is over sixty years of age; active, ongoing programs for senior citizens operate within the county including Meals on Wheels (MOW),-Title VII program, volunteer groups of senior citizens, Senior Citizen Clubs and a Tri-County Council on Aging; no other food behavior research has been conducted in the area; and the inter- viewer was familiar with the county. Contacts were made by the researcher with personnel affiliated with the following agencies and programs: Human Development Commission (sponsor of the Meals on Wheels Program), Title VII Program, Volunteer Bureau, Department of Social Services and the Cooperative Extension Service. The professionals approached indicated a willingness to cooper- ate with the study. In three instances possible inter- viewees were named. Purposive Sample The sample was chosen by the researcher from names suggested by personnel from agencies in the county and from names suggested by local contacts. The potential interviewees were selected in an attempt to include both men and women, participants of nutrition programs in the 26 county and the homebound. The person who did the majority of the food preparation was interviewed. The researcher contacted all potential interviewees by telephone and briefly explained the project. Appoint- ments were made, at the convenience of the interviewee, with those who agreed to be interviewed. Ninety percent of those contacted indicated they were willing to be inter- viewed for the study. The five peOple who refused to take part in the study cited their reasons as poor health and lack of information about food and nutrition (two each) and bad eating habits (one). The reasons given for refusing to be a part of the study may suggest a particular bias in the sample. Lack of knowledge, poor health, and "bad" eating habits may be factors which effect a change on food behavior with age. Goal Statements Goal statements identifying personal values were rated by respondents on a 1-5 scale based on the importance of the goal to them. Four health related goals were selected by the researcher to serve as indicators of the importance of health, physical fitness and weight control to the sample. There were twelve goal statements in all. 27 Interview Process The interviews were conducted from September through December, 1975. It was necessary to spend more than three hours and/or make additional appointments in order to com- plete the interview schedule in seven cases. The longest interview lasted six hours and required four appointments. However, the majority of the data were collected during one interview which required between two and three hours to complete. Food Models To assist interviewees in estimating their usual serving sizes, food models were used. The models (Christen— sen, 1973) were made of polyurethane and shaped into: (1) white mounds to represent serving sizes of cottage cheese, ice cream, potatoes, rice and canned fruit; (2) gray mounds to represent serving sizes of cooked vegetables and casseroles and pork and beans; (3) flattened orange and yellow mounds to represent servings of cheese, butter and margarine; and (4) brown patties to represent meat. The volume of the mounds was determined by water displacement V in measuring cups. Plastic cups and bowls were used to estimate serving sizes of juice, milk, soup, lettuce salad and cereal. It was assumed that a person usually eats the same size serving for a given food from one time to 28 another and that an individual can estimate what quantities of the foods he/she can eat. Interview Schedule The researcher conducted all fifty-one interviews. Before the interview the interviewees were informed of the confidentiality of their response and the consent form was explained to each and signed by all interviewees. The interview consisted of a twenty-three page interview schedule including: demographic and food behavior data; information on changes in food behavior experienced with age; food frequency information; food portion size infor- mation (using the food models previously described); and health related and goal statements. Data Analysis A codebook for the NC 108 interview schedule was developed by the technical committee of the North Central Regional Experiment Station Project. The responses obtained from the NC 108 portion of the interview were punched on computer cards. The cards were processed at Iowa State University, Ames, Iowa. Printouts from the analysis included: mean daily intakes of protein, calcium, iron, vitamin A, C and thiamin for each respondent; a composite picture of the entire group of persons based on the intake of the above six nutrients; comparisons of 29 individuals' mean daily intakes with the 1974 Recommended Dietary Allowance; and number of four food group servings eaten each day. Tabulation of the frequency of responses from the thirteen original questions were completed. The mean values from demographic data were used to construct a sketch of a typical respondent. The sketch of a typical respondent represented no single individual in the sample. The sketch was intended to describe the environmental factors, food behavior, and change in food behavior commonly found in the sample. Two additional case studies of nutrition program participants were constructed. The case studies of the HDMP recipient and Title VII participant were actual participants in the study. RESULTS Sample Characteristics The total sample consisted of fifty-one individuals over the age of sixty years, forty-three females and eight males, living in Huron County, Michigan. This sample represented less than one percent of the total population sixty plus years in the county. Eight percent of the respondents were recipients of home-delivered meals and eighteen percent attended an Elderly Nutrition Program regularly. Twenty-six percent of the total sample were receiving meals through nutrition programs in Huron County, Michigan. The nutrition program in Huron County currently serves approximately 500 meals per week to approximately fifteen percent of the elderly population. The demographic characteristics of the fifty-one respondents are shown in Table 1. The mean age of the sample was 73.6 years with a range of sixty to ninety-five years. Mean annual income was an amount between $5,000 and $6,000. Eighteen percent of those interviewed had annual household incomes below $3,000. Eleven percent indicated 30 31 TABLE 1.--Demographic Characteristics of Respondents. Demographic Characteristics Number Percenta Range Annual Income n = 0-$2,999 9 17.7 -- $3,000-$5,999 20 39.2 -- Greater than $10,000 10 19.6 $10-22,000 Don't know 6 11.8 -- Education (years completed) 8 or less . 23 45.1 2-8 9-12 12 23.5 -- Greater than 12 16 31.4 13-20 Age (years) 60-69 18 35.3 -- 70-79 25 49.0 -- 80+ 8 15.7 80-95 Place of Dwelling City (population under 5,000) 34 66.7 -- Rural non-farm 12 23.5 -- Farm 5 9.8 —- LivingrArrangements Living alone 28 54.9 -- Living with spouse 20 39.2 -- Living with relative other than spouse 3 5.9 -- Living with person other than relative 0 0.0 -- aIn some cases percent greater than 100 due to rounding error. 32 that they had no knowledge of their annual income. In some cases, it was necessary to ask the spouse to answer the question about income. The formal education completed by the group also is shown in Table l. Forty-five percent of the sample had an education level of eight years or less. Thirty-one percent had completed an education level beyond high school. The mean education level of those interviewed was 10.9 years with a range of two to twenty years. Almost sixty-eight percent of the pOpulation sample lived within the limits of towns of less than 5,000 peOple. Five people still resided on a farm. The remainder of the respondents were rural non-farm residents. More than half of the respondents lived alone. Forty percent lived with their spouse. The remainder lived with a relative other than a spouse. Use of Special Diets and Vitamin Supplementation Table 2 lists special diets and use of vitamin and/or mineral supplements. Special diets prescribed by a physician were reported by twenty-two percent of the respondents. The most frequently (six percent) reported diet followed was the diabetic diet. Weight reduction and modified fat diets were cited by four percent of the sample each. 33 TABLE 2.--Use of Special Diets and Vitamin and/or Mineral Supplements by Main Meal Preparers. Use of Diets and/or a Vitamin/Mineral Supplements Number Percent Special Diets Diabetic 3 6 Weight Reduction (physician prescribed) 2 4 Modified Fat 2 4 Weight Reduction (self prescribed) 2 4 Ulcer l 2 Restricted Salt 1 2 Vitamin and/or Mineral Supplementsb ll 22 aIn some cases percents greater than 100 due to rounding error. bRespondents indicated whether they used supplements, the type and dosage were not described. Both an ulcer and a restricted salt diet were reported. Four percent of the respondents were following self-prescribed weight reduction diets. All diets, both physician and self-prescribed, were reported by women. Twenty-two percent of the respondents stated that they took a vitamin and/or mineral supplement each day. The type of preparation complex and dosage were not des- cribed by respondents. None of the respondents indicated they took more than one vitamin/mineral preparation. All respondents taking vitamin supplements were women. 34 Change in Food Behavior with Age When the respondents were asked whether they had changed their food behavior as a result of age, eight percent reported no change. Fourteen percent of the respondents stated that they were eating better than they did when they were younger. Almost seventy-eight percent changed their food behavior with age, citing loneliness and health as reasons most frequently. Twenty-eight percent of the cases stated they were eating less food less often. Twenty-six percent indicated they were no longer cooking as they had when they were younger. Adjustments Made in Food Purchasing Behavior The food purchasing behavior of respondents is described in Table 3. More than twenty-five percent of the annual income was spent for food by twenty-two percent of the respondents. When asked what adjustments were made because of the increase in food prices, seventy-five per- cent of the respondents indicated that they had made some adjustments in their food purchasing behavior. Twenty percent mentioned the high price of meat as a factor they considered when shopping. More than twenty percent of the sample stated that having a garden and preserving food were methods they used to "stretch" their food dollar. 35 TABLE 3.—-Food Purchasing Behavior of Main Meal Preparers. Food Purchasing Behavior Number Percenta Percent Income for Food n = 51 Less than 10 2 4 11-15 11 22 16-20 6 12 21-25 10 20 26-30 2 4 Greater than 30 9 18 Don't know 11 22 Adjustments Made by_Main Meal Preparers Due to an Increase in Food Prices Purchase foods desired 13 25 Use coupons, watch ads ’ 18 35 Watch meat prices 10 20' Have a garden . ’ 10 20 aIn some caSes, percents greater than 100 due to rounding error. Over one-fourth of the respondents bought the food they desired regardless of the cost. As one respondent stated, "you have to eat no matter what the cost." Nutrient Intake of Main Meal Preparers The dietary intake of six nutrients (calcium, protein, thiamin, iron and vitamins A and C) of main meal preparers is described in Table 4. The food frequency and food quantity data were calculated as percents of the 1974 Recommended Dietary Allowance (RDA) for men and for women over fifty-one years of age, separately. 36 TABLE 4.--Percent of Main Meal Preparers with Dietary Intakes Less than 66 Percent RDA, 66-100 Percent or Greater than RDA for Selected Nutrients. Less Than a Greater Than Nutrient 66% RDAa 66-100% RDA 100% RDAa % % Protein 8 8 86 Calcium 22 38 42 Iron 6 22 68 Vitamin A 2 4 94 Thiamin 10 ll 70 Vitamin C 4 4 94 aBased on 1974 individual Recommended Dietary Allowances for adult men and women 51 plus years. Eighty-six percent of the respondents had protein intakes which exceeded one hundred percent of the 1974 RDA for protein. Combined with the percent of those reaching 66-100 percent of the RDA for protein, more than ninety percent of the respondents met at least two—thirds of the RDA for protein. The mean protein intake for this sample was 68 grams per day, with a standard deviation of 22 grams. Calcium intake exceeded two-thirds of the RDA for seventy-eight percent of the respondents. The mean intake of calcium for the total sample was 796 milligrams per day, with a standard deviation of 341 milligrams. Iron intake levels were below the two-thirds RDA in three cases, all male respondents. Over ninety percent of the sample met or exceeded the two-thirds of the RDA 37 for iron. The mean intake was 12 milligrams per day, with a standard deviation of 4.6 milligrams. Nearly ninety-five percent of the sample had vitamin A intakes which exceeded one hundred percent of the RDA. Only one respondent had a vitamin intake that did not meet the requirements set by 2/3 RDA for vitamin A. Vitamin C intake in ninety-four percent of the respondents exceeded one hundred percent of the RDA. Only two respondents did not meet the requirements set up by the RDA for vitamin C. Thiamin intake met the two-thirds the RDA in eight percent of the cases. Approximately twenty percent of the respondents did not meet the two-thirds RDA for thiamin. Importance of Goal Statements to Main Meal Preparers Goal statements were rated for importance by main meal preparers (Table 5). The statements concerned the importance of physical fitness, weight control, the