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FOOD BEHAVIOR FACTORS INFLUENCING THE
DIETARY FIBER INTAKE OF OLDER WOMEN

IN SOUTHEASTERN MICHIGAN

By

Carolyn Kristin Johnson

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

1978

ABSTRACT

FOOD BEHAVIOR FACTORS INFLUENCING THE
DIETARY FIBER INTAKE OF OLDER WOMEN
IN SOUTHEASTERN MICHIGAN

By

Carolyn Kristin Johnson

Fifty-nine noninstitutionalized elderly women were interviewed
about their food behavior including usual meal pattern, health, and
understanding about fiber. Calculation of the dietary fiber (DF)
content of the diets, based on Southgate's data, showed mean DF
intake was 14 g/day (range 3-34 g/day). DF intakes were significantly
lower for those with a tendency to constipation who took laxatives
than for those who did not take laxatives or had no tendency to consti-
pation. Those in poor health also had significantly lower DF intakes.
Factors not related to DF intake included age, participation in a meal
program, living arrangement, understanding of fiber, and functional
health. Fruits and vegetables were eaten regularly by 93 and 98
percent of respondents respectively. Half of bread eaten was reported
to be dark, whole wheat or rye. Bran cereals accounted for 30 percent

of cereal consumption.

ACKNOWLEDGMENTS

I would like to express my sincere thanks to the following people:

To Dr. Kathryn Kolasa for her complete support of this research
and her guidance and patience throughout my graduate program. Her
insistence on high standards was appreciated.

To Drs. Wanda Chenoweth, Maurice Bennink, and Marilyn Parkhurst
for their encouragement and advice. Drs. Chenoweth and Bennink are
especially thanked for their assistance in planning the project and
their confidence in spite of the complications.

To Maggie Hammer, Jane Nowak, and other staff of the Oakland
Livingston Human Service Agency for their suggestions and cooperation
in approving the project and arranging for the selection of the
research population.

To the study participants who welcomed me into their homes so
graciously and were so kind and cooperative.

To the Department of Food Science and Human Nutrition and the
Michigan Agricultural Experiment Station for financial assistance.

To Patricia Britten for her experienced advice and help with
the computer programming.

Finally, a personal note of thanks to my husband, Carl W.
Johnson, Jr., without whose understanding, support and capable assist-

ance this project would not have been completed, and to my children

for their help in keeping the homefires burning.
ii

TABLE OF CONTENTS

Page
LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . v

LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . vi

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OPERATIONAL DEFINITIONS . . . . . . . . . . . . . . . . . . . . 4
REVIEW OF LITERATURE . . . . . . . . . . . . . . . . . . . . . . 5
Definition of Dietary Fiber (DF) 5
Analysis of Dietary Fiber . . . . . . . . . . . . 8
Physiological Effects of Dietary Fiber . . . . . . . . . . . . 9
Levels of Dietary Fiber Intake . . . . . . . . . . . . . . . . 15
Food Behavior Related to Dietary Fiber Intake . . . . . . 18
Health and Environmental Factors Associated with Low Energy
Intakes or Poor Nutrient Status . . . . . . . . . . . . . . 21
Measurement of Nutritional Status . . . . . . . . . . . . . . 24
Measurement of Laxation . . . . . . . . . . . . . . . . . . 26
Measurement of Functional Health . . . . . . . . . . . . 27
The General Public and Dietary Fiber (DF) . . . . . . . 28
Measurement of Attitudes Toward the Practice of Nutrition . . 30
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

METHODS AND PROCEDURES . . . . . . . . . . . . . . . . . . . . . 33
Development of the Instruments . . . . . . . . . . . . . . . . 33
Sample Selection . . . . . . . . . . . . . . . . . . . . . . . 38
Analysis of Data . . . . . . . . . . . . . . . . . . . . . . . 40

RESULTS AND DISCUSSION . . . . . . . . . . . . . . . . . . . . . 49

The Sample . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Sample Characteristics .p. . . . . . . . . . . . . . . . . . . 50
Food Purchasing Behavior . . . . . . . . . . . . . . . . . . . 54
Food Preparation Behavior . . . . . . . . . . . . . . . . . . 59
Food Consumption Behavior . . . . . . . . . . . . . . . . . . 61
Health of Respondents . . . . . . . . . . . . . . . . . . . . 68
Dietary Fiber Intakes . . . . . . . . . . . . . . . . . . . . 77

iii

Contribution of the Major Food Groups to Dietary Fiber
Intakes .

Respondents' Understanding of Concept of Fiber in Food

Attitudes Toward the Practice of Nutrition .
Factors Influencing Dietary Fiber Intake . . . . .

SUMMARY AND CONCLUSIONS .

General Summary . . . . . . . . .
Conclusions and Implications . . . .

LIST OF REFERENCES
APPENDICES
Appendix
A. Interview Schedule . . . . . . . . . . . .
Explanation of Interview Schedule .
Equipment for Conducting the Interview
Introductory Letter . . . . . . . .
Participant Identification Form .
Consent Form . . . . . . .
Interview Schedule
Food Card Response Forms
Schedule Cards
B. Food Demonstration . . . . . . . . . .

C. Conversion Factors

D. Supplementary Food Card Data

iv

Page

81
9O
94
99

112

112
115

119

130

130
131
134
136
137
138
152
155

158
159

167

Table

10.

ll.

12.

13.

14.

15.

LIST OF TABLES

Comparison of Dietary Fiber Measured by Three Methods .

Selected Household and Family Characteristics of the
Sample . . . . . .

Food Purchasing Behavior of Respondents

Frequency of Eating Away From Home and Mean Food
Expenditure .

Food Consumption Behavior .

Use of Therapeutic Diets By Respondents .

Health Problems Reported By Respondents .
Respondents' Self-Assessment of Weight Category .
Guttman Functional Health Scale .

Activities of Respondents .

Laxation Scores of Respondents

Dietary Fiber Intake from the Major Food Groups .
Respondents' Knowledge of Food Fiber

Comparison of Levels of Dietary Fiber Intake and Laxation
Group for 58 Respondents . . . . . . . . . . .

Comparison of Scale of Health Problems and Levels of
Dietary Fiber Intake . . . . . . . . . . . . . .

Conversion Factors for Estimating Dietary Fiber Content
Of FOOdS O O O O O O O O O O O O C O O O C O C O O O O 0

Consumption of Fiber Foods Reported by Respondents . . . .

Page

10

51

55

57
62
66
69
7O
72
74
76
79

91

101

107

159

167

LIST OF FIGURES

Figure Page
I. Guttman Functional Health Scale . . . . . . . . . . . . . 41
2. Dietary Fiber Consumption of Respondents . . . . . . . . 78

vi

INTRODUCTION

Indigestible plant fibers in food, commonly called dietary
fiber, contribute to the production of a large, soft, well-formed
stool that is easy to pass (Cowgill and Anderson, 1932), and have been
associated with the maintenance of a normal healthy colon throughout
life (Hodgson, 1975; and Painter, 1969). Due to technological advances
in the last century refined foods, from which dietary fiber (DF) has
been removed, have become widely available in many nations, leading to
changes in the food behavior of many populations (Robertson, 1972).

The long-range effects of these changes in food behavior are uncertain.

Painter and Burkitt (1971) suggested that inadequate DF in
western diets was responsible for the high incidence of diverticular
disease found among older people in western countries. Other evidence
has suggested that DF may influence serum lipid levels (Jenkins et al.,
1975b) and reduce mineral absorption (Stiles, 1976). Research on the
role of DF in human well-being has been hindered by the lack of satis-
factory data on the DF composition of foods (Van Soest and McQueen,
1973), as well as lack of knowledge of the interrelated effects of the
various constituents of DF on colon function and other body processes
(Spiller and Amen, 1975).

Some studies have shown that vegetables and fruits, which are
important DF sources, are not consumed in adequate quantities by many

older individuals (Pao, 1971; and Lyons and Trulson, 1956), and that
1

sweets, which are often poor sources of DE, are popular (Swanson,
1964). A U.S. Department of Health, Education and Welfare survey of
3,500 elderly individuals prior to participation in the Demonstration
Nutrition Program for the Elderly (Pelcovits, 1972) revealed that 34
percent had eaten no fruit and 18 percent no vegetables in the previous
24 hours. The DF content of cereal grain foods rarely has been con-
sidered in food consumption studies, so evidence is lacking for the
contribution of whole grains to the DF content.

If DF is necessary for good health, it is imperative that
physicians and dietitians be aware of the DF content of foods and
understand the factors which influence the DF intake of individuals.

The usefulness of the usual calculations of the DF content
of diets (Brodribb and Humphreys, 1976a; and Bergan and Brown, 1976)
is limited because results are stated in terms of crude fiber (CF),
the century-old AOAC (1970) method of fiber determination in which
substantial portions of DF are lost (Van Soest and McQueen, 1973).
Newer methods of analysis, using detergents (NDF) (Van Soest and
Wine, 1967) or enzymes (EZF) (Southgate, 1969; and Hellendoorn et al.,
1975) to separate DF from the other constituents of food, yield values
which are considered to be closer approximations of BF. While NDF and
EZF values are available for a limited number of foods, the published
values (Spiller and Amen, 1975; Hellendoorn et al., 1975; and South-
gate, 1976 and 1977) are sufficient in number to allow for the calcu-
lation of the approximate DF content of diets. These approximations
of DE intake can then be used in examining the factors which influence

the DF content of diets.

An ecological approach is necessary if one hopes to delineate
the factors which affect DF intake (Sims et al., 1972). The nutrient
content of a person's diet depends on the choices he makes in getting,
selecting, preparing, consuming, and disposing of his food, that is, a
person's nutrient intake depends on his food behavior. Many factors
influence a person's food behavior-~his health, his life situation, his
knowledge about and attitude toward food. These all must be considered
in examining food behavior.

The objectives of this research were to: (a) describe the food
behavior, health and life situation of a selected population of older
women, (b) to estimate the DF content of their diets, and (c) to
identify and describe the factors in their food behavior, health, and
life situation which appeared to influence their DF intake. Older
women were chosen as subjects because their laxative use suggests that
they frequently suffer from constipation (Connell et al., 1965),
which may be related to diets low in DF. Older women also suffer a
high incidence of diverticular disease (Manousos et al., 1967) which
suggests that they may be likely to exhibit many food behaviors which

limit DF intake.

OPERATIONAL DEFINITIONS

Dietary Fiber.--All the plant polysaccharides and lignin in

 

the diet that are undigested by human digestive enzymes.

Food Behavior.--The way in which an individual or group

 

selects, prepares, consumes, and disposes of food.

Independent living adult.--An adult who is not living in an

 

institution.

Nutrition Program for the Elderly (Nutrition Program).--A
government program funded under Title VII of the Older Americans Act,
which is designed to provide one meal a day for up to five days a
week in a congregate setting to people sixty years old or older who
are not eating properly for economic or social reasons.

Nutrition Site.--A location at which the meals of the Nutrition

 

Program for the Elderly are served.

Nutrition Meal.--A meal served at a Nutrition Site, which has

 

been planned to provide one-third of the Recommended Dietary Allow-
ances for all nutrients.
Laxation.—-The process of evacuating the bowels.

Site Host.--The supervisor of a Nutrition Site.

REVIEW OF LITERATURE

Definition of Dietary Fiber (DF)

 

Any discussion of food behavior in relation to dietary fiber
(DF) intake must be preceded by a definition of DE, yet the effort to
define what is meant by "dietary fiber" has been fraught with much
confusion and disagreement.

The term was first used by Hipsley (1953) to refer to "lignin,
cellulose, and hemicelluloses," It was not used again until Trowell
(1972) proposed a new definition based on physiological considerations.
Influenced by the early work of McCance and Widdowson (1929; and 1960)
and the recent work of Southgate (1969) at Cambridge with "unavailable
carbohydrates," Trowell (1972) defined DF as "the remnants of plant
cells resistant to hydrolysis by the alimentary enzymes of man."

Because of Van Soest and McQueen's (1973) investigation of the
constituents of plant cell walls, Trowell (1974) equated DF with the
indigestible polysaccharides and lignin in the walls of plant cells.
Recently Trowell and coworkers (1976) have extended the definition of
BF to include undigested storage polysaccharides present within the
cell as well as cell wall polysaccharides and lignin. Southgate
(1977) has accepted this definition, calling it a "philosophical"
definition, since it refers to the theoretical 'true fiber' in the diet
and does not denote any method or analytical procedure.

5

The fiber studies of Van Soest and McQueen (1973) have utilized
plant cell walls, not including the soluble polysaccharides. In a re-
cent review, Van Soest and Robertson (1977) did not accept the more
inclusive definition of BF and suggested that the soluble polysaccha-
rides should be recognized as a separate class of substances, since they
require a different analysis and possess some prOperties not shared
with the insoluble polysaccharides.

In contrast, Southgate (1977) supported the inclusion of these
indigestible soluble polysaccharides in the definition of DF, on three
main grounds. First, the soluble polysaccharides are related struc-
turally, in a chemical sense, to the insoluble polysaccharides present
in plant cell walls. Second, these soluble polysaccharides behave
physiologically in a similar way in increasing stool bulk and water
retention. Finally, it is virtually impossible to distinguish,
analytically, some components in the diet derived from the plant cell
walls from those derived from other sources.

Spiller and associates (1976a) concurred with the DF definition
of Trowell and coworkers (1976), but proposed a new term 'plantix'
to replace the variously defined 'dietary fiber.‘ Although lignin is
unrelated chemically to the indigestible polysaccharides, it is gener-
ally accepted as part of DF because of its intimate association with
the polysaccharides of plant cell walls while not belonging to any
other-major food compartment (such as plant cell wall proteins).

Several unresolved questions concerning the definition of
fiber have been pointed out (Trowell, 1977), including how to classify

other indigestible non—plant or non-polysaccharide substances, such

as the products of the Maillard reaction, cell wall proteins and
lipids, animal polysaccharides and synthetic polysaccharides used in
food. It has been suggested that the indigestible proteins and lipids
(waxes and cutins) associated with cell walls be included, along with
DF, in a more comprehensive category called DF complex (Trowell et al.,
1976) or complantix (Spiller and Shipley, 1976b).

For the purpose of this research, the widely accepted definition
of DE was used, that is, DF includes all the plant polysaccharides
and lignin in the diet that are undigested by the endogenous secretions

of the human digestive tract (Southgate, 1977).

Components of Dietary Fiber

 

The components of dietary fiber have been described in several
reviews (Cummings, 1973; Spiller and Amen, 1975; and Southgate, 1977),
and include lignin, cellulose, and the non-cellulosic polysaccharides,
hemicelluloses, pectic substances and gums.

The physicochemical structure of the non-cellulosic poly-
saccharides, about which Van Soest and Robertson (1977) and Southgate
(1977) have disagreed, has not been elucidated completely, nor is the
relationship between the subcategories clear. There is evidence from
cultured sycamore cells that the pectins, hemicelluloses and cellulose
are linked with covalent and hydrogen bonds into a cell wall macro-
molecule (Theander, 1977). Albersheim (1965) suggested that there is
a continuum of polysaccharides from those containing a high percentage
of uronic acid, the pectic substances, to those with a low degree of

uronides, the hemicelluloses, and that the separation of pectins or

hemicelluloses is the result of the ease with which certain bonds are

hydrolyzed under acid or alkaline conditions.

Analysis of Dietary Fiber

The standard crude fiber procedure (AOAC, 1970) for measuring
fiber in the diet is being abandoned by researchers in favor of newer
methods of analysis that give a more complete analysis of dietary
fiber. Practical methods for analyzing dietary fiber can be grouped
into three categories: simple empirical procedures such as those of
Van Soest and Wine (1967) for measuring neutral detergent fiber (NDF);
procedures which measure indigestible residue by the in vitro
digestion of food, such as the enzymatic method (EZF) of Hellendoorn
and coworkers (1975); and more involved procedures such as that of

Southgate (1969) which measure unavailable carbohydrate.

Fiber Values Found in the Literature

 

Values for the crude fiber content of foods are found in Food
Values of Portions Commonly Used (Church and Church, 1975). These
values are considered unsatisfactory by most researchers (Spiller and
Amen, 1975; Van Soest and Robertson, 1977; Trowell, 1977; and South-
gate, 1977) but are still the basis of some recent studies (Bergan
and Brown, 1976).

Values for the neutral detergent fiber of a limited number of
representative foods have been reported by Spiller and Amen (1975)
based on analysis by Robertson and Steh at Cornell University. A few
NDF values also are found in a report by Van Soest and McQueen (1973).
Values for the enzymatic fiber in a few representative foods have been

reported (Hellendoorn et al., 1975; and Hellendoorn, 1976).

Southgate (1976) has published a guide to calculating intakes
of BE in which values for the DF content of many, though by no means
all, foods are presented. Many of the same values are given again in
a later paper (Southgate, 1977).

DP values for many foods have not been published, particularly
for some vegetables and many fruits. NDF or EZF values are available
for some of these foods, but only crude fiber values can be found for

others.

Comparison of Analytical Methods

 

Results of the analysis of some representative foods by three
procedures are shown for comparison in Table 1. Values for the grain
products display considerable agreement. For fruits and vegetables,
values for neutral detergent fiber and indigestible residue (enzymatic
method) are generally lower than those for unavailable carbohydrates

as the pectic substances are lost during these procedures.

Physiological Effects of Dietary Fiber

 

Many studies have shown that adding bran to the diet increased
the daily stool weight significantly (Eastwood et al., 1973; Cummings
et al., 1976; Fuchs et al., 1976; and Findlay et al., 1974). Williams
and Olmsted (1936) demonstrated that the fiber in carrots, corn germ
meal, cabbage, and agar agar also increased subjects' stool weights

' and cottonseed hull

substantially, while canned peas, 'cellu flour,
resulted in smaller increased in stool weight. Cummings and coworkers
(1976) found that the increase in percent water content of the stool

after the addition of wheat fiber to the diet was significant when

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11

large amounts of wheat fiber were added, but Wyman and coworkers (1976)
found the increase in percent water content to be minimal when less
fiber was added. Fantus and Frankl (1941) investigated increases in
fecal volume but results were inconclusive because of difficulties in
accurate measurement.

Two studies have shown that the addition of 20 g/day of bran
to the usual diet increased the rate of passage of food through the
digestive tract in persons with initially slow transit times, and also
decreased the rate in those with rapid transits (Harvey et al., 1973;
and Payler et al., 1975). Bran also was found to be effective in
normalizing the frequency of defecation in those with infrequent,
irregular bowel movements (Painter et al., 1972).

Studies have shown that several factors are involved in pro-
ducing the effects of DF on laxation. McConnell and associates (1974)
showed that the water binding capacity of polysaccharides is large but
variable. The large water binding capacity of the mucilagenous poly-
saccharide in psyllium seeds accounts for its use as a stool softener,
bulk-forming agent in treating constipation (Baker, 1975). Kirwan and
coworkers (1974) also found that particle size influenced water binding
capacity of cereal fibers, with coarse bran producing a greater decrease
in intestinal transit times than finely ground bran. Wyman and co—
workers (1976) compared Kellogg's All Bran and unprocessed miller's bran
and found that the processed bran was less effective than the unpro-
cessed bran in increasing stool weights.

Polysaccharides in the colon are attacked by bacterial action
in the bowel and partially degraded to form volatile fatty acids and

other nutrients consumed by bacterial cells, methane and carbon

12

dioxide (Van Soest and Robertson, 1977). The volatile fatty acids are
thought to have a direct cathartic action on the bowel as well as
drawing water by osmosis.

In an early study, Williams and Olmsted (1936) found that the
increase in stool weight associated with ingestion of various kinds of
fiber was related more closely to the bacterial degradation of fiber
in the colon and the associated increase in fecal volatile fatty acids
than to the amount of fiber consumed.

Recently Cummings and coworkers (1976) observed a significant
decrease in transit time and increase in fecal weight associated with a
highly significant (p<.005) increase in total volatile fatty acids per
day following the addition of 28 g/day DF to the diet of six subjects.
These researchers also noted that the concentration of fecal volatile
fatty acids remained the same, suggesting that they were partially con-

trolling fecal water content.

Dietary Fiber and Diverticular Disease

The hypothesis linking DF and diverticular disease was first
proposed by Painter and Burkitt (1971). Burkitt (1970) found from
epidemiological evidence that populations consuming a traditional
African diet which was high in fiber had a low incidence of diverti-
cular disease, while in England the incidence of diverticular disease
had risen to high levels following a rise in the consumption of highly
refined foods and meats in the late 19th century.

At the same time, Painter and associates (1965) found that
intra—colonic pressures in diverticular patients were unusually high,

due to hypersegmentation. Painter (1969) proposed that the high

13

intra-colonic pressures observed caused the formation of diverticula
in the sigmoid colon. Painter and Burkitt (1971) then proposed that
the lack of sufficient residue in the typical English diet was the
cause of diverticular disease.

Other researchers have observed localized high pressure areas
in the colon, or hypersegmentation, in the colons of subjects who were
constipated (Connell, 1962), patients with spastic-type irritable
colon (Chaudhary and Truelove, 1961) and rabbits fed a low residue
diet (Hodgson, 1975). Morson (1975) observed that muscle thickening
but not inflammation was characteristic of the colons of diverticular
patients.

While the issue of the etiology of diverticular disease has
not been resolved, increased levels of DF in the diet have been used
with apparent success in treating patients with diverticular disease.
In a study of 70 patients by Painter and associates (1972), treatment
included a high fiber diet of fruits, vegetables and whole grains,
plus as much unprocessed bran as was required to produce a soft bowel
movement that did not require straining. Symptoms were relieved or
abolished in 89 percent of the patients by the high fiber diet with
bran (3-45 g/day), while three of the patients were improved by the
high fiber diet alone.

In another study (Brodribb and Humphreys, 1976b), 40 patients
with diverticular disease were treated with wheat bran (24 g/day).
Thirty-three patients showed a very satisfactory clinical response,
with 60 percent of symptoms abolished and a further 28 percent

relieved. Examination also showed that stool weights increased

14

significantly, transit times tended to normalize, and intracolonic
high pressure waves decreased, especially during and after eating.
Efforts which have been made to conduct double blind studies
of the effect of increased DF on colonic disorders have shown dis—
appointing results. In two studies of patients with irritable bowel
syndrome, treatment with muffins or biscuits which did or did not
contain bran produced no significant improvement (Lyford et al., 1975;
and Séltoft et al., 1976). The obvious effects of DF on laxation as
well as the variable response of individuals to level of dietary fiber
observed by Painter and coworkers (1972) and Findlay and coworkers

(1974) may have spoiled the double blind aspect of the studies.

Other Physiological Effects of Fiber

In vitro and in vivo evidence showing that bile acids and
neutral sterols are strongly absorbed by certain fractions or types
of fiber has been reviewed by Spiller and Amen (1975), suggesting that
DF may influence blood cholesterol levels. Early studies with human
subjects (Keys et al., 1960) showed that an 'Italian style diet,‘
characterized by an abundance of fruits and vegetables produced con-
sistently lower serum cholesterol levels than an American type diet
with more simple carbohydrates. Further studiesixxthe controlled
conditions of a metabolic unit (Keys et al., 1961) demonstrated that
pectin but not cellulose (15 g/day) produced a significant reduction in
serum cholesterol of about five.percent.

In more recent tests in London (Jenkins et al., 1975b), guar
gum or pectin but not wheat fiber (36 g/day) added to the normal diet

of healthy volunteers resulted in a significant drop in serum

15

cholesterol levels. Other studies have noted also that wheat bran has
little effect on serum cholesterol levels (Brodribb and Humphreys,
1976c; Connell et al., 1975; and Heaton and Pomare, 1974). In contrast,
legumes have been shown to have a significant hypocholesteremic

effect (Hellendoorn, 1976).

Other physiological changes some of which may be detrimental
have been noted in association with increased ingestion of dietary
fiber. These observations include reduced serum folate (Brodribb
and Humphreys, 1976c), reduced serum iron and ionized calcium
(Persson, 1976), and decreased efficiency of absorption of energy
nutrients (Southgate and Durnin, 1970). Hill (1974) has proposed that
DF alters the balance of intestinal microflora, reduces the concen-
tration of fecal bile acids, and lowers fecal pH, leading to less
degradation of fecal sterols to potentially carcinogenic or cocarci-
nogenic compounds which might lead to cancer of the colon. Eastwood
and coworkers (1976) have suggested that volvulus of the colon is
related to the consumption of large amounts if dietary fiber in rural
Africa, while Heaton (1973) hypothesized that food fiber is an

obstacle to energy intake.

Levels of Dietary Fiber Intake
There has been little evidence upon which to base a recommended
daily allowance for fiber, since, until recently, there was little
evidence that indigestible residues in the large intestine might be
essential for good health (FNB, 1974). Nearly 50 years ago Cowgill
and Anderson (1932) studied the laxative effects of changing the

crude fiber (CF) content of diets and concluded that a CF intake of

16

90-100 mg/kg of body weight might be a 'physiological roughage mini-
mum,’ as this amount of CF in the diet was required before all subjects
had easy bowel movements. No other research concerning a recommended
level of DF intake was found, yet a recent medical article (Benson,
1975) has recommended the same level of intake, 100 mg/kg of 'bulk
residue' daily, or about 6 g/day for a 60 kg person. No recommendations

for levels of dietary fiber intake were found.

Current Levels of Dietary Fiber Intake

 

Levels of CF intake less than 90-100 mg/kg have been reported
among persons consuming U.S. or European diets. In a large study based
on 10—day diet records, Bergan and Brown (1976) found CF intakes of
4.0 and 2.8 g/day for males and females, respectively, aged 14-96
years.

In England, Brodribb and Humphreys (1976a) reported CF intakes
of 2.6 g/day for subjects with diverticular disease, and 5.2 g/day for
age- and sex-matched controls. These subjects were 75 percent female,
so that the fiber intake of the control subjects, (5.2 g/day) repre-
sented a substantially higher fiber intake than a group of the U.S.
subjects (Bergan and Brown, 1976) with the same proportion of females
would have had (3.1 g/day).

In Holland, Groen (1973) reported the approximate fiber content
of a typical.”western'diet containing generous amounts of meat and fats
at 5 g/day, a value comparable to that of the control subjects in the
study by Brodribb and Humphreys (1976a). Higher fiber values of
7, 8, and 13 g/day also were reported by Groen (1973) for Arab

Bedouins, Yemenite Jews, and Trappist monks, respectively.

17

The dietary fiber content of a 'standard Western type diet'
produced in a metabolic kitchen for research purposes was reported by
Cummings and coworkers (1976) to be 17 g/day, using DF values from
Southgate (1976). The crude fiber content of the same diet was 3.8
g/day (Jenkins et al., 1975a), a value only one-fifth the DF content
of the diet.

Examining CF contents of British diets from a different
point of view, based on national statistics relating total food
supplies, Robertson (1972) found that daily fiber intakes rose from
2.1 g in 1880 to 4.2 g in 1970, with a peak of 5.3 g in 1942, during
World War II.

Little effort has been made to document nutritional status
with respect to fiber in relation to health except for general state-
ments that people consuming 'western' diets are bothered more by con-
stipation because they don't consume enough fiber, and as a result
probably are subject to a number of diseases common in western coun-
tries (Burkitt et al., 1974).

Nutrient Intakes Related to Dietary
Fiber Intake

 

While little has been done to investigate the DF content of
diets or document DF status in relation to health, nutrient intakes of
energy provide some evidence that DF intakes may be low since many
foods which provide calories also contain DF. Many studies have shown
that energy intakes of older women tend to be low (Ohlson et al., 1948
and 1950; Exton—Smith et al., 1965; Joering, 1971; Schlenker, 1976;

and Brown et al., 1977). Steinkamp and coworkers (1965) noted that

18

subjects in a longitudinal study had significantly reduced food intakes
after age 75, but no significant differences in distribution of calo-
ries from fat, carbohydrate, protein, and alcohol, and concluded that
the reduction in caloric intake with age appeared to be related to a
general decrease in the amount of food consumed, rather than a reduc-
tion in consumption of specific foods. In contrast, a cross-sectional
study by Bergan and Brown (1976) showed that calorie intakes showed a
tendency to decrease with age while fiber intakes did not.

Garcia and coworkers (1975) studying women in different age
cohorts observed that when the intakes of individuals born in a parti-
cular year were evaluated over time, no significant changes occurred
in mean intakes of food energy. The researchers concluded that it was
important to account for generation or cohort effects before making
inferences about the effects of aging on dietary intakes.

Food Behavior Related to Dietary
Fiber Intake

 

 

A person's usual intake of any nutrient is determined by the
choices that person makes in getting, selecting, preparing, consuming
and disposing of his food (NRC, 1945). These choices are usually
habitual and constitute a complex of individual food habits which are
referred to as food behavior.

Few researchers have examined the food behavior which deter-
mines the dietary fiber content of diets. Groen (1973) observed that
the western diet which is relatively low in fiber contains generous
amounts of meat and fats. In contrast, he noted that Yemenite Jews,

with medium levels of fiber intake, consumed more bread and less fat

19

than was found in the western diet, and Arab Bedouins, with medium
levels of fiber intake, consumed large amounts of bread and little
meat, fats, fruits, or vegetables. On the other hand Groen found
that Trappist Monks who ate large quantities of bread, potatoes and
legumes, no meat, and little fat, had very high fiber intakes.

The 'standard' western-type diet used by Jenkins and associates
(1975a) and Cummings and associates (1976) contained meat, milk, eggs,
vegetables, sugar, butter, and refined breads and cereals.

Painter and Burkitt (1971 and 1975) examined the change in
food behavior which influenced fiber intake in Britain during the
previous 100 years. They noted that large amounts of stone ground
wheat mixed with rye, together with oatmeal porridge, were commonly
consumed until 1880, when the advent of roller milling made available
flour from which two-thirds of the fiber had been removed. Then
increased prosperity, better transportation, and better refrigeration
made other foods cheap and available. Meat imports doubled and sugar,
jam and white bread became part of the diet of the poorest classes.
Sugar consumption doubled between 1865 and 1890, while bread consump-
tion declined.

Robertson (1972) challenged the findings of Painter and Burkitt
(1971), noting the general increase in the crude fiber content of
British diets in the last 90 years, which was due to an 87 percent
increase in available fruits, vegetables and nuts, even though use of
potatoes and cereal products had declined. A peak in fiber intakes
during WOrld War II was due to the use of large quantities of high

extraction flour during the war years.

20
Food Behavior of Older Persons Related
to Dietary Fiber (DP) Intakes

Some researchers have documented food behavior of older
individuals which would relate to DF intakes. A U.S. Department of
Health, Education and Welfare survey of 3,500 elderly individuals
prior to participation in the Demonstration Nutrition Program for the
Elderly (Pelcovits, 1972), indicated that 34 percent had eaten no
fruit and 18 percent no vegetables in the previous 24 hours.

Swanson (1964) observed that the overall consumption of fruits
and vegetables by older women was lower than that of younger women,
while consumption of cereal products tended to remain constant, though
providing a greater share of total calories, and sweets were often
consumed in excessive quantities. Other researchers have reported
that fruits and vegetables rich in vitamins A and C often are omitted
from the diets of older persons (Steinkamp et al., 1965; LeBovit, 1965;
and Clancey, 1975) but the implications of these findings for DF
intakes is uncertain.

The DF content of cereal grain foods rarely has been considered
in food consumption studies. Rountree and Tinklin (1975) reported
that whole grain bread and rolls were used daily by nine percent of
elderly subjects in Kansas. No other evidence was found for the con-
tribution of whole grains to the DF content of diets.

Health Factors Related to Dietary
Fiber (DE) Intake

Levels of DE intake have been implicated in problems with

laxation (Williams and Olmsted, 1936; Eastwood et al., 1973; and

Cummings et al., 1976). No U.S. studies were found which investigated

21

the incidence of constipation among older persons. A British study
(Millard, 1971) found that 17 percent of women over 70 years were
constipated although 56 percent were taking laxatives. Another
British reseracher (Wigzell, 1969) found that 78 percent of persons
aged 90-99 years had normal bowel habits. Again a large percentage of
the subjects (66%) were taking laxatives. Methods of assessing con-
stipation were not reported in either of these studies.

Yet another British study (Connell et al., 1965) measured
laxation by the number of bowel movements per week and found that
the percent of subjects with a bowel frequency of 5-7/wk tended to
decrease through the sixth decade. Numbers in the age group 60-69
years were too small to draw conclusions about that trend in later
life. A trend to increased use of laxatives with age was seen, with
14 and 30 percent of 60-69 year old subjects in the two populations
studied reporting laxative use more than once a week. Results were
not reported by sex.

Health and Environmental Factors Associated with Low
Energy Intakes or Poor Nutrient Status

 

Many health, social, and environmental factors have been
associated either with low energy intakes or poor nutrient status.
Ohlson and coworkers (1948) found that elderly women in poor health
tended to consume fewer vegetables and whole grains, and consistently
ate less food than those in good health. LeBovit (1965) observed that
the food limitations imposed by weight control and poor appetite
were closely related to poor diets of older persons, while the presence

of physical disability in the elderly was significantly related to poor

diets in a study by Caird and associates (1975).

22

Guthrie and coworkers (1972) found that 46 percent of elderly
subjects in rural Pennsylvania had inadeqaute caloric intakes, with
consistently more subjects in the low than in the high income groups,
consuming inadequate intakes of all nutrients evaluated. Significantly
more of the high than the low income groups rated their health good
to very good, while fewer of the high income groups were receiving
medical treatment under a physician's care, and only half as many had
chewing problems.

A 1962 study of elderly English women (70 years and over) by
Exton-Smith and coworkers (1965) revealed a sharp fall (19%) in calorie
intake during the years between 70 and 80. A follow-up study seven
years later of those subjects who were available and willing to parti-
cipate (Stanton and Exton-Smith, 1970) showed that about one-sixth of
the original sample showed little decrease in their intake of calories
or protein since the previous study, and also little deterioration
in health. The remaining follow-up subjects who showed decreases in
calorie and protein intake also consistently showed a deterioration
in health. Stanton and Exton-Smith (1970) concluded that the decrease
in caloric intake seen with age is the result, not of age, but of the
deteriorating health which afflicts a large portion of persons in the
eighth decade.

Several researchers have noted that older people who are living
alone with little social interaction are less interested in eating
(LeBovit, 1965), have lower nutrient intakes (Clancey, 1975; Davidson,
1962), and poorer eating patterns (Anderson, 1971).

Other social and environmental factors which have been asso-

ciated with poor nutrition in older women have been low incomes and

23

poor lifetime eating patterns (Wruble, 1976), amount spent on food
(Caird et al., 1975), and for low-income women studied by Exton—Smith
and coworkers (1965), lack of adequate food storage space, difficulty

in shopping and lack of incentive to prepare meals.

The Nutrition Program for the Elderly

Needs in the area of elderly nutrition were shown to be great
from experiences and findings of the research and demonstration program
to improve nutritional services for the elderly enacted in 1968 under
Title IV of the Older Americans Act of 1965. Title IV projects proved
to the Congress and President of the United States that the proper
provision of congregate meals for groups of elderly fostered social
interaction, facilitated the delivery of supportive services and met
emotional needs, while at the same time it improved nutrition (AOA,
1973c). For example, a study by Joering (1971) evaluating the nutri—
tional impact of a Cincinnati pilot congregate meal program showed that
the average daily nutrient intake was greater for all nutrients when a
center prepared meal was included in the subject's meals for the day.

Congress responded to these demonstrated needs of the elderly
by enacting, in 1972, Title VII of the Older Americans Act, for the
purpose of providing older Americans, particularly those with low
incomes, with low cost, nutritionally sound meals served in strategi-
cally located centers where they could obtain other social and rehabi-
litative services. Besides promoting better health among the older
segment of the population through improving nutrition, the program was
aimed at reducing the isolation of old age, offering older Americans

an opportunity to live their later years in dignity.

24

The Nutrition Program for the Elderly is currently serving
27,000 meals daily in Michigan at 617 Nutrition Sites (Perri, 1978).
Most projects provide five meals a week.

Kohrs (1976) evaluated the influence of the Congregate Meal
Program in central Missouri on dietary practices and nutritional status
of participants and found that between 40 and 60 percent of the total
daily intake of each nutrient was obtained from the program meal on
days that subjects ate at the site. Subjects who ate at the meal site
consumed significantly more calories, protein, and calcium than those
who did not. Kohrs also found that the inclusion of a program meal in
the day's meals eliminated the differences in calorie and protein
intakes that were found to relate to socioeconomic factors in those who

did not eat a program meal.

Measurement of Nutritional Status

 

Nutrient intake depends on food behavior, including all the
choices a person makes in getting, selecting, preparing and consuming
his food. A person's choice of what foods to eat is a complex be-
havior dependent on past experience, personal taste preferences,
resources, and food availability (Gifft et al., 1972). No statement
about food behavior is complete which does not include:

identification of the food eaten so that it is possible to state
that food in terms of nutrients; identification of the human
being eating the food so that it is possible to define him
further in terms of the entire body of cultural practices which
he now embodies in his behavior; identification of the place from
which the food comes or, put another way, the position of the
human being in a food production and distribution system; the
exact time at which the act under analysis is taking place.

(NRC, 1945)

25

In a study of young children, Sims (1971) pioneered in using an
ecosystem approach to the study of nutritional status which might be
applied to the study of older persons as well. Sims and coworkers
(1972) recognized that the influences upon a person's well-being act as
a complex of interacting factors. Identification and analysis of the
interrelationships among such variables were recognized as essential for
a complete understanding of nutritional status. They proposed that
current family setting, resource availability and use, and social-
psychological attributes be studied as they provide input into dietary
intake which results in measurable signs of well—being. Demographic
data, physical description of the near environment, psychological
characteristics, dietary assessment, and biochemical and anthropolo-

gical measures were analyzed within this framework.

Dietary Assessment

Twenty-four hour recall methods of dietary assessment are easy
but do not adequately characterize the diets of individuals unless
several randomly repeated 24-hour recalls are taken (Marr, 1971;
Balogh et al., 1971).

Weighed diet records give an accurate picture of food intake
but often require more subject cooperation than the elderly are able
or willing to give (Marr, 1971). Ohlson and coworkers (1950) found
that food intakes apparently were altered by the restrictions of
keeping a weighed diet record.

Burke (1947) suggested that, for research, it is important to

know average dietary intake for a given period, rather than specific

26

dietary intake for a particular period of time, and developed a diet
history method to fill that need.

The reliability of the Burke-type diet history was assessed in
Israel by Reshef and Epstein (1972) by comparing interviews taken
several months apart. Analysis showed no significant differences
between estimated intakes of individuals from the two interviews for
several food categories.

Schlenker (1976) found that the dietary recall records
obtained from elderly women were essentially the same as the written
diet records, suggesting that memory lapses were not a problem in
assessing food intakes. On the other hand, Madden and associates
(1976) found that elderly subjects using food models tended to under-
estimate large servings and overestimate small servings when recalling
food intake from a meal that had been unobtrusively observed and
measured by the researchers.

Moore and coworkers (1967) observed that the use of the food
models in taking diet histories saved time and reduced the frustration
of respondents who had formerly searched for words to describe size,
volume and weight. Data handling also was reduced because answers

were definite and comparable.

Measurement of Laxation

 

Connell and coworkers (1965) noted that simple methods of
measuring laxation may be misleading as no single variable, such as
frequency of bowel movements, stool consistency, or use of laxatives,
provides a reliable measure of degree of problem with constipation.

Williams and Olmsted (1936) observed that the subjects' subjective

27

estimation of relative laxation effect was related to increment in
stool weight. Cowgill and Anderson (1932) noted that subjects felt
subjectively that evacuation was easier and more satisfactory and
complete when one ounce of bran was added to a basal diet although
laxation rate changed very little. They concluded that subjective
impressions as well as fecal weights were the most sensitive indicators
of a significant laxative effect, although laxation rate and transit

times were more objective.

Measurement of Functional Health

Functional health of older people has been defined by Rosow
and Breslau (1966) as the degree to which they report they can manage
adequately or are restricted in their activities because of their
physical condition or capacity. They observed that a person's
functional capacity is sociologically more significant than his tech-
nical medical condition. As a simple way of measuring the subject's
self-assessment of functional health, Rosow and Breslau (1966) deve-
loped a Guttman Scale of responses to questions about the subjects
ability to function in ordinary activities. Steps in the Guttman
scale included: (1) subject still healthy enough to do without help
when going out to movie, church, meeting, or visit; (2) subject
walks up and down to second floor without assistance; (3) subject can
walk half a mile; (4) subject chose statement 'I am not limited in
any activities'; (5) subject has no physical condition or illness now;
(6) subject still able to do heavy work around without help.

A perfect Guttman scale is cumulative, each step of the scale

indicating that that step plus each of the previous steps is true of

28

the respondent (Guttman, 1951). That is, ideally, all those who, for
example, have given three positive responses, will have responded
positively only to the questions in steps 1, 2 and 3.

Results of the study of 1200 older persons in Cleveland by
Rosow and Breslau (1966) showed that 69 percent of the subjects gave
3 or more positive responses, 53 percent 4 or more, 46 percent 5 or
more and 21 percent 6 positive responses. They concluded that for
surveys and sociological studies of the aged which must effectively
depend on self-assessments of health in interviews, this scale provides
a simple, economical means of differentiating functional health within

a sample.

The General Public and Dietary Fiber (DF)

A search of dictionaries and books for the general public about
nutrition or health showed that the word 'fiber,' as a constituent
of food, did not appear commonly until the 1970s. Neither the Oxford
English Dictionary (OED, 1971) nor the Random House Dictionary (Stein
and Urdang, 1966) listed the nutritional meaning of the word 'fiber,'
but 'crude fiber' is given as a meaning of 'fiber' in the latest
edition of Webster's Unabridged Dictionary (Gove, 1976), with crude
fiber being defined as "the chiefly cellulose material obtained as a
residue in the chemical analysis of vegetable substances, as foods
or animal feed.

A popularly written, reliable book on nutrition (Deutsch,
1971) used the word 'fiber' twice without defining it, in the first
case in describing cellulose as a part of carbohydrate which "makes up

much of the bulk and fiber necessary to keep our intestines working

29

well," and in the second case when explaining chronic constipation,
"other foods such as low-fiber foods tend to slow intestinal motility."
A more recent book for the general public by the same author (NNC, 1975)
referred to fiber more extensively than the earlier book, explaining
why a diet of nothing but refined foods is not recommended. Cellulose
was equated with fiber in this book, and was exemplified by:

fibrous material in celery or the strings in beans. These

materials are sometimes called fiber . . . Smaller bits are

found in all foods from plants . . . We know that fiber supplies

much of the bulkiness of our food and that it is helpful in

stimulating the movement of food in the intestines. (NNC, 1975)

A recent paperback medical encyclopedia (Wingate, 1972)
referred to the dietary fiber concept in these words: "Undigested
ballast (roughage) such as vegetable fibre improves the mechanical
efficiency of the intestine." Another medical encyclopedia (Kuhne,
1960) described sources of "roughage" as whole wheat bread, the coarse

varieties of vegetables and vegetables like lettuce and radishes.

A large-print cookbook called Cookipg for Two (USDA, 1974) which con-

 

tained some nutrition information commented that "whole grain breads
and cereals provide bulk."

'Roughage' and 'bulk' do appear in the Random House dictionary
(Stein and Urdang, 1966). Roughage was defined as "food, as green
vegetables, bran, and certain fruits containing a high proportion of
indigestible cellulose which stimulates peristalsis in the intestines."
Bulk is defined as "food which forms a fibrous residue in digestion,
allaying hunger and promoting normal elimination."

Research findings in the late 19603 and early 1970s (Cleave

et al., 1969; and Painter and Burkitt, 1971) prompted a sudden surge of

30

interest in fiber in the popular press. The Natural High Fiber Life

 

Saving Diet (Subak-Sharpe, 1976) and The Save Your Life Diet (Reuben,

 

1975) appeared on bookstands. A guide to fiber in foods (Kraus, 1975)
was published. High-fiber breads containing added cellulose
(McCormick, 1976) appeared on grocery shelves and were advertised
widely in newspapers. The high fiber diets and high fiber breads
were discussed on television programs. The influence of the general
interest in fiber on elderly persons has not been documented.
Measurement of Attitudes Toward
the Practice of Nutrition
Attitude is frequently defined as a predisposition to react
in a particular way toward a given object (Zimbardo and Ebbesen,
1970). If this supposition is correct then knowledge of attitudes
toward the practice of nutrition as an object might enable the
researcher to observe relationships between attitude and behavior in
the practice of nutrition. Attitudes cannot be measured directly but
must be inferred from an observable response. In a study of nutrition
education assistants by Carruth (1974) attitudes toward the practice
of nutrition were inferred from a Likert-type attitude instrument.
A 40-item attitude instrument was developed consisting of statements
about food and nutrition that reflected a willingness or disposition
to be persuaded (that is, adaptability) or reflected rigidity (that is,
inflexibility). Factor analysis of the responses to the items in the
instrument showed that 17 items contributed significantly to a compo-
nent designated 'Factor I: Change Dimension' which indicated "change

is good" or "change is not good." Scores on Factor I: Change Dimension

31

were related to other variables, namely, scores on the observed
behavior of the subjects classified as applications of nutrition know—
ledge and scores on verbal behaviors related to the practice of nutri-
tion. Carruth concluded that the statements in Factor I: Change
Dimension represent a beginning point for the deve10pment of further

attitude instruments to be used in research.

Summary

A review of the literature has shown that little is known
about food behavior related to dietary fiber. Problems in the defi-
nition and analysis of fiber were noted. One aspect of health, namely
laxation, is clearly related to the consumption of foods containing
fiber, but the exact nature of this relationship has not been eluci-
dated. Research in the field of dietary fiber is hindered by the lack
of values for dietary fiber content in tables of food composition,
but DF values for some foods have been published and provide the
basis for estimating DF intakes.

Low calorie intakes seen frequently in older women suggest
that fiber intakes may also be low. Environmental factors which
influence caloric intake may also affect DF intakes. The incidence
of constipation and use of laxatives seen in older women may be related
to DF intakes.

Dietary assessment of older persons is difficult, as no method
of assessment is entirely satisfactory and any method used must be
a compromise between precision and practicality. Also, better methods

for measuring laxation are needed.

32

Information about fiber, some of it unreliable, has become
available to the general public in recent years. The impact of this
information on food behavior or DF intakes has not been assessed.

The present study was designed to estimate the DF intakes of
a sample of older women and document the food behaviors, as well as

health and environmental factors, that influenced DF intake.

METHODS AND PROCEDURES

The subjects selected for study were older women (60 years
and over) enrolled in a meal program for the elderly in Oakland County,
Michigan. The data collection method was an hour long interview
with each participant. Specific factors studied were the respondent's
usual meal pattern and other food behavior information, living
situation, self-assessment of health, laxation, activity level, know-
ledge of fiber, and attitudes toward eating in general and dietary

fiber in particular.

Develppment of the Instruments

 

The ecosystem approach was used by the researcher in developing
the Interview Schedule, with questions included about current family
setting, food behavior, nutrition knowledge and attitudes, and health,
factors which a review of the literature had shown to influence food
intake. This approach required a lengthy interview with the respon-
dent, which was likely to lead to fatigue in older subjects. The
researcher wished to avoid a second interview and at the same time
make the interview move swiftly for the respondent. To meet these
requirements, colorful visual aids were designed to focus the attention
of the respondent and at the same time facilitate the collection of
data. The interview was planned to take about one hour to administer.

Most questions in the Interview Schedule were open-ended, with

33

34

responses recorded as completely as possible. The complete Interview
Schedule, alone with explanation and description of the materials is

found in Appendix A.

Data Collected

Information obtained during the interview included living
situation and family background, food behavior, health of the respon-
dent, diet history, knowledge of dietary fiber and attitude toward
fiber. Demographic questions about income and education were excluded
from the Interview Schedule because they frequently are construed as
an unnecessary invasion of privacy and were not considered essential
to the study.

Included under food behavior were questions about food expen—
ditures, grocery shopping, meal planning, kitchen facilities, meals
eaten away from home, and therapeutic changes made in the diet.
Questions about weight category, bothersome health problems, outside
activities, and laxation were asked to assess the respondent's
general health. In addition, the respondent's ability to function in
ordinary household tasks was assessed by a series of questions
adapted from a Guttman health scale for the aged developed by Rosow
and Breslau (1966). Data also were collected on frequency and ease of
evacuation, consistency of the stool, use of laxatives, and occurrence
of constipation or diarrhea.

A modification of the Burke diet history method (Burke, 1947)
was used to assess food intake and included the Usual Meal Pattern
and food frequency information. Collected through the Usual Meal

Pattern were data about the types of foods usually eaten during the

35

course of the week, with emphasis on qualitative and quantitative data
about foods containing fiber. The protocol for the Usual Meal Pattern
is found in Appendix A as Schedule Cards A and B. Food frequency infor-
mation on plant foods was collected through the use of Food Cards

(p. 36).

The respondent's knowledge of and attitude toward dietary
fiber were assessed by means of a series of carefully ordered open-
ended questions about any foods they ate to avoid constipation, where
and what they had heard about 'fiber,' what came to mind when they
heard the word 'fiber,' if they paid any attention to the amount of
'roughage' in their diet, and their use of bran and the reason for
its use. Probing questions were asked if respondents gave a response
which did not reveal their understanding of fiber.

Finally, the respondent's attitude toward the practice of
nutrition was assessed by a series of ten Likert—type "Viewpoints on
Eating" statements adapted from those of Carruth (1974), which were

purported to measure "willingness to change."

Construction of Visual Aids

 

As an aid in the collection of quantitative data for the
Usual Meal Pattern, Food Models (Christensen, 1973) were constructed
to assist respondents in estimating portion sizes. The models were
constructed by the researcher and consisted of plain rounded foam
shapes painted in appropriate colors to represent a wide variety of
foods. A description of the Food Models is found in Appendix A,

Equipment For Conducting The Interview.

36

To facilitate the collection of food frequency data, Food
Cards illustrating common fruits, vegetables, and other miscellaneous
fiber-containing foods were constructed, along with Colored Boxes
for sorting the Food Cards. The Food Cards were made from 4" x 6"
white card stock. Pictures of the foods for the Food Cards were cut
from seed catalogs and magazines, and heat-sealed onto the card stock
and then heat-laminated with plastic. Foods for which no pictures
could be found were photographed, and the pictures cut from the prints,
heat-sealed to the card stock, and laminated with pressure adhesive
plastic. Each card was labeled in large print with the name of the
food. The foods pictured on the Food Cards are listed on the Food
Card Response Forms (Appendix A). The Food Cards were sorted by the
respondent into the Colored Boxes which were color-coded and labeled
with the following categories: Very often, more than once a week
(green); Often, about once a week (yellow); Occasionally, less than
once a week (orange); Less than 5-6 times a year (white); Cannot eat
(pink); Dislike (red); and Other (blue). Foods eaten very often in
season were also noted. The Colored Boxes are listed in Equipment for
Conducting the Interview (Appendix A). Protocol for the use of therod
Cards and Colored Boxes is found in Schedule Card C (Appendix A).

To assist in answering questions about body weight category,
stool consistency and limitations on activity and in responding to
the ten Likert-type "Viewpoints on Eating" statements, probe cards
were designed. These consisted of large-print copies of the response
choices mounted on colored posterboard and lamdnated with pressure

adhesive plastic. Because the word 'probe' was considered

37

potentially offensive by agency personnel, these cards were called
Response Aids and are listed in Equipment For Conducting The

Interview (Appendix A).

Gift to Participant

 

As a means of conveying the gratitude of the researcher for the
respondent's participation in the study, and to maintain good will
among the research population, a gift was offered to participants at
the close of the interview. Two books were offered of which the

participant could choose one. The books were Cooking for TWO (USDA,

 

1974) and Nutrition Labeling,fiHow It Can Work For You (NNC, 1975).

Fieldnotes

 

In addition to the data recorded on the Interview Schedule,
fieldnotes were recorded, which included length of interview, general
impressions from each interview, and further details related by the
respondent.

Informed Consent-—The Introductory
Letter and Consent Form

 

An introductory letter explaining the study to potential parti-
cipants and encouraging their participation was developed. The Consent
Form also was developed to be signed by those participating in the
study indicating that they understood the project, participated
willingly, knew they could stop at any time, and knew that the infor-
mation provided would be treated confidentially. The introductory

letter and Consent Form are also found in Appendix A.

38

Pretesting

The research tool was pretested for clarity, length, and ease
of administration with 16 volunteers from the community, 12 of whom were
women over 50 years of age. Minor revisions were made to increase

clarity, shorten the interview and facilitate the recording of data.

Approval of Research Involving
Human Subjects

 

 

The complete Interview Schedule was approved by the Michigan
State University Committee on Research Involving Human Subjects.
Approval of the study, including Interview Schedule, also was obtained
from the appropriate professionals of the Oakland Livingston Human
Service Agency (OLHSA), sponsor for the Nutrition Program for the

Elderly in Oakland County, source of participants for the study.

Sample Selection

 

Older women were selected for study for several reasons. In the
interest of obtaining an homogeneous sample, sex was eliminated as a
variable since caloric intakes, and therefore probably DF intakes, vary
with sex. The caloric requirements of women are generally lower than
those of men, and also appear to decrease with age. In so far as
dietary fiber content of diets is related to caloric intake, older
women are more likely to consume small amounts of dietary fiber, which
might lead to greater incidence of constipation. The greater incidence
of infrequent stools in older subjects seen in the study of Connell and
Coworkers (1965), as well as the greater use of laxatives with age,
does suggest that older women suffer more constipation. Women also
display a high incidence of diverticular disease (Manousos et al.,

1967) .

39

Participants for this study were selected from a population
of older (60+ years of age) urban women who were living independently.
Because of the difficulties involved in obtaining the names and
cooperation of participants from the general population, and to control
expense, participants were selected from among women who had enrolled
in the Nutrition Program for the Elderly in urban Oakland County,
Michigan. OLHSA professionals cooperated in selecting representative
Nutrition Sites and enlisting the assistance of the Site Hosts in
obtaining the names of potential participants.

Four Nutrition Sites were selected, representing a variety of
types of audiences: (1) Lake Orion Multipurpose Center, a large
suburban site with many participants living in their own homes; (2)
First Christian Church, a small urban site not connected with housing
for the elderly; (3) Woodland Heights, an urban site associated with an
apartment complex for the elderly in a low income area; and (4) Cliff-
view, a suburban site associated with an apartment complex for the
elderly in a high income area.

Names of potential participants were obtained from the files
of the Site Hosts. Because of the large number of inactive names on
file, people who had moved or died, each Site Host assisted in the
drawing of a population of names. Names of women known to be too ill
to participate were eliminated. A population of 186 names was
deve10ped, from which the prospective participants were selected
randomly within each site, using a table of random numbers.

In preparation for the actual interviewing the researcher

visited each site to become acquainted with the participants through

40

a brief food demonstration about flavored milk drinks (Appendix B).
Potential participants were contacted by means of an individually
typed, personally addressed introductory letter followed by a telephone
call to make an appointment for the interview. At least three attempts
were made to contact each potential participant by phone unless infor—
mation was received that she was away for an extended period or was

too ill to participate.

Analysis of Data

 

Information collected on the Interview Schedule was coded by
the researcher and analyzed on a CDC6SOO computer using programs in

Statistical Package for the Social Sciences (Nie et al., 1975).

 

Scales for health problems, functional health, and laxation were
constructed in preparation for analysis of the data. The dietary
fiber content of the diets was also computed using an original pro-

cedure developed for the study by the researcher.

Scale of Health Problems

 

In order to provide a measure of the degree of ill health of
respondents a Scale of Health Problems was constructed by scoring two
points for each serious or life-threatening health problem mentioned
by the respondent and one point for each other health problem men-
tioned. Conditions counted as serious health problems included severe
arthritis, gastric ulcers, history of heart attack or stroke, evidence
of heart disease, cancer, recent or impending major surgery, kidney

trouble and obesity.

41

Guttman Functional Health Scale

 

Functional health, defined as the degree to which persons claim
they can function in ordinary household tasks or are restricted in their
activities by their physical condition, was measured using the method
of Rosow and Breslau (1966) for developing a Guttman functional health
scale.

Responses to questions pertaining to the respondent's ability
to function in ordinary household activities were tested for their
ability to form an acceptable Guttman Scale. The resulting five—point
scale, with an acceptable coefficient of scalability of .77, was used
for measuring the functional health of respondents. The steps of the

Guttman Functional Health Scale are shown in Figure l.

Laxation Scale

 

Factors which the literature has shown to be involved in
laxation (Connell et al., 1965; Williams and Olmsted, 1936; and
Cowgill and Anderson, 1932) were included in questions about laxation

asked of respondents. The responses to these questions were coded on

 

 

 

 

 

 

 

5 Does extensive walking or yard work
4 Does heavy housework
3 Is "not limited in any activities"
2 1 Does ordinary housework

 

 

1 Climbs stairs, at least to a limited extent

 

 

Figure l. Guttman Functional Health Scale

42

a four-point scale indicating perceived degree of problem with consti-
pation (1 being greatest and 4 least problem) and the questions then
tested for their ability to form a reliable scale of laxation. Five
factors which formed a scale with an acceptable reliability coefficient
(alpha = 0.91) were bowel consistency, ease of bowel movement, frequency
of bowel movement, occurrence of constipation or diarrhea, and fre-
quency of laxative use. The sum of the values for each factor then
constituted the score on the Laxation Scale, which was used as a

measure of laxation.

Coding of the Diet History Data

 

Using a conversion chart developed by the researcher, food
intakes recorded on the Usual Meal Pattern as Food Model sizes and
common measures together with food intakes from the bran consumption
question were coded into the following major food groups in units of
one-eighth cups per week, unless otherwise noted: bread (slices or
equivalent/wk), cereal, potatoes, cooked vegetables, vegetable salads
or raw vegetables, fruit, bran (oz/wk), legumes, nuts, peanut butter,
pie and cake or cookies. Each food on the miscellaneous Food Cards
(Appendix A, p.154 ) was coded in the same way. Intakes from the Usual
Meal Pattern, the Food Card data, and the bran question were compared
and differences reconciled. Intakes of refined cereals and white
bread were calculated by subtracting from total cereal and bread
intakes, values for whole grain cereal and bread consumption obtained

from the miscellaneous Food Card data.

Assignment of Dietary Fiber Values

 

For the purpose of this research, the dietary fiber definition

of Southgate (1977) was accepted, i.e., dietary fiber includes all the

43

plant polysaccharides and lignin in the diet that are undigested by

the endogenous secretions of the human digestive tract. By Southgate's
(1977) definition dietary fiber included cellulose, hemicellulose,
pectin, and lignin. Southgate's definition of dietary fiber differed
from that of Van Soest and Robertson (1977) in that Southgate included
pectin within dietary fiber. This researcher agreed with the logic of
Southgate that there was not sufficient justification for excluding
pectin from dietary fiber as Van Soest had done (Southgate, 1977; and
Van Soest and Robertson, 1977).

Having accepted Southgate's definition of dietary fiber, this
researcher selected the analytical method of Southgate (1969) as best
representing the dietary fiber content of foods, since this procedure
measures all components of dietary fiber, including pectin. Published
values for the dietary fiber content of foods analyzed by the Southgate
method (Southgate, 1976 and 1977) were used in calculating the dietary
fiber content of the diets in this study. Since Southgate dietary
fiber values have not been published for many foods, other fiber values
that have been published, based on Van Soest's neutral detergent method
(NDF) (Van Soest and McQueen, 1973; and Spiller and Amen, 1975), an
enzymatic method (EZF) (Hellendoorn et al., 1975) and the crude fiber
method (CF) (Adams, 1975) provided a basis for estimating the dietary
fiber content of other foods for which dietary fiber values were not
available. This researcher observed that, when compared on a dry
weight basis, the ratios of DF to NDF, EZF or CF values were similar
for related foods. Degree of tenderness, type of vegetation, calorie

content, and ability to form gels were factors which appeared to relate

44

to these ratios. These ratios then provided the basis for estimating
the dietary fiber content of foods for which no Southgate values had
been published, using the formula:

DF of Foodx = R X NDF, EZF, or CF of Foodx

where R is the ratio of DF to NDF, EZF, or CF for a related food or
group of foods for which both values are known, with all values stated
in percent or grams per 100 grams. Details of these calculations are
given in Appendix C, Table A-1.

Calculation of Estimated Dietary
Fiber Intakes

 

 

After DF values had been designated for all foods on the Food
Cards as well as other fiber-containing foods which were commonly
mentioned in the Usual Meal Pattern, these DF values were then used to
calculate Conversion Factors for translating the volumetric data from
the Usual Meal Pattern into estimates of DE intake, using the

formulas:

ZDF(fresh wt)

100 X Fresh wt/unit

 

Conversion Factor (g/unit vol.b) =

c
vol.

% dry matter8
100

 

ZDF(fresh wt) = ZDF(dry wt) X

 

aValues from U.S. Agriculture Handbook No. 456 (Adams, 1975).

bThe unit of volume used for coding most foods was one-eighth
cup, which yielded values between 01 and 99. Bread was coded in terms
of slices, or slice equivalents, while bran, bran cereal, and popcorn
were coded directly in ounces.

cValues calculated from information in Food Values of Portions

 

Commonly Used (Church and Church, 1975), or in a few cases measured
by the researcher.

 

45

Details of the calculation of Conversion Factors used in programming
the computer are found in Appendix C, Table A-1.

For the actual computation of the estimated dietary fiber
contents of the diets, foods containing fiber were divided into 10
major food groups: cooked vegetables, bread, fruit, legumes, potatoes,
cereal not including bran, salads and raw vegetables, nuts, bran, and
desserts. The estimated dietary fiber intake from each food group
was computed separately. DF intakes for each group except fruit and
cooked vegetables were computed directly with the Conversion Factors
for bread, bran cereals, cereals, legumes, and miscellaneous foods

found in Table A-1 (Appendix C), using the formula:

DF(g/day) = (21C1-+ 2202 + 23C3 + . . . . ZiCi)/7
where Zi = amount of 'i'th food in the group
C1 = Conversion Factor for the 'i'th food

Nutrient intakes calculated from detailed food frequencies are
subject to large error because of the accumulation of errors likely in
estimating the many frequencies required, especially with a large
class of food like fruits or vegetables. In order to avoid this large
accumulation of error, the researcher used the fruit and vegetable
frequency data to calculate the approximate pattern of fiber con-
sumption for use in estimating the fiber contribution of the usual
amount of fruits and vegetables eaten. The fruits and vegetables were
grouped according to DF/8th-cup in three levels of DF content for
fruits and three levels for cooked vegetables. Common Conversion
Factors were assigned to each of these groups and used in step 2

in the next paragraph.

46

The following three steps were used in calculating the dietary

fiber contribution of fruits and vegetables consumed (not including

potatoes). The example is given in terms of fruits:

1.

The number of fruits of 1 fiber content

Count Fif’ where F
consumed with f frequency

if

i = the level of fiber content of fruit,3
H - 0.5 grams per eighth-cup
M - 0.3 H H H
L _ 0.1 II N M

f = the relative frequency of consumption,

3 - more than once a week (0.6)
2 — once a week (0.3)
l - less than once a week (0.1)

Calculate the Conversion Factor for fruits consumed with f
frequency (Dngrams/eighth-cup), using the Conversion Factors
for the fruit groups given in Table A-1 (Appendix C)

= (F x 0.5) + (FMf x 0.3) + (FLf x 0.1)

FHf 1" FMf + FLf

Df Hf

f

 

Calculate DF intake from fruit (grams/day) using the Conversion
Factors from Step 2.

Z eighth-cups/wk
7 days/wk

 

DF intake (fruit) = X (0.6 X DF3) + (0.3 X DFé)
+ (0.1 x DFl)

where Z = total eighth-cups of fruit consumed per week.

The method of computation of DF intakes used in this study

produces values which are only estimations, since many of the values

for the DF content of foods are estimates. For the sake of simplicity,

these values for the estimated dietary fiber content of the respondents'

diets will hereafter be referred to as dietary fiber (DF) intakes.

 

aConversion Factors for low~, medium-, and high-fiber fruits

and vegetables from Table A-1, Appendix C.

47

Respondents' Understanding of the
Concept 'Food Fiber'

 

Responses to the open-ended questions about fiber were
clustered into the following categories: (1) Respondent had not heard
of fiber in food; (2) Respondent had heard of fiber, but did not
mention improved bowel function or correct sources of fiber; (3)
Respondent gave evidence of limited understanding of fiber by making
vague or uncertain comments about the function of fiber and correct
sources of fiber; (4) Respondent gave evidence of understanding fiber
by mentioning improved bowel function and correct sources of fiber.

Respondents who stated that bran helped elimination, made the
bowels move, or a similar comment were considered to have adequate

understanding of the relation of bran to bowel function.

Willipgness to Change Scale

 

The 10 Likert type opinion statements about nutrition devised
to measure "willingness to change" were tested for their ability to
form a reliable scale. A Willingness to Change Scale was constructed
from four statements which demonstrated an acceptable reliability
coefficient (alpha = .73). The statements are as follows:
1. It is fun to try out new foods and old foods fixed in a new way.
2. I like to stick with my old favorite meals rather than experi-
ment with new kinds of foods.
3. I try new recipes frequently.
4. Food selection is a personal matter, people shouldn't try

to persuade me to change.

48

Scoring the responses to each of the four statements from 1 (most
willing to change) to 5 (least willing to change), the sum of the
scores on the four statements divided by four constituted the score

on the Willingness to Change Scale.

Statistical Analysis

Frequencies were computed for all variables. Means and ranges
were computed for total dietary fiber intake as well as the DF intake
from each of the major food groups. Respondents were grouped into
three equal groups according to level of DF intake for use in chi-
square analysis of the factors relating to DF intake. Factors which
were tested for their relationship to DF intake were age, living
situation, history of having lived on a farm, food expenditure,
frequency of produce shopping, number of meals consumed at Nutrition
Site, Scale of Health Problems, score on Guttman Functional Health
Scale, frequency of outside activities, Laxation Scale, understanding
of concept dietary fiber, and Willingness to Change Scale. Chi—square
analysis also was used for comparing knowledge of fiber in food with
awareness of roughage in the diet. Student's t test was performed on
the means of food expenditures for those who did and did not eat at a
Nutrition Site or elsewhere away from home, and also for means of DE
intake for those who did and did not watch the amount of roughage in
their diet and for the Laxation Groups. Pearson correlation coeffi-
cients were computed for the Scale of Health Problems, the Guttman
Functional Health Scale, and age. Fisher's exact test was used to
test the significance of variations in the proportion of respondents

at different levels of DF intake who had different Laxation Scores.

RESULTS AND DISCUSSION

The Sample

 

Interviews with 59 older women were completed between May 5 and
July 30, 1977, from 102 initial letter contacts, a completion rate of
58 percent. One interview could not be completed because of poor
health of respondent, and was not included in the analysis. An average
of 3.2 phone calls were required for each appointment made and com-
pleted. Reasons for failure to complete an interview included the
researcher's inability to contact subject (28 percent), ill health of
subject (23 percent), subject too busy (21 percent), subject unwilling
to cooperate (21 percent), and other reasons (7 percent).

Participation rates varied considerably between sites, from
80 percent at Cliffview to 43 percent at First Christian Church.
Twenty-five respondents were from the pOpulation of names obtained
from Lake Orion Multipurpose Center, 11 from First Christian Church,
11 from Woodland Heights Apartments, and 12 from Cliffview Apartments.

Interviews were conducted in the homes of all but five respon-
dents who preferred to meet the researcher at the Nutrition Site. The
rights of the subject were explained to each respondent at the begin-
ning of the interview and her signature obtained on the Consent Form.
Two respondents gave their verbal consent and were interviewed, but

refused to sign the Consent Form because they "never sign anything."

49

50

The average length of an interview was about 80 minutes,
although the interview could be completed in 50 minutes with no dis-
tractions or extra conversation. It had been anticipated by some
professionals who approved the research project that elderly subjects
would show signs of fatigue after 30 minutes of interviewing. This was
not the case, as most respondents completed the entire interview
without showing marked signs of fatigue or boredom such as restlessness
or yawning. Several respondents remarked how quickly time had passed.
Four interviews lasted two hours because the participants enjoyed
talking and volunteered much additional information. The researcher
got the impression that the use of visual materials helped to provide
a change of pace during the interview which prevented boredom.

Communication difficulties due to hearing impairment pre-
sented the greatest deterrent to completion of an interview. One
interview could not be completed because the participant was in poor
health and could not take the strain of trying to communicate. Another
interview required a second visit for completion, with the daughter-in-

law present to help interpret and answer questions.

Sample Characteristics

 

The 59 women ranged in age from 58 to 89 years (Table 2),
with a mean age of 73.2 years. Age verification was not requested
before the interview, since Nutrition Program participants must be
60 years or over, except for spouses of eligible participants. Hence
it was found during the course of interviewing that two respondents

were less than age 60. The health of these two respondents was

51

Table 2.-—Selected Household and Family Characteristics of the

 

 

Sample.
a
Characteristics Number Percent
N = 59
Age (years)
58-64 11 19
65-69 6 10
70-74 17 29
75-79 10 17
80-84 12 20
85—89 3 5
Living Arrangement
Live alone 40 68
Live with husband 16 27
Live with daughter and family 2 3
Roomers in household 1 2
Type of Dwelling
Private House 30 51
Apartment for elderly 23 39
Other apartment 5 9
Mobile Home l 2
Ethnic Origin
Black 5 8
White 54 92
England, Ireland, Scotland 20 34
Germany, Switzerland 15 25
Other European countries 8 14
Mixed European ancestry 8 14
Didn't know 3 5
Birthplace
Country of Ethnic Origin 8 14
United States, Canada 51 86

 

aTotals greater than 100% due to rounding error.

52

relatively good, but not better than that of many older respondents,
so these individuals were included in the sample.

All but two of the respondents lived in the city of Pontiac
or its surrounding suburbs in Oakland County, Michigan, although
several were currently living on semi-rural lake front property. The

other two respondents lived in a rural area of northern Oakland County.

LivingiSituation

 

About two thirds (68%) of the respondents were living alone,
while 27 percent lived with their husbands. Two respondents lived with
a daughter and family and one had roomers living in her house.

Nationally, 33 percent of women 65 years and older are living
with their husbands (AOA, 1971), a somewhat higher proportion than the
27 percent seen in the present study, which included younger women aged
58-64 years. This may reflect a tendency for women who are living
alone to be more interested in the Nutrition Program because of the
opportunity it presents for socializing, an important benefit of a
congregate meal program, which helps to improve interest in good food
(Rankine and Taylor, 1975; and Sherwood, 1973).

National statistics also show that 26 percent of women aged 65
years and older live with relatives other than husbands (AOA, 1971).
The very low proportion of respondents in the present study who were
living with other relatives (3%) is more difficult to explain. Even
after excluding the 23 respondents from the two Nutrition Sites that
were associated with special housing for the elderly, where one would
not expect to find resident living with a relative other than husband,

only six percent of respondents were living with other relatives. It

53

may be that older women who live with other relatives may have more
difficulty with transportation to the site, or may be reluctant to
leave the other relative if he/she is too young to be eligible to
participate in the Nutrition Program.

About 50 percent of the respondents lived in private houses,
while nearly 40 percent lived in apartments constructed for the
elderly. Five of the respondents lived in other apartments and one
in a mobile home. A higher than usual proportion of respondents
lived in apartments, as only 28 percent of Detroit Area residents

live in dwellings housing two or more families.

Ethnic Background

Fifty-four of the 59 respondents were of European ancestry. Of
these, 20 were of English-speaking ancestry, 15 of German-speaking
ancestry, and 16 were from other areas of Europe or had a mixed
European background. Three of the white respondents could not
identify their ethnic origins. The remaining 5 respondents (8%) were
black, and, generally, knowledge of their immediate ancestors had
been lost. The proportion of black respondents reflected the general
population of elderly in Michigan, who are also 8 percent black (10%
in urban areas) (AOA, 1973b). Eight of the respondents were born in

the country of their ethnic origin.

Farm Background

 

Nearly half of the respondents (44%) had lived on a farm at some
time during their childhood. Six of these also had done some farming

as adults. An additional seven respondents had not lived on a farm

54

as a child but had done some farming or extensive gardening at some
time during their adult years. Forty-four percent had never lived

on a farm.

Food Purchasing Behavior

 

The respondents estimated weekly food expenditures, including
cost of food eaten out, and the estimates ranged from $3—32, with a
mean of $13 per week (Table 3). The face value of food stamps was
to be used in calculating the weekly food expenditures, in effect
raising the estimate above the amount of actual money spent. To avoid
embarrassment the researcher did not inquire about the reSpondents'
use of food stamps, and few volunteered the information.

Estimating weekly food expenditures was difficult for many
respondents. Ten respondents could give no estimate and five said
their food expenditures varied so greatly because of stockpiling that
they could not give an average expenditure. When present, husbands
frequently helped answer the question. The low food expenditure of
three dollars was cited by a woman who lived with a daughter and her
family who raised and preserved a large portion of their food.

Comparing the food expenditures of these elderly women with
"Cost of food at home for week" for a woman 55 years and over
(USDA, 1977), it appears that one quarter of the respondents were
spending about at the level of the USDA thrifty plan ($8.60), while
one third spent in the range of the low or moderate cost plans
($11.30 and $13.90, respectively). Nine individuals reported food

expenditures in the range of the liberal plan ($16.50), but the

55

Table 3.--Food Purchasing Behavior of Respondents.

 

 

Number Percent
Average Cost of Food, per week N = 59
Less than $5 1 2
56-10 14 24
$11-15 20 34
$16-20 5 9
More than $20 4 7
Could not estimate, highly variable 5 9
Didn't know 10 17
Principle Means of Transportation
to Grocery Store
Drives own car 26 44
Walks 1 2
Rides with husband, relative, friend 15 25
Rides bus 9 15
Shopping done by husband, relative,
or friend 8 14
Fresh Produce Shopping N = 57
Frequency
Less than once a week 14 25
Once a week 26 46
More than once a week 17 30
Sources
Supermarket only 28 49
Supermarket plus store specializing
in fresh produce 26 46
Both of above plus home storage 3 5
Supplementary Produce Sources in Summer 3
Have garden 19 33
Gift from garden of friend, relative 16 28
Bought from local producer 12 21
None 19 33

 

aTotal more than 100 percent because of responses in more
than one category.

56

uncertainty of the other 15 respondents suggests that they were not
on a tight food budget and may also have been spending liberally for

food.

Comparison of Food Expenditures

Twenty-two percent of elderly persons (65 years and over)
living in urban areas of Michigan fell below the poverty line in the
1970 Census (AOA, 1973a), although there has been a decrease in the
percent of elderly considered poor since 1970. A somewhat higher
proportion of respondents in the present study (26%) appeared to be
spending at the level of the USDA Thrifty plan. Since older individ-
uals who live alone are more than three times as likely to be poor as
those who live in families (AOA, 1973a), one would expect to find more
poor individuals among respondents, since the proportion of respondents
living alone was twice the national average.

Since the relatively high cost of eating at restaurants contri-
buted to the food expenditures of many respondents (Table 4), while
the use of low cost meals available at the Nutrition Sites may help to
extend the food budget of others, the food expenditures of those who
ate often at a Nutrition Site and those who did not were compared,
using Student's t test (Table 4). Those who ate three or more times
a week at a Nutrition Site, and could give an estimate of food expendi-
tures, spent significantly less money for food than those who ate at
a Nutrition Site less often.

0n the other hand, there was little difference between the
food expenditures of those who did or did not eat elsewhere frequently,

although more of those who frequently ate elsewhere could not give an

57

Table 4.--Frequency of Eating Away From Home and Mean Food

 

 

 

 

Expenditurea
Respondents (N = 59)
No S Gave $
Total Estimate Estimate $/wk
Eating away from home N N row% N Mean
At Nutrition Site
3 3 times/week 23 5 22 18 11.4r
< 3 times/week 36 10 28 26 14.3S
Elsewhere
3 2 times/month 44 13 30 31 13.5t
< 2 times/month 15 2 13 13 12.5t

 

aCommon superscripgssindicate no significant differences
(p < .05) within columns ( , , ) using Student's t test.
estimate of their food expenditures, which would tend to skew the
results (Table 4). One would expect those who eat out often to spend
more money on food, but it is possible that some respondents failed to
include money spent at restaurants in their food expenditure estimates

although they were instructed to include them.

Grocery Shopping

 

Most respondents (86%) did their own grocery shopping. The
most common means of transportation was the respondent's own car
(Table 3, p. 55), with 44 percent driving themselves. Twenty-five
percent went shOpping with their husband, a relative, or a friend, and

15 percent took the bus. One respondent always walked to the store,

58

although an additional five individuals walked to the store part of the
time. A friend, relative, or husband did the food shopping for the
remaining eight respondents.

Sherman and Brittan (1973) found that 79 percent of elderly
shoppers in a low to moderate income core city area walked to the store,
while 10 percent drove. Several used bus transportation. In contrast
they found that only 15 percent of elderly shoppers in an upper middle
class neighborhood away from the central city walked to the store,
while 73 percent drove. In the present study most respondents (69%)
drove to the store as did the upper middle class shoppers in Sherman
and Brittan's (1973) study. On the other hand, respondents who lived
in Woodland Heights, the apartment complex in a low income urban area,
resembled the low income group in Sherman and Brittan's (1973) study
in that few used automobiles regularly for shOpping. Forty-five
percent of Woodland Heights respondents had to use the bus at least
part of the time to go grocery sh0pping, compared to 8 percent of the
rest of the respondents. Woodland Heights respondents did not walk
to the store because of distance and fear of violence. Problems
with transportation were mentioned by several women in this group,
as few drove and friends and relatives were often not available for
transportation. Rountree and Tinklin (1975) also found that fewer
elderly high-rise apartment residents used a personal car for
shopping than did non-high-rise subjects. Exton-Smith and coworkers
(1965) also noted that difficulty in shopping was a problem related to
nutrition among low income women. In contrast, Guthrie and coworkers

(1972), in studying two groups of elderly persons in a rural area of

59

Pennsylvania, found that the poorer group relied much more on either
friends or relatives for transportation to the store and help in

food purchasing than did the higher income group.

Fresh Produce Shopping

 

Because access to fresh fruits and vegetables might influence
the dietary fiber intake of individuals, questions were asked concern-
ing produce shopping. The majority of respondents (75%) shopped for
fruits and vegetables at least weekly (Table 3, p. 55). Among the 14
respondents (25%) who shopped for fresh produce less often few indi-
cated problems in getting enough fresh produce.

Nearly 50 percent shopped in the supermarket for fruits and
vegetables. Three of the four Nutrition Sites were near a store
which specialized in fresh produce. One of these specialty stores was
mentioned as the main source of produce by 51 percent of respondents.
In addition three respondents reported home storage of fresh produce
bought or grown in season, including storage in freezer or root
cellar.

Summer brought additional sources of fruits and vegetables, as
33 percent reported growing food in their own gardens, 28 percent
received gifts of food from the gardens of friends and relatives, and
21 percent said that they bought produce directly from growers

(Table 3).

Food Preparation Behavior

 

All but two respondents did all their own meal preparation

when they ate at home. Only the two who lived with their daughters

60

did not usually prepare their meals. Although these two women both
helped in the kitchen, each considered her daughter to be a capable
cook and in charge of the household kitchen. Thirty-six percent of
respondents usually ate their main meal away from home, so meal pre-
paration at home was simplified. A few women mentioned that noon was
a better time than evening to eat at a restaurant because a luncheon

meal was adequate but less costly than a dinner meal.

Kitchen Facilities

 

All respondents indicated that they had satisfactory kitchen
facilities, including stove with oven, refrigerator with freezer
space, and adequate workspace, storage space and equipment for pre-
paring and serving food. While many kitchens were small apartment
kitchenettes, several individuals mentioned that the kitchenette was
adequate since they did less cooking and entertaining than they used
to. The one complaint expressed by several respondents was the limited
freezer space in the single-door refrigerators which were standard
equipment in the apartment complex for the elderly in which nine
respondents lived. Recent statistics from the Detroit area (U.S.
Dept. Com., 1972) showed that only two percent of year-round housing
units and four percent of renter-occupied housing units do not have
complete kitchen facilities, so respondents in the present study
were typical of the area in that they all had kitchen facilities. In
contrast, 15 years ago Davidson and coworkers (1962) reported that ten
percent of elderly subjects in Boston did not have a refrigerator and

16 percent had to share a stove. Twenty-one percent of the subjects

61

lived in a furnished room. This difference probably reflects an

improvement in housing conditions in recent years.

Food Consumption Behavior

 

Most of the respondents (93%) followed a traditional three-
meals-a-day pattern (Table 5). Of these, 46 percent also included
snacks in their meal pattern. Of the remaining respondents, three
ate two meals a day plus snacks and one ate one meal a day plus
snacks.

The main meal of the day was eaten with equal frequency at
noon and in the evening (Table 5). Forty-two percent of respondents
usually ate their main meal at noon and 36 percent ate in the evening.
Another 14 percent usually ate their main meal in the evening except
when they are away from home at noon, in which case they would eat a
small meal in the evening. The other five respondents usually ate a
full-course meal both at noon and in the evening.

Early studies reported that older women generally ate three
meals a day (Lyons and Trulson, 1956; and Davidson et al., 1962) and
that snacks were consumed by 30 to 60 percent of the subjects. In
contrast Swanson (1964) noted that snacks were not common among the
elderly subjects studied. Pao (1971) reported that nearly one-half
of more than 500 subjects from the North Central region of the United
States ate four or five meals a day, while the remainder ate three
meals a day, but a "meal" included any intake of food or beverage other
than water, so the pattern was similar to that of the respondents in

the present study.

62

Table 5.--Food Consumption Behavior.

 

 

Percenta
Number (N = 59)

Meal Patterns

3 meals a day, no snack(s) 28 48

3 meals a day plus snack(s) 27 46

2 meals a day plus snack(s) 3 5

l meal a day plus snacks 1 2
Time of Main Meal

Normally eaten at noon 25 42

Normally eaten in the evening 21 36

Normally eaten in the evening unless

noon meal was eaten out 8 14
Full meal eaten both at noon and in
the evening 5 9

Meals Eaten at Nutrition Site

Less than one per week 22 37

1-2 per week 14 24

3 or more per week 21 36

Delivered to home 2 3
Meals Eaten Elsewhere

One per month or less 15 25

2-3 per month 12 20

1-2 per week 23 39

3 or more per week 9 15
Total Meals Eaten Away from Home

Two or less per week 21 36

3-4 per week 17 29

5 or more per week 21 p 36

 

aTotals more than 100 percent due to rounding error.

63

In contrast, a recent study in Tennessee (Todhunter et al.,

1974) found that 84 percent of elderly white women ate three meals per
day and only 53 percent of black women did so, while 16 percent of
white women and 44 percent of black women ate two meals per day.
Forty-eight percent consumed snacks daily or several times a week.
Black women were more likely than white women to eat snacks throughout
the day. In a small study of elderly persons in Detroit, Unnewehr
(1977) reported that 68 percent of subjects ate an average of three
meals a day, while 18 percent said they usually ate two meals a day,
with the morning meal most frequently skipped. Most individuals
studied by Unnewehr mentioned that they consumed snacks, especially
before bedtime. Only seven percent of respondents in the present study
ate less than three meals a day. Methods of evaluating meal patterns
are not standardized, but are subject to the interpretation of the
investigator, so results from different studies are not always directly
comparable, as shown by the method of Pao (1971).

Few researchers have reported details of meal patterns, but an
early study by Jordan and coworkers (1954) reported that 40 percent of
the elderly subjects surveyed had their large meal at noon, a result

similar to the present study.

Meal Eaten Away from Home

Although the respondents' names had been obtained through the
Site Hosts, not all respondents ate meals regularly at the Nutrition
Sites. Thirty-seven percent ate at a Nutrition Site (Table 5) less

than once a week. Of these three quarters said they rarely ate

64

at a Nutrition Site. Twenty-four percent of respondents ate a
nutrition meal 1-2 days a week, and 36 percent ate 3 or more meals
a week at a Nutrition Site.

Two individuals were receiving a home delivered meal from
3 Nutrition Site. About 15 percent of the meals from the Nutrition
Sites in Oakland County are delivered to the homes of recipients
(MacQueen, 1978). Hence the sample was not representative of all
regular participants in the Oakland County Nutrition Program for the
Elderly. On the other hand many of the healthy individuals whose
names were on the roles at the Nutrition Sites attended the meal
program rarely but were well represented in the sample.

Many respondents also ate regularly elsewhere (Table 5),
most frequently at a restaurant offering a full selection of foods or
at the home of a friend or relative. Thirty-nine percent mentioned
eating elsewhere once or twice a week and 20 percent two to three
times a month. Fifteen percent ate elsewhere three or more times a
week, while 25 percent went elsewhere to eat rarely or no more than
once a month.

There was little relationship between the number of meals
eaten at the Nutrition Site and the number of meals eaten elsewhere.
That is, of those who ate often at a Nutrition Site some frequently
went out to other places to eat, and some rarely ate elsewhere, while
the same was true of those who rarely ate at a Nutrition Site. Over-
all more than half the respondents (64%) ate three or more meals a
‘week away from home.

Other recent research also has noted the frequency of meals

eaten away from home. Schlenker (1976) found that nearly three

65

quarters of the older Michigan women studied ate outside the home at
least once a week. In studying 185 participants of a meal program in
Cincinnati, Joering (1971) noted that the majority did little home food
preparation. In contrast, Todhunter and coworkers (1974) reported that
28 percent of white women and 9 percent of black women ate lunch away
from home one or more times a week, while 13 percent of white women

and 6 percent of black women ate the evening meal away from home that
often. Guthrie and coworkers (1972) found that 13 percent of elderly
subjects in rural Pennsylvania had eaten out in the previous 24 hours,
but no report is given of how many ate out during the course of a week.
Researchers in the 19505 found that less than 20 percent of the elderly
person studied ate some meals away from home (Jordan et al., 1954; and
Lyons and Trulson, 1956). While most respondents in the present study
ate elsewhere frequently, only a few (9%) mentioned that they did little

cooking anymore.

Use of Therapeutic Diets

 

Forty-three percent of the respondents reported following
some diet restriction or special diet suggested by their physician,
while an additional 34 percent said they had made recent changes in
their diets of a therapeutic nature (Table 6). Low salt diets and
low fat or cholesterol diets were each being followed by 14 percent of
respondents. Ten percent of respondents were on a high fiber diet or
one including more fruits and vegetables. Weight loss and bland diets

were each mentioned by nine percent of respondents.

66

Table 6.--Use of Therapeutic Diets By Respondents.

 

 

Percenta
Number (N = 59)
Use of Therapeutic Diets
Physician-prescribed diet 25 43
One 18 31
More than one 7 12
Self-prescribed diet change 20 34
None 14 24
Therapeutic Diets Prescribed by Physician
Low salt 8 14
Low fat, low cholesterol 8 14
High fiber, more fruits & vegetables 6 10
Weight reduction 3 5
Bland, avoid bothersome foods 5 9
Diabetic, prediabetic 2 3
Self-Prescribed Diet Changes Related to Health
Less salt and/or more potassium 3 5
Less fat or frying 6 10
More roughage, wholegrains, fruits,
vegetables 4 7
Less food 9 15
Less starch, sugar, junk foods 6 10
Avoids bothersome foods 5 9
More food supplements 2 3

 

aTotal greater than 100 percent due to rounding error.

Self-Prescribed Diet Changes

 

The most common self-prescribed diet change reported was eating
less food, mentioned by 15 percent of respondents who were not on a
weight reduction diet (Table 6). Ten percent said they were eating
less fat, another 10 percent mentioned less sugar, starchy foods or
junk foods, while 5 percent reported eating less salt and/or more

potassium. Avoidance of bothersome foods was noted by nine percent

67

of respondents who were not on a bland diet. Two respondents stated

they were taking more food supplements.

Fiber Related Diet Changes

 

In all, over 75 percent of the respondents reported making some
health related change in their diet. In 10 cases this involved a change
that would increase fiber intake and in 10 cases a change that would
tend to decrease fiber intake. Of particular interest in this study
were the diet modifications cited by 11 respondents who reported having
diverticular disease, since fiber content of the diet has been a factor
in the treatment of the disease. None of these women reported restric-
tions on their fiber intake while three reported eating more fruits
and vegetables or more roughage because of the disease. In contrast,
two years earlier Schlenker (1976) found that the four Michigan women
studied who had diverticular disease were all required to avoid all
raw fruits and vegetables as well as whole grains. This contrast
reflects the changing methods of treatment of diverticular disease.

Few other food behavior researchers studying older persons
have reported on diet modifications related to health. LeBovit (1965)
found that eight in ten subjects had some diet limitation linked to
health, a ratio similar to the 75 percent found in this study. In
contrast Wruble (1976) found that 22 percent of the subjects inter—
viewed reported the use of a special diet prescribed by a physician
while four percent were following a self-prescribed weight reduction
diet.

The present study found that nearly 20 percent of the respon-

dents were restricting sodium intake or using less salt, while Wruble

68

(1976) found that only two percent of rural Michigan subjects were
restricting salt. Todhunter and coworkers (1974) reported that six
percent of white elderly women and nine percent of black women were
following a low salt diet. In contrast, Jordan and associates (1954)
reported 20 years ago that 31 percent of the subjects restricted use

of salt.

Health of Respondents

 

The most frequently mentioned health problems that bothered
respondents are shown in Table 7. High blood pressure, arthritis, and
heart disease were the most common problems, each cited by 35-40
percent of respondents. Diverticular disease and eye problems also
were common, reported by 19 and 17 percent of respondents, respec-

tively.

Obesity

Obesity was not considered a health problem by any of the
respondents, but upon further questioning many indicated that they did
have a weight problem. Table 8 shows the weight categories into which
respondents placed themselves.

In some cases the respondents' perception of their weight
category did not agree with the subjective judgement of the researcher.
TWenty-five respondents (42%) considered themselves 'just right,‘ but
the researcher disagreed in six cases, judging five to be overweight
and one underweight. The researcher also disagreed with the four
women who regarded themselves as 'very overweight,‘ judging them to be
'moderately overweight' instead. One respondent judged by the re-

searcher to be very overweight thought of herself as just right.

69

Table 7.--Health Problems Reported by Respondents.

 

 

a
Health Problem Number Percent
N = 59
Problems of the Gastrointestinal Tract
Diverticular disease 11 19
Diverticulosis 7 12
Diverticulitis 2 3
Bowel resection due to diverticular
disease 2 3
Colitis, ulcers, nervous disorders 6 10
Hiatus hernia 5 8
Hemorrhoids 3 5
Cancer of the colon 1 2
Other 2 3
None 30 51
Other Health Problems
High blood pressure 23 39
Arthritis 20 34
Heart disease 21 36
Cataracts, glaucoma 10 17
Nervousness 6 10
Allergies 4 7
Other cancers 2 3
Elevated blood sugar 5 8
None 4 7
Scale of Health Problems
0-2 14 24
3-4 23 39
5-10 22 37

 

aTotal more than 100 percent because of responses in more than
one category.

70

Table 8.--Respondents' Self-Assessment of Weight Category.

 

 

Weight Category Number Percent

N = 59
Too thin 5 9
Just right 25 42
Slightly overweight 15 25
Moderately overweight 10 17
Very overweight 4 7

 

Respondents considered to be moderately or very overweight in
the subjective judgement of the researcher were classified as obese
by the researcher. Thirty-one percent of the respondents were judged
to be obese. Subjective estimation of weight category is not a precise
method for measuring obesity, but was considered adequate for the
limited purposes of this study because of the complications involved in
making a more precise weight assessment.

A wide variation in the incidence of obesity has been observed
by other researchers. Hollifield and Parson (1959) measured the
incidence of obesity in older persons in Virginia twenty years ago, and
found that only 16 percent were more than 20 percent above the average
weight for their height and age, while Davidson and coworkers (1962)
found 25 percent of Boston subjects similarly overweight. LeBovit
(1965) judged a third of the New York subjects surveyed to be over-
weight. Among the Michigan subjects studied by Schlenker (1976) more
than one half were 20 to 40 percent over ideal weight.

Obesity is difficult to define or measure. The variability
found in these studies may reflect variations in the methods of

measurement or regional differences in the incidence of obesity.

71

While the reliability of the subjective assessment of obesity used in
the present study is limited, it was considered adequate as an appro-
ximation of weight level. Many respondents had difficulty responding
to this question even with the presence of the Response Aid (Appendix
A, p. 132) listing the weight categories and asked the researcher's
opinion. Use of the researcher's assessment of weight level rather

than that of the respondent was justified on these grounds.

Scale of Health Problems

 

Resulting scores on the Scale of Health Problems (Table 7)
showed that nearly one quarter of respondents (24%) had scores of two
or less indicating few health problems, while 39 percent had scores
of three or four indicating a moderate number of health problems.
Several health problems were reported by more than one-third (37%)

of respondents, with scores of five to ten.

Guttman Functional Health Scale

 

Scores on the Guttman Functional Health Scale (Table 9) indi-
cated that 44 percent of respondents had excellent functional health,
with scores of 4 or 5, showing that they did heavy housework, often
walked more than half a block, or did extensive yard work. Sixty-one
percent had a score of 3 or more meaning that they did not feel
limited in any of their activities. Twenty-five percent of the
respondents had a score of 2, indicating that they did ordinary house-
work, but were limited in their activities, including housework, and

three felt that they could no longer climb stairs.

72

Table 9.--Guttman Functional Health Scale.a

 

 

Scale Items on Numb r Percent Cumulative
Step Interview Schedule e N = 59 Percent
5 Does extensive walking and/or 15 25 25
yardwork
4 Does heavy housework ll 19 44
3 Is not limited in any 10 17 61
activities
2 Does ordinary housework 15 25 86
1 Is able to climb stairs, at 5 9 95

least to limited extent

0 3 5 100

 

8Coefficient of Scalability - .77
Coefficient of Reproduceability - .93

Rosow and Breslau (1966), in developing a similar health scale
during a study of 1200 older persons in Cleveland found that 53 percent
of the subjects were not limited in any activities. Steinkamp and
coworkers (1965) noted that 50 percent of elderly subjects in the
follow-up San Mateo study reported that their activities were not
affected significantly by disability conditions. A somewhat higher
proportion of respondents in the present study (61%) fell into a simi-

lar category, 'is not limited in any activities, suggesting that this
group of older women had somewhat better than normal health for
persons of their age.

Rosow and Breslau (1966) also found that 21 percent of elderly

subjects studied could still do heavy work around the house. This

73

compares to 44 percent in the present study, further suggesting rela-
tive good health in these subjects.

Because one would expect the ability to function in ordinary
household tasks to be related to the general health of the subject, the
Scale of Health Problems and Guttman Functional Health Scale were
compared and found to correlate significantly (r = .28, p < .05).

Although one would expect the older subjects to be in poorer
health and less able to do housework than the younger subjects, there
was no significant correlation between age and the Scale of Health
Problems or the Guttman Functional Health Scale. This may be due to
the exclusion from the study of those who were in such poor health

that they could not be interviewed.

Activity Patterns

 

Most respondents engaged in activities away from home more than
once a week. Four women went out of the house infrequently for activi-
ties other than shopping. Only one stayed home for health reasons. In
contrast 29 percent of the women studied by Schlenker (1976) seldom left
home. This comparison again suggests that this group of women may have
been healthier than normal for people their age. Those individuals
with many health problems still managed to get out regularly. One
would expect the respondents in the present study to be healthier
than normal, since the length of the interview required the elimination
from the sample of those who were considered too ill to participate.

The most frequent activity of respondents (81%) was eating out,
either at a Nutrition Site, a restaurant, or the home of a friend or

relative (Table 10). Social visits, religious meetings, club meetings,

74

Table 10.--Activities of Respondents.

 

 

Percent

Activity Number N t 59
Meals eaten out 48 81
Social visits 32 54
Religious meetings 27 46
Club meetings 21 36
Shopping trips (other than for food) 21 36
Yard and garden work 17 29
Classes and other special activities 13 22

for the elderly

Part-time employment 6 10

 

shopping at a mall and classes or special activities for the elderly
were mentioned frequently as popular activities by the respondents.

Six respondents (10%) were employed part-time. This compares well with
the 10 percent of women age 65 and older who are employed nationally
(AOA, 1971).

Unnewehr (1977) reported similar activities by older urban
residents of Michigan. Many participants in the study (63%) attended
the Nutrition Program for the Elderly, but then many subjects had been
recruited through the Nutrition Sites. Eating out at restaurants was
not reported as an activity, but church was mentioned by 59 percent.
Bridge clubs, gardening, women's groups and Girl Scouts also were

reported as popular activities by these subjects.

Laxation Scale

 

Scores on the Laxation Scale clustered into four groups (Lax
Groups): Lax Group 1, tendency to hard, infrequent bowel movements but

laxatives used frequently; Lax Group 2, tendency to hard, infrequent

75

movements but did not use laxatives frequently; Lax Group 3, regular,
well-formed movements without use of laxatives; and Lax Group 4,
tendency to loose, runny movements. The laxation scores after
clustering into Lax Groups are shown in Table 11.

Two-thirds of the respondents (67%) had normal laxation (Lax
Group 3). Ten percent had a tendency to hard stools but rarely used
laxatives (Lax Group 2). Nineteen percent had hard stools moved with
considerable straining and frequently used laxatives (Lax Group 1).

Two respondents had frequent loose movements and constituted Lax
Group 4.

Because the use of laxatives has shown an inconsistent rela-
tionship to incidence of constipation in other studies (Connell et al.,
1965; Wigzell, 1969; and Millard, 1971) the use of laxatives by respon-
dents was examined separately. Sixty-three percent of respondents
rarely or never took laxatives. All of these respondents indicated
they were never bothered by constipation, or at the most only occa-
sionally under special circumstances such as traveling. Thirteen
respondents (22%) took laxatives frequently or more than once a week.
Eleven of these individuals were the eleven respondents in Lax Group
1 who had a tendency to be bothered by constipation. One of the other
two took a fiber-containing stool softener to control diarrhea. The
slowing effect of fiber on abnormally fast transit times has been noted
by several researchers (Payler et al., 1975; Harvey et al., 1973; and
Painter et al., 1972). The other woman took a laxative after her
bowels hadn't moved for two days, about once a week, and therefore

displayed a tendency to constipation. The remaining nine respondents

76

Table ll.--Laxation Scores of Respondents.

 

 

Lax Laxation Number
Group Scale Meaning Scores N = 58a Percent
1 Hard stools moved with consider- 5-8 11 19
able straining, frequent use
of laxatives
2 Tendency to hard stools, 9—13 6 10
occasional laxative use
3 Soft, well-formed stool, moved 14-17 39 67
easily, infrequent laxative
use
4 Frequent, loose stools 18-19 2 3

 

aOne respondent with colostomy excluded from calculation.

bTotal less than 100 percent due to rounding error.

who reported taking laxatives 'sometimes' or 'once or twice a month'
were constipated only occasionally. Thus laxative use was consistent
with incidence of constipation in this sample of older women.

Heavy use of laxatives by older persons has been reported by
other researchers. Jordan and coworkers (1954) reported that laxatives
were taken routinely, three times a month to daily, by 55 percent of
elderly subjects surveyed. In Scotland, Wigzell (1969) found that 66
percent of the 90-99 year-old independent living persons studied took
laxatives regularly, although 78 percent of them had normal bowel
habits. Millard (1971) found that 17 percent of the English women
studied were constipated, but 56 percent were taking laxatives. This
reported heavy use of laxatives by older persons may reflect excessive

use of laxatives or may result from inconsistencies in the definition

77

of laxative use and constipation. Connell and coworkers (1965) found
that laxatives were used more than once a week by 14 and 30 percent of
subjects from two different populations respectively. Connell and
coworkers (1965) also noted a decline in laxative use compared to the
results of a 1940 study, although they found a strong trend toward
increased use of laxatives with age. Davidson and others (1962) found
that 22 percent of subjects took laxatives daily or almost daily, a

figure very similar to the results of the present study.

Dietary Fiber Intakes

 

Results of the calculation of the dietary fiber content of the
respondents' diets (procedure, p. 44) are shown in Table 12. The
mean of total dietary fiber intake per day was 14 g, with the intakes
of most individuals falling within the range of 8 to 23 g (Figure 2).

Unusually low fiber diets of 3, 5, and 6 g respectively were
described by three respondents. The first individual reported that
she had been consuming no fruits, vegetables, whole grains or nuts
out of fear of aggravating an ulcer that had flared up two years pre-
viously. The second individual currently was consuming only one small
meal a day in an effort to treat refractory obesity which was aggra-
vating heart disease. The 6 g low fiber meal pattern was that of a
very small 86-year-old lady with a tiny appetite who consumed no whole
grain bread and did not like fruit.

One unusually high fiber meal pattern, 34 g/day, was
described by an individual, also in her 80's, who ate few processed
foods, did her own baking using whole grains and wheat germ, and placed

heavy emphasis on fruits, vegetables, salads and nuts in her diet.

Number of respondents

13-
12-1

 

T1—

78

 

511';

Figure 2.

 

 

 

 

 

 

 

 

' I U I

swunwumzzézszsasz

Dietary fiber, g/day

Dietary Fiber Consumption of Respondents.

79

Table 12.--Dietary Fiber Intake from the Major Food Groups.

 

 

 

Dietary Fiber g/day Percenta

Food Category of Total
Mean Range

Total intake 14.0 3.2-33.8
Cooked vegetables 2.9 0-8.1 21
Bread 2.6 0.3-7.7 19
Fruit 1.9 0-8.6 14
Legumes 1.6 0-7.7 11
Potatoes 1.3 0-3.9 9
Cereal, not including bran 1.0 0-4 4 7
Salads, raw vegetables 1.0 0-2.8 7
Nuts 0.8 0-7.3 6
Bran 0.6 0-5.1 4
Desserts 0.5 O-l.9 4

 

aTotal more than 100 percent due to rounding error.

Few researchers have measured the dietary fiber content of
diets. Crude fiber intakes of 2.8 g/day for women and 4.0 for men
(Bergan and Brown, 1976), 2.6 for diverticular patients and 5.2 for
controls (Brodribb and Humphreys, 1976a), and 5 for men (Groen, 1973)
have been reported. In tests with men on the relation of fiber to
laxation, Cummings and coworkers (1976) and Jenkins and coworkers
(1975a) used a standard western type diet which contained 17 g/day of
dietary fiber as calculated from Southgate (1976) values and 3.8 g/day
of crude diber (a DF:CF ratio of 4.5). The diet was produced in a
metabolic kitchen and contained white bread, biscuits made from white
flour, and corn flakes as cereal sources, hence was low in fiber
because of the absence of whole grains, but high in calories

(2800 Cal./day).

80

The dietary fiber content (17 g/day) of the diet used by
Cummings and coworkers (1976) is somewhat higher than the mean dietary
fiber intake of 14 g/day found in the present study, probably because
calorie content of that diet was higher than the typical calorie intake
of older women. Multiplying the ratio (4.5) of dietary to crude fiber
found in the studies by Cummings and coworkers (1976) and Jenkins and
coworkers (1975a) times the crude fiber intake (2.8 g/day) of women
in the Rhode Island study (Bergan and Brown, 1976) produces a dietary
fiber value of 13 g/day, which is comparable with the results of the
present study. Higher crude fiber intakes for men reported by Bergan
and Brown (1976) and Groen (1973) are no doubt due to the higher calo-
rie intake of men, as compared to women.

Limitations of the Method of Diet
Assessment

 

 

The methods of diet evaluation, the Usual Meal Pattern and
food frequency estimates, and fiber calculations using estimated values
for dietary fiber content of foods, used in this research are not
precise. Madden and coworkers (1976) found, in studying the validity
of the 24-hour dietary recall, that subjects tended to overestimate
small amounts of food eaten and underestimate large amounts, even
though food models were used to assist in making the estimates, a
phenomenon they call "talking a good diet." This may have been a
problem in the present study in the estimates of serving size. Mart
(1971) commented that the aged introduce more error into diet his-
tories because of forgetfulness, although women remember more about

what they eat than men. Schlenker (1976) reported that written dietary

81

records collected for that study indicated essentially the same nutrient
intakes as the recall records and cited that fact as evidence that
memory lapses are not necessarily a limitation on the validity of

recall dietary records for older individuals. It appears that no
method of dietary assessment is entirely satisfactory. The researcher
must select the method of dietary assessment which meets the needs of
the particular study, in this case the diet history, while recognizing
the limitations of the method.

The second step of diet evaluation, calculating nutrient
intake, presents unusual problems in the case of fiber. The unaccepta-
bility of crude fiber methods has been reviewed. The limitations of
the method of estimating dietary fiber used in the present study are
recognized but were considered more acceptable than those associated
with the use of crude fiber. There is an obvious need to meet the
challenge of agreement on a new standard for measuring fiber, and
develop the required tables of food composition. It is hoped that the
present study will contribute to that effort.

Contribution of the Major Food Gropps
to Dietary Fiber Intakes

 

 

The contribution to dietary fiber intakes of the ten major food
groups are shown in Table 12. Cooked vegetables provided the largest
proportion of dietary fiber, followed closely by bread, 2.9 and 2.6
g/day, respectively, or about 20 percent of total each. Nearly 15
percent of the fiber was furnished by fruit. Other food groups which
supplied about 10 percent of the DF included legumes, potatoes, cereal,

and salads. Bran, nuts, and desserts made small contributions to

the total daily fiber intake.

82

As indicated by the range values in Table 12, all categories
of foods except desserts furnished large amounts of DE for some
individuals even though the average DF contribution of that food
group was small. Only bread consumption was reported by every respon-
dent, although more than 95 percent of respondents reported that they
ate cooked vegetables, potatoes, fruit and salads.

Combining cooked vegetables, potatoes, salads and legumes into
one general vegetable category showed that vegetables provided
nearly 50 percent of the DF intake of respondents, while the cereal
grain category, bread, cereal and bran, furnished 30 percent of the
fiber.

Trowell (1972) and Robertson (1972) have examined the relative
contribution of the food groups to crude fiber intake in the U.S. and
Britain, using information from published research studies and national
statistics relating to total food supplies for the population as a
whole. They reported that 6-13 percent of crude fiber intakes came
from the cereal grain group, values substantially lower than the 30
percent seen in the present study.

The limitations of using crude fiber for assessment are made
apparent by examination of the 1863 consumption of bread and potatoes,
reported by Robertson (1972) to contain an apparently low 2.4-4.1
g/day of crude fiber. Comparing the crude fiber content of stone
ground white flour used by Robertson (1972) (0.2-0.5%) with the DF
content of white flour reported by Southgate (1976) as 3.15 percent,
shows at least a six-fold difference, so that if recalculated using
Southgate (1976) values, the 1863 fiber intake becomes 25 g/day of DF,

a substantial amount of DF.

83

Apparently the crude fiber analytical procedure produces ab-
normally low fiber values for white flour (5-10% of DF), which tend to
obscure the contribution of the cereal grains to fiber intake when used.
The same is not true of crude fiber values for whole wheat which are
the expected 20-25 percent of DF. Thus further comparison of dietary
fiber contributions in the present study with crude fiber values found

in other studies must be approached with caution.

Vagetable Consumption of Respondents

 

The food groups were further analyzed to characterize the
nature of their contribution to dietary fiber intake. Cooked vege-
tables and fruit provided substantial amounts of fiber for most
individuals, while only 50 percent of respondents consumed salads
supplying l g/day of fiber.

Data collected through the use of the Food Cards (Appendix A,
p.152 ) showed that the most popular vegetables, eaten regularly by
more than 75 percent of respondents, included green or wax beans,
onions, green peas, potatoes, corn, carrots, lettuce, cabbage,
celery, tomatoes, lima beans, and cucumbers or pickles. Also well-
1iked, but consumed somewhat less frequently and by fewer than 75
percent of respondents were asparagus, broccoli, green peppers,
summer squash or zucchini, winter squash, sweet potatoes, cauliflower,
muchrooms, radishes, spinach and beets.

Bean sprouts, brussels sprouts, all varieties of greens,
potatoes with skins, and root vegetables like turnips, parsnips, and
rutabaga were eaten at least occasionally by fewer than 60 percent of

respondents. The least preferred vegetables were okra and eggplant,

84

eaten by 25 percent of respondents and also, along with greens,

placed in the dislike category by another 25 percent of respondents.

Vegetables Avoided for Health Reasons

 

Avoiding some vegetables for health reasons can influence
dietary fiber intake. Only three respondents omitted more than five
vegetables from their diet for health reasons, citing a very bland
ulcer diet, a very bland diet after colostomy, and a very low sodium
diet as reasons for the omissions. Sixty-five percent of respondents
excluded no more than one vegetable from their diet for health
reasons. The remaining 30 percent avoided two to five vegetables for
a variety of reasons, most commonly indigestion or flatulence. Peppers
and radishes most commonly were cited in this respect, avoided by 15
and 20 percent of respondents respectively. Collards, corn, cucum-
bers, onions, lima beans, and brussels sprouts were avoided by about
10 percent of respondents because of reported indigestion or flatu-
lence. Ten percent of respondents also excluded potatoes with skins
and beets from their diet for a variety of health reasons, most
notably high blood pressure in the case of beets. Other vegetables

were excluded by fewer than seven percent of respondents.

Fruit Consumption of Respondents

 

The fruits eaten regularly by most respondents included
applesauce or peeled apple, peaches, bananas, oranges, pears, pine-
apple, and grapefruit. Consumed somewhat less frequently and by less
than 75 percent of respondents were plums, raisins, prunes, apricots,

and tangerines or mandarin oranges. Certain fruits were consumed more

85

often when they were in season and could be eaten fresh. The most
popular of these fruits, eaten by 75 percent of respondents, were
strawberries, cantaloupe and grapes, followed by blueberries, rasp-
berries and watermelon, consumed by 60 percent. About 50 percent of
respondents reported eating cherries, cranberries, dates, and apples
including the skins. The least favored fruits were avocado and figs,

consumed by about 25 percent of respondents.

Fruits Avoided for Health Reasons

 

Over 65 percent of respondents avoided no more than one fruit
from their diet for health reasons. Two respondents omitted nearly
all fruits from their diet, one because of an ulcer diet and the
other because of food allergies. One respondent excluded many fruits
because of food allergies and diverticulitis, another omitted fruits
with a high calorie content. The remaining 27 percent of respondents
avoided from two to five fruits for a variety of health reasons.

Figs and the skins on apples were most commonly cited as sources
of health problems when consumed, by 17 and 32 percent of respondents,
respectively. The most common reasons mentioned were difficulty
chewing and indigestion, and for figs, the calorie content. Dates
also were rejected by three respondents for their high calorie content.
Cantaloupe, watermelon and prunes each were noted by four respondents
as causes of indigestion. Raisins and grapes were refused by several
for a variety of medical reasons. Other fruits examined caused

medical problems for fewer than six percent of respondents.

86

Legume Consumption of Respondents

 

Respondents' consumption of legumes was examined separately
from other cooked vegetables because of the high fiber content of the
mature vegetable seeds and because they are commonly believed to cause
flatulence. The best liked legumes, consumed at least once a month by
65 percent of respondents, and less frequently by another 15 percent,
were white beans, either baked or in soup. About 40 percent of respon-
dents regularly ate red beans in stew or salad, and pea soup, and
another 20 percent ate them a few times a year. Garbanzo beans were
eaten in small amounts by nearly 50 percent of respondents. Lentils,
soybeans, and blackeye or crowder peas were unfamiliar to many respon-
dents and eaten by fewer than 25 percent.

The flatulence caused by beans is due to gas formed as a result
of the fermentation by intestinal bacteria of that part of the carbohy-
drates of the beans which has not been digested and absorbed in the
small intestine (Hellendoorn, 1976).

Red beans were the legumes most frequently (17%) avoided
because of flatulence. Many of these same respondents also omitted

other legumes from their diet.

Cereal Grain Consumption of Respondents

The average daily consumption of bread and related grain pro-
ducts such as crackers was two slices or the equivalent, mostly in the
form of bread, providing 2.6 g/day DF, or about 20 percent of the total
fiber intake. Of this bread, over half was reported to be something
other than white bread. Dark, wheat, or whole wheat bread was eaten

by 78 percent of respondents and accounted for 42 percent of the

87

total bread reported. Rye bread was consumed by 50 percent of respon-
dents, but amounted to only 10 percent of total bread intake. The new
types of bread with fiber added were eaten by only 10 percent of respon-
dents and represented four percent of total bread intake. Two respon-
dents reported consuming wheat germ.

Whole grain cereal consumption rarely has been reported, but
Rountree and Tinklin (1975) observed that only 9 percent of elderly
subjects used whole grain bread or rolls daily.

Eighty percent of respondents reported consuming cereal
regularly, including whole grain, refined, and bran cereals, which
provided a mean daily intake of dietary fiber of 1.6 g, or 11 percent
of total DF. Among those respondents eating cereal regularly con-
sumption averaged about one-half cup of cereal per day. Whole
grain cereals such as oatmeal, puffed wheat and whole wheat flakes
accounted for about 45 percent of the total cereal consumption and
provided nearly 50 percent of the DF from cereal.

Almost 30 percent of cereal intake was in the form of bran
cereals contributing nearly 40 percent to cereal fiber. Refined
cereals such as farina and Rice Krispies represented less than 15
percent of cereal consumption or seven percent of cereal fiber. Pop-
corn and brown rice also were included with cereals and accounted for
six and two percent of cereal fiber, respectively. Twenty-seven
percent of respondents reported eating popcorn while 19 percent said
they ate brown rice occasionally.

Ten percent of respondents rejected whole grain breads or

cereals for a variety of medical reasons, including difficulty

88

digesting or chewing and use of a bland diet. Only one respondent
could not eat dark wheat bread. On the other hand nearly 20 percent
of respondents refused popcorn for several health reasons, most commonly

difficulty in chewing.

Nut Consumption of Reapondents

 

The mean DF intake from nuts was 0.8 g/day, constituting
about six percent of the total DF consumed. Over 75 percent of
respondents reported that they ate nuts or peanut butter, although
fewer consumed nuts (53%) than peanut butter (61%). Nuts were used
in greater quantities than peanut butter and consequently contributed
over 75 percent of the total fiber from nuts.

Twenty percent of respondents rejected nuts for health
reasons, including indigestion, calorie content, and difficulty in

chewing. Fewer respondents (12%) could not eat peanut butter.

Other Foods Consumed bngespondents

Other foods which made small contributions to DF intake
included cake, cookies, and pie, particularly fruit pie. Because
these foods are highly variable in DF content, sometimes including
large quantities of sugar containing no fiber and sometimes containing
high fiber fruit or nuts, the estimate of DF intake from these foods
can be stated with much less confidence, but appeared to account for
about five percent of the total DF intake. Most respondents reported
eating these dessert foods although 13 women did not.

Consumption of pasta type products and refined rice was

reported infrequently. Since information concerning their DF content

89

was not available and was assumed to be low, no effort was made to
probe for the extent of their consumption and include them in the DF
calculation. If reported they were categorized as white bread in the

fiber calculation.

Discussion

 

Other researchers have noted health problems associated with
certain foods. LeBovit (1965) reported that three elderly persons
out of 10 surveyed had difficulty chewing. After men had been fitted
with dentures it was found that they ate less bread and more crisp,
raw vegetables in a study by Anderson (1971). In contrast, Davidson
and coworkers (1962) observed no correlation between oral condition
and nutrient intake of older subjects, and in fact were surprised at
how well they ate with no teeth or with ill-fitting dentures.
Schlenker (1976) found that only one of the 28 older women studied
had difficulty chewing. The present researcher also noted that, at
least in relation to plant foods, few foods were rejected because of
chewing difficulties. Only apples were mentioned as a frequent source
of chewing problems (32%) and were often eaten peeled.

Another common health problem with foods mentioned by other
researchers is flatulence or "gas." Davidson and coworkers (1962)
noted that food was eliminated if it was thought to give gas.
Schlenker (1976) found that 64 percent of subjects did not eat gas-
forming vegetables such as cabbage or onions. In the present study
only 17 percent of respondents avoided dried beans for health reasons,

and fewer (9%) avoided onions, while just two refused cabbage for this

9O

reason. The 20 percent who avoided radishes were the highest per-

centage who avoided any fiber-containing food for health reasons.

Reapondents' Understanding_of the Concept
of Fiber in Food

 

Awareness of the concept of fiber in food may influence con-
sumption of fiber in the diet. To examine the respondents' under-
standing of this concept they were asked if they remembered reading
or hearing anything about fiber in the food they eat, and what came
to mind when they heard the word 'fiber.' Results are based on 58
interviews.

Forty-one percent gave no indication that they understood
the concept of fiber in food, although three quarters of these respon-
dents reported that they had heard or read something about food fiber
(Table 13).

A similar proportion of the 58 respondents (43%) (Table 13)
demonstrated adequate understanding of food fiber by citing appro-
priate sources of fiber and noting its relation to proper bowel
functioning. The remaining nine respondents displayed a limited
understanding of food fiber.

Several respondents expressed their uncertainty about fiber,
while one mentioned the idea that fiber improved bowel function but
added she didn't believe it, and another noted the function of the
fiber when added to bread as a filler to lower calories.

Many respondents (32%) mentioned a new kind of bread which
contains added fiber, when asked what they had read or heard about

fiber. This bread had apparently been the subject of much discussion

91

Table 13.--Respondents' Knowledge of Food Fiber.

 

 

 

 

 

Number Percent
Understanding of Concept Food Fiber (N = 58)
No understanding of food fiber 24 41
Had not heard of fiber in food 6 10
Had heard of fiber, referred to bread
with added fiber 13 22
Had heard of fiber but did not refer
to bread with added fiber 5 9
Limited understanding of food fiber 9 16a
Referred to appropriate sources of fiber 6 10
Also referred to bread with added fiber 3 5
Acceptable understanding of relation of food
fiber to bowel function 25 43
Referred to appropriate sources of fiber 22 38
Also referred to bread with added fiber 3 5
Understanding of Bran in Relation to Bowel Function (N = 59)
Adequate understanding 51 86a
Displayed knowledge, but uncertain 2 3
No understanding 4 7
Recalled use of bran on farm 3 5
Sources of Information About Food Fiber (N = 51)
Television programs 26 51b
Magazine and newspaper articles and
advertisements 14 27
Newspaper advertisements for bread
with added fiber 3 6
Friends, relatives 7 14
Nutrition professionals 2 4
Couldn't remember 7 14
Had known about fiber for a long time 3 6

 

aTotal not exact due to rounding error.

bTotal more than 100 percent due to overlapping categories.

92

on TV talk shows and at the Nutrition Sites, because several respon-
dents expressed dismay at the report that there were "woodchips" in
this bread. The researcher refrained from commenting on these concerns
until the fiber section of the interview was completed, at which point
the safety of using trees as a source of cellulose was explained. The
frequent mention of the new bread with added fiber illustrates how
rapidly information and misinformation about food can be disseminated
if there is something that sparks interest.

Rountree and Tinklin (1975) tested elderly subjects on their
nutrition knowledge and found that only 25 percent answered more than
35 percent of the questions correctly. This compares with 43 percent
of respondents in the present study who understood the concept 'food

fiber.’

Sources of Information About Fiber in Food

 

The most common source of information about food fiber, cited
by over 50 percent (Table 13) of those respondents who had heard
about fiber, was television programs. One quarter of these respondents
also reported reading about fiber in newspapers or magazines. Dis-
cussions with friends or relatives provided information for 14 percent
of these respondents. Three respondents mentioned magazine and news-
paper advertisements for the bread with added fiber. Two respondents
reported receiving information about fiber in food from health pro-
fessionals and one indicated popular health food magazines as a source

of information.

93

Knowledge of the Relationship between
Bran and Bowel Function

 

 

Although only 43 percent of respondents demonstrated that they
understood the concept of food fiber, most respondents (85%) (Table 13)
mentioned the role of bran in regulating bowel function, when asked
what they knew about bran. An additional two respondents mentioned
this function of bran, but were uncertain whether they were correct.

Mention of bran brought back memories for three respondents
of early days on the farm, where bran was a byproduct of wheat milling
used for feeding livestock or making dark bread. Only two respondents

said they didn't know anything about bran.

Ways of Avoiding or Relieving Constipation

 

As further illustration that food fiber was recognized
unconsciously (before fiber was mentioned in the interview) as related
to bowel function, many respondents cited foods containing fiber when
asked about their special ways of avoiding or relieving constipation
without the use of laxatives. Fruits and prunes most commonly were
reported, by 39 and 30 percent of respondents respectively. Vegetables
and bran each were cited by about 25 percent of respondents, while 10
percent mentioned roughage. Also mentioned by about 20 percent of
respondents were water, hot water with lemon, or coffee, and by six
individuals, some form of exercise. Four women indicated they didn't
know of any special ways of avoiding constipation because they were
never bothered by it. On the other hand six said nothing ever worked
to relieve their constipation. Four of these six respondents had low

DF intakes of 12 g/day or less, while the other two had higher intakes

94

of 15.1 and 17.0 g/day respectively, and both reported they had

suffered attacks of diverticulitis.

Attitudes Toward the Practice of Nutrition
Several respondents demonstrated behaviors which revealed their
attitudes toward the practice of nutrition. One respondent displayed
unusual beliefs about food, expressing strong opinions about several
matters of nutrition. She had many popular books on nutrition and

read Prevention magazine. One respondent showed the researcher the

 

food supplements she was taking that she had gotten from a relative
who was a supplier. Two respondents lived with family members who
were organic gardeners. One individual mentioned her fear of eating

"poisons" in foods and indicated that she read Prevention magazine.

 

On the other hand, two women mentioned being active in cooper-
ative extension. The diet histories of several women who had pre-
scribed diets, as well as the comments of these women, indicated

that they were trying to follow their diets carefully.

Willingness to Change Scale

 

Attitudes toward the practice of nutrition were measured by the
Willingness to Change Scale (p. 47). Scores on this Scale were
clustered into three groups. Nineteen percent of respondents had
scores of 1.5-2.3, indicating willingness to change, while 22 percent
had scores of 4.0-4.5, indicating lack of willingness to change.

Many respondents (56%) had intermediate scores of 2.5-3.5 suggesting

uncertainty or ambiguity of feelings.

95

Responses to the 10 Likert-type opinion statements (Appendix A,
p. 151) were generally not very consistent. Statements which mentioned
the word 'nutrition' were more difficult for persons to respond to
and did not correlate well with other statements, and were eliminated
during scale construction. Respondents rarely chose the responses
indicating uncertainty or strong opinions. The researcher got the
impression that it was difficult for the respondents to think in terms
of a five-point scale of responses.

Attitudes Toward Food Selection as
Revealed by Cereal Selection
Attitudes

Indications of attitudes toward food selection were obtained
by inquiring about the factors which were considered when choosing
cereal. Of the 47 respondents who indicated that they did consume
cereal, the largest group, more than 50 percent, stated that they
bought what they liked. TWenty-six percent of respondents said they
did not want added sugar in their cereal. Five respondents looked for
natural cereals or cereals without preservatives. Only three reported
that they wanted fortified cereals, while two respondents indicated
they felt that hot cereals had greater food value.

Specific health factors were mentioned by one quarter of the
respondents in selecting cereal. Eating bran for constipation was
cited by six women, as a reason for cereal choice, while ease of
chewing the cereal, blandness, low sodium content and ease of digestion
were noted by one or two individuals. Only two respondents reported

that price was a consideration in choosing cereal.

96

Other researchers have rarely examined the attitudes of older
persons in selecting foods. As in the present study, Schlenker (1976)
found that half of those studied considered taste preference when
choosing foods, while fewer considered food value and very few

financial considerations.

Attitudes Toward Fiber

 

Roughage and bulk are traditional terms for food fiber and
were therefore used in the interview to explore attitudes toward food
fiber. Asked if they found that they had to pay attention to the
amount of roughage or bulk in their diet, 60 percent of respondents
said no, saying they didn't think about it, or didn't need to watch
because they normally ate enough roughage or were not bothered by
constipation. Two respondents said they didn't think about it because
eating more roughage didn't help their constipation.

The remaining 40 percent of respondents paid attention to the
amount of roughage in their diet, but only 33 percent followed with a
satisfactory explanation, including mention of foods containing fiber
or mention of how roughage helped elimination. The other four women
gave explanations which indicated that they were confused about the
meaning of roughage. Comparison of the knowledge of food fiber
between the 33 percent who did give a satisfactory explanation of how
they watched the amount of roughage in their diet and the remaining
respondents showed a significantly higher proportion of the first
group (65%) than the second (33%) displayed acceptable understanding
of fiber in food (x2 = 5.21, d.f. l, p < .05). On the other hand,

using Student's t test for the comparison of the mean fiber intakes

97

of those who did and those who did not watch the amount of roughage
in their diet showed no differences in fiber intake. Only one woman
said that she watched not to get too much roughage.

The three participants who mentioned being bothered by hemorr-
hoids present an interesting illustration of the interplay between
knowledge of and attitude toward fiber. Two of the three women had
low laxation scores and moderate dietary fiber intakes (10-11 g/day),
and took laxatives regularly, a stool softener and mineral oil,
respectively. The other woman had a high dietary fiber intake (20
g/day) and was not bothered by constipation. None of the three indi-
cated that they paid attention to the amount of roughage in their diet
although two of the women displayed knowledge of the function of fiber.
The woman with the high dietary fiber intake gave no indication that
she knew anything about fiber, but was consuming four times more bran
than the mean consumption. In other words, although the first two
women associated fiber in the diet with improved bowel function, they
apparently chose to treat their constipation with medication rather
than increasing the roughage in their diet. In contrast, the third
woman did not appear to understand the function of fiber, but never-
theless was consuming a high fiber diet. It appears that knowledge
about matters of health or nutrition, attitudes toward these matters,

and actual behavior are often not well coordinated.

Special Treat Choices
Responses to the closing question, asking the respondent's
choice of a special treat to buy at the grocery store revealed an

attitude of acceptance of nutritious foods as treats. Nearly half of

98

respondents (42%) named some fruit or, in some cases, a vegetable as

a special treat. Eleven mentioned meat, fish or poultry, while less
than one-third listed a high calorie dessert. Four chose other foods
like salty snacks and six didn't know what they would choose or couldn't
decide. There were some multiple choices.

Pao (1971) found a different pattern in examining the snack
food preferences of older women. He reported that cake, cookies, and
pies were listed above fruit in order of preference. While some of
the foods mentioned as special treats by respondents in the present
study are not often thought of as snacks, such as vegetables and
meats, these foods are promoted as nutritious snacks by nutritionists
(MDPH, Undated).

A question that might be asked is, did the subjects in the
present study respond to the stimulus of the many colorful fruit and
vegetable Food Cards (Appendix A) by selecting these nutritious foods
as special treats? Further investigation of this question would provide

valuable information for nutrition educators.

Presentation of Gifts
Gift books were presented to 56 respondents, 29 copies of the

large print cookbook, Cooking for Two, (USDA, 1974), and 27 copies of

 

the nutrition information book, Nutrition Labeling, (NNC, 1975).

 

Three individuals did not receive books because of inability to read,
poor eyesight, and disinterest. The choice of the nutrition informa-
tion book by nearly half of the respondents was a surprise to the
researcher. Many respondents commented spontaneously on their

choice of book. Twelve cited poor eyesight as a reason for choosing

99

the large print cookbook, although three others already had the book

and therefore chose Nutrition Labeling. Five chose Nutrition Labeling

 

 

because they did little cooking anymore, while six said they had
plenty of cookbooks. Nine commented that they really did want to know
more about nutrition or they would have liked to have both books. On
the other hand, six people commented that they were not interested in

more nutrition information.

Factors Influencing Dietary Fiber Intake

 

In order to explore possible relationships between dietary
fiber intake and other characteristics observed in respondents,
comparisons were made between dietary fiber consumption and other fac-
tors which might influence dietary fiber intake, using chi-square
analysis. For the analysis, respondents were divided into three equal
groups according to level of DE intake. These levels of DF intake
were labeled low, medium, and high. Results showed no relationship
between dietary fiber intake and age, living situation, history of
having lived on a farm, food expenditure, frequency of produce shopping,
number of meals consumed at a Nutrition Site, score on the Guttman
Functional Health Scale, frequency of outside activities, understanding
of the concept dietary fiber, or scores on the Willingness to Change
Scale. Only in comparing DF intake with Laxation (Lax) Group and the
Scale of Health Problems were significant relationships found.

Comparison of the proportion of respondents in each Lax Group
who had low, medium, and high fiber intakes showed that 82 percent of
respondents in Lax Group 1 displayed low fiber intakes, while only

17 percent of those in Lax Group 2 and 22 percent in Lax Groups 3 and

100

4 consumed low fiber diets. The initial chi-square analysis showed
that there were significant differences (p < .01), but did not explain
which differences were significant. Fisher's exact test was used for
this purpose. Because Lax Group 4 was so small and similar in laxation
characteristics to Lax Group 3, these two groups were combined for the
analysis. Also because there was little differences in the propor-
tions of each Lax Group that had medium and high fiber intakes, while
several of these cells were very small, the medium and high fiber
groups were combined for the analysis, forming a 2 x 3 table. Results
of this analysis are shown in Table 14.

Chi-square analysis of the relationship between Lax Group
and DF from cereal grains (the bread, cereal and bran food groups
combined) did not show significant differences.

Confirmation of the general belief that constipation is
affected by lack of dietary fiber in the diet is found in these
data, in that those respondents who used laxatives (Lax Group 1)
generally had low fiber intakes, while those who did not use laxatives
(Lax Groups 2, 3 and 4) had generally medium or high dietary fiber
intakes. Many other investigators also have found evidence of the
relationship of low fiber intakes to constipation (Cowgill and Sulli-
van, 1933; Williams and Olmsted, 1936; and Hoppert and Clark,

1942a and 1942b) although little recent research has been done.

Resistance to the Effects of Fiber
Several facts stand out upon examination of the data from those
respondents who did not follow the general pattern of Lax Groups 1 and

2. The two women in Lax Group 1 who had higher dietary fiber intakes

101

Table 14.--Comparison of Levels of Dietary Fiber Intake and Laxation
Group for 58 Respondentsa’b.

 

Level of Dietary Fiber Intake

 

 

Laxation Ex lanation
Group p Low Medium to High
Total 12.2 g/day 12.2 g/day
N % N row% N row%
1 Tendency to hard 11 19 91‘ 82 2r 18
stools, frequent
laxative use
2 Tendency to hard 6 10 1S 17 5S 83
stools, infrequent
laxative use
3,4 Normal, loose 41 70 9S 22 32S 76

stools

 

aRespondent with colostomy not included.

bCommon superscripts indicate no significant differences
(p < .05) within columns (r,s) using Fisher's exact test.

both had suffered an attack of diverticulitis and were presently taking
stool softeners. One mentioned that her physician had recommended that
she consume more roughage. In response to the question about special
ways of avoiding constipation without taking laxatives, each remarked
that nothing ever seemed to relieve their constipation.

Other researchers have noted an apparent resistance to the
usual effects of high fiber intake on laxation. Southgate measured
the disappearance of dietary fiber during transit through the gastro-
intestinal tract and found apparent digestibility ratios for cellulose
ranging from 0.20 to 0.65 in elderly women and 0.24 to 0.84 in

elderly men (Southgate and Durnin, 1970).

102

Flynn and coworkers (1977) weighed the fecal residue of 10
healthy men who were eating four weighed constant diets and found that
the fecal fiber content as percent dry weight varied greatly, from
6.7 to 18.6 percent. Results for each individual for the four diets
were more consistent and suggested variability in the way each sub-
ject's digestive tract handled the dietary fiber.

Even the early researchers Cowgill and Sullivan (1933) found
that some patients required the addition of more bran to their diets
for relief of constipation, apparently because they exhibited greater
breakdown of fruit and vegetable fiber in the digestive tract.

This apparent resistance to the effect of dietary fiber has
been observed also in patients with diverticular disease. In experi-
ments with the use of bran in treating diverticular disease, Painter
and associates (1972) found that subjects required the addition of
highly variable amounts of bran (3-45 g/day) in addition to a high
fiber diet, to achieve a soft stool that was easy to move. They noted
that some but not all of this variation was due to variations in fiber
content of the rest of the diet.

Findlay and associates (1974) also found that subjects with
diverticular disease responded differently than normal subjects when
fed 20 g/day of raw bran in addition to regular meals. The normal
subjects showed a statistically significant increase in wet and dry
stool weight while subjects with diverticular disease did not show a
significant difference in wet or dry stool weights.

Brodribb and Humphreys (1976b) also used bran (24 g/day) for

the treatment of diverticular disease and noted that the increase in

103

fecal weight in patients with diverticular disease after increasing
their fiber intake was less than normal subjects after a similar
increase in fiber intake.

One might speculate that the two respondents with diverticular
disease in the present study who had high intakes but were bothered by
constipation also displayed this apparent resistance to the effects of

dietary fiber observed in these other studies.

Resistance to Bowel Irregulariry

Turning again to other respondents in Lax Groups 1 and 2 who
did not fit the expected pattern of relationship between dietary fiber
intake and laxation, it was found that the one individual in Lax Group
2 who had a low fiber intake had indeed a very low intake (3.2 g/day).
She reported that although her stools were hard and difficult to
move, she had a daily movement without taking laxatives. None of the
other respondents in Lax Groups 1 or 2 claimed to have daily bowel
movements unless they were taking laxatives frequently. In contrast
nearly all the respondents in Lax Group 3 did have daily movements,
even those with low fiber intakes. Only 10 percent of the 39 respon-
dents in Lax Group 3 had movements less than once a day. There also
was a sharp distinction between Lax Groups in their reported inci—
dence of constipation. Only 18 percent of those in Lax Groups 1 and 2
said they were infrequently bothered by constipation and rarely took
laxatives, while 95 percent of those in Lax Groups 3 and 4 said the
same.

Studies by several investigators have suggested that abnormal

bowel motility is a cause of constipation and other bowel disorders.

104

Some have observed abnormally high intraluminal colonic pressures in
subjects who were suffering from recurrent attacks of unexplained
abdominal pain (Holdstock et al., 1969), pain and constipation
(Connell, 1962), and diverticular disease accompanied by constipation
(Painter et al., 1965). Connell (1962) also noted hypoactive bowel
motility in older subjects who took laxatives frequently. Chaudhary
and Truelove (1962) frequently observed hypermotility in patients
with spastic colon which was stimulated by discussion of specific
disturbing topics of importance in the patient's life. Goy and
coworkers (1976) also found evidences of disordered bowel habit in
subjects with diverticular disease and spastic type irritable bowel
syndrome, and noted that these subjects also had significantly less
fecal magnesium and calcium, which was related to hypermotility.
Hodgson (1975) produced hypermotility in rabbits fed a low residue
diet.

These studies suggest that disturbed bowel motility is a
factor in constipation and other bowel disorders and may result from
a variety of other causes besides insufficient dietary fiber. Again
one might speculate that the one individual in the present study who
had daily but hard bowel movements and a very low fiber intake, but
never took laxatives, somehow avoided the abnormal bowel motility

associated with constipation, and therefore had daily movements.

Physiological Fiber Minimum

 

Forty-five years ago, Cowgill and Anderson (1932) measured the
effect on laxation of varying the crude fiber content of standard

diets and noted a "physiological roughage minimum" required to produce

105

easy bowel movements, a daily crude fiber intake of 90-100 mg/kg of

body weight (5-6 g for a 60 kg person). Almonds, apple-butter, potatoes
and bananas were removed from the high fiber diet in the Cowgill and
Anderson (1932) study to produce a diet which promoted marked bowel
stasis unless bran was added to the diet. Cowgill and Anderson (1932)
also noted that some individuals had satisfactory laxation at slightly
lower fiber intakes.

No research has been done since the 19305 to test the hypo-
thesis that there is a minimum intake of dietary fiber that protects
most people from constipation. Yet a recent medical article about
constipation (Benson, 1975) recommended 100 mg "bulk residue" /kg body
weight daily to prevent constipation, the same figure suggested by
Cowgill and Anderson (1932).

The methods of diet assessment and dietary fiber computation
used in the present study were not adequate for testing a hypothesis
about minimum fiber intake, but a marked difference in estimated DF
intakes was observed in those bothered by constipation, between those
who took laxatives frequently (Lax Group 1) and those who did not
(Lax Group 2) (Table 11, p. 76). Mean DF intake for Lax Group 1 was
10.5 g/day (s = 3.5) and for Lax Group 2, 14.6 (s = 6.3). Student's
t test showed this difference to be significant (t = 1.75, d.f. 15,

p < .05). With the exception of the two women who reported having
diverticulitis (p. 101) all the respondents in Lax Group 1 had DF
intakes of 12 g/day or less. In contrast, with the exception of the
woman consuming very low amounts of fiber discussed on page 103, all

the respondents in Lax Group 2 had DF intakes of 12 g/day or more.

106

Among those who were not bothered by constipation, Lax Groups 3 and 4,

DP intakes covered a wider range, 7-34 g/day.

Dietary Fiber Intakes and Scale of
Health Problems

 

Scores on the Scale of Health Problems also showed a signifi-
cant relationship to dietary fiber intake (Table 15). Only 22 percent
of respondents with few health problems (scores of 0-4 on the Scale of
Health Problems) had low dietary fiber intakes (less than 12.2 g/day)
while 55 percent of those with more health problems (scores of 5-10)
were in the low fiber group.

Examination of the diets of respondents with low fiber intakes
who had high scores on the Scale of Health Problems showed that seven
women had low fiber intakes resulting from health problems, namely,
low calorie intake due to weight reduction diets or poor appetite,
low fiber ulcer diet, fiber restriction due to colostomy, and frequent
indigestion.

Many researchers have observed that low nutrient intake was
related to the presence of medical problems. Jordan and coworkers
(1954) found that medical reasons were often given for changes in
eating habits. Wruble (1976) observed that changes in eating habits
usually resulted in decreased food intake with increased risk of
malnutrition and also noted that physical handicaps were associated
with greater nutritional risk. Caird and coworkers (1975) also found
that poor diets were related to physical disability, while Ohlson and
coworkers (1948) associated chronic ill health with lower quality and

quantity of food intake. In a longitudinal study of women 76 years

107

Table 15.--Comparison of Scale of Health Problems and Levels of
Dietary Fiber Intakea.

 

Scale of Health Level of Dietary Fiber Intake

Problems

 

 

Low Medium to High
Total <12.2 g/day 312.2 g/day
Score N % N row% N row%
r r

Few health 0-4 37 63 8 22 29 78
problems

More health 5-10 22 37 128 55 10S 45
problems

 

aCommon superscripts indicagesno significant differences

(p < .01) within columns ( , ) using the chi-square test.
old, Stanton and Exton-Smith (1970) found that nine of the women had
shown little change in their diet since the first study six years
earlier, and also maintained their health, while 13 who showed
decreases in calorie and protein intakes consistenly showed a deterio-
ration in their health. Stanton and Exton-Smith (1970) concluded that
the decrease in nutrient intake seen in the first study (Exton-Smith
et al., 1965) between the 70 and 80 year old subjects was due to ill
health rather than age. The present study provides support for these

findings in the special case of dietary fiber.

Dietary Fiber and Diverticular Disease

Since diverticular disease is a health problem which has been
associated with low fiber intakes (Painter and Burkitt, 1971), the fiber
content of the diets of respondents who reported having diverticular

disease was examined. Four respondents in this study reported having

108

diverticulitis, treated successfully by colon resection in two cases.
The individuals with diverticulitis which had not been treated by sur-
gery had high fiber intakes but were bothered by constipation, and
reported resistance to the usual effects of dietary fiber on laxation,
as was discussed on pages 101-102. Both of these individuals were
consciously eating more roughage, one because her physician had
recently changed the recommended mode of treatment from a low to a high
fiber diet. The two colon resection patients described normal laxation
patterns and high fiber intakes. Since these respondents did not show
resistance to the usual effects of dietary fiber on laxation it

appears that the removal of the defective section of the colon may have
allowed the return to normal laxation. No inquiry was made into the
history of laxation before colon resection, but severe pain and hard,
pellety stools, as well as inflammation, are common symptoms of diver-
ticulitis (Goy et al., 1976).

Seven respondents reported that they had been told they had
diverticulosis. Four of these women had normal laxation, or in one
case a tendency to have loose movements, and said they did not watch
the amount of roughage in their diets, although the DF intake of only
one was considered to be high. The other three individuals had DF
intakes of about 12 g/day, which apparently was adequate to prevent
constipation. Although none of these women reported paying attention
to the amount of fiber in their diets, one mentioned that the doctor
had said that it was important to eat plenty of fruits and vegetables.

Of the remaining three respondents reporting diverticulosis,

two said they were watching the amount of roughage in their diet

109

because of the diverticulosis. One of these individuals also reported
being bothered by diarrhea which was being treated with a high fiber-
type stool softener as well as increased fiber in the diet. There is
evidence that diarrhea is associated with painful hypermotility in
spastic colon patients (Chaudhary and Truelove, 1962), even though it
has been suggested that diarrhea is due to lack of segmental contrac-
tions of the distal colon which delay transit of the fecal material

so that absorption of water may take place (Connell, 1962). Goy and
coworkers (1976) present evidence that spastic colon and diverticular
disease have a common etiology, therefore it may be that the diarrhea
seen in the present case of diverticulosis is related to disturbed
bowel motility in which excess activity alternates with the absence

of activity, leading to high pressures sufficient to produce diverticula
alternating with episodes of diarrhea.

The other respondent with diverticulosis who was watching the
roughage in her diet had a low fiber intake of 10 g/day, which in her
case was associated with normal laxation. Her low fiber intake was
due to several diet restrictions, including a weight reduction diet of
1000 calories and severe sodium restriction, so that her food intake
was low and ordinary whole grain breads which contain salt were not
consumed. She also reported taking medication for bowel spasms that
reportedly caused the diverticulosis to "act up."

Severe calorie restriction due to a needed weight reduction
diet limited the fiber intake of the remaining woman with diverticu-
losis to a very low 5 g/day. She also was very bothered by consti-

pation. The diverticulosis had shown up on recent X-rays, but had

110

not bothered her, so she did not seem concerned about treatment,
probably because of other, more serious illnesses.

The case histories of these respondents with diverticular
disease illustrate the complexity of factors that can influence dietary

fiber intake.

Food Behavior and Dietary Fiber Intake

It has been observed that many factors influence dietary fiber
intake, but since nutrient intake is determined by food behavior, the
Usual Meal Patterns were examined to see what characterized the food
habits of those with the highest and lowest intakes. As mentioned
above (p. 101), several respondents had low fiber intakes which were
explained by health problems, low calorie intake, fiber restriction,
and indigestion. Personal preference appeared to account for the
low fiber intake of many other individuals, that is, dislike of vege-
tables, whole wheat bread, dried beans and/or nuts led to the consump-
tion of other foods which were lower in fiber.

Examination of the diets of the 10 individuals with the highest
dietary fiber intakes showed that bran consumption was a factor in the
high fiber intake of several, taken for bowel regularity by some and by
personal preference by others. On the other hand several respondents
with high DF intakes did not consume any bran other than that occurring
naturally in whole grain breads and cereals. Personal preferences
for whole wheat bread, nuts, dried peas and beans, fruit and vegetables
also characterized this group. High calorie intake appeared to con-
tribute to fiber intake for a few individuals, but caloric intake was

not measured, so could not be compared. High fiber intakes were not

111

usually the result of eating excessive amounts of one fiber rich food,
such as bran, but were generally the result of eating many different
foods rich in fiber.

Evidence has shown that different plant foods influence
laxation to varying degrees (Williams and Olmsted, 1936; and Hoppert
and Clark, 1945) and also that physical characteristics of plant foods
such as particle size of bran (Kirwan et al., 1974) and method of
preparation of bran and beans (Wyman et al., 1976; and Hellendoorn,
1976) resulted in different responses to ingestion. The present study
was not designed to determine if one source of dietary fiber is better
than another in improving bowel function. This is an area which needs

extensive investigation.

SUMMARY AND CONCLUSIONS

General Summary

 

The estimated dietary fiber intakes of 59 older women were
determined. Most DF intakes fell within a range of 8-23 g/day, with a
mean of 14 g/day. All major plant food groups made contributions to
the DF intakes of most respondents. No single food group predominated
as a source of fiber, although cooked vegetables and bread each
contributed about one-fifth of the total DF intake. Bran contributed
only four percent of total DF intake, but up to 5 g/day for some
individuals. The contribution of vegetables of all kinds, including
potatoes and legumes, to DF intake was nearly 50 percent. Vegetables
were generally well liked and less than one-third of the respondents
avoided more than one vegetable for health reasons. Dried cooked
beans were avoided for health reasons by only 20 percent of respondents.
Over 40 percent of bread consumption was reported to be dark, wheat,
or whole wheat bread.

Two health factors found to relate significantly to DF intakes
were scores on the Laxation Scale and Scale of Health Problems.

Eleven of the respondents with low laxation scores reported having
hard, infrequent stools for which they frequently took laxatives. Most
of these women had low fiber intakes. On the other hand, six women
reported having a tendency to hard infrequent stools but rarely took

laxatives. Most of these women had medium or high fiber intakes. Most

112

113

of the women (70%) reported that they rarely or never were bothered

by constipation. Some of these women had low fiber intakes. The evi-
dence suggests that low fiber intakes may lead to constipation in some
individuals who have a tendency to become constipated, but not in others
who do not exhibit this tendency.

Generally the respondents were a healthy group of older women
with few health problems that kept them confined at home, although most
women mentioned some health problem associated with aging such as high
blood pressure or arthritis. This was expected since the requirements
of the lengthy interview precluded the interviewing of those who were
in very poor health. Among those respondents who reported several
health problems and therefore had higher scores on the Scale of Health
Problems a higher proportion had low DF intakes than among the health-
ier women. Dietary information collected from these respondents
suggested that poor health often resulted in low food intakes, and
therefore low DF intakes, due to diet restrictions or poor appetite.

There was no evidence that the older women (over 80 years) had
lower DF intakes nor were they less healthy than the younger women.
Again, this may have been due to the exclusion from the sample of
those in very poor health. 0n the other hand, the existence within
the sample of this group of healthy older women who were consuming
average amounts of fiber is evidence that health and vigor, and pro-
bably appetite, are maintained by many women as they pass their 80th
birthday.

Personal food preferences for foods high in fiber appeared to
be a major factor resulting in high fiber intakes for some respondents.

Consumption of legumes, whole grains, and nuts, as well as generous

114

amounts of fruits and vegetables, characterized the diets of those with
high fiber intakes. The well distributed contributions of the major
food groups to DF intake suggest that all plant foods should be empha-
sized in a high fiber diet. Bran has often been used to increase the
DF content of test diets, but in the present study DF intakes from
cereal grains did not show the same relationship to laxation that was
shown by total DF intakes. On the other hand, since there is evidence
from other studies that the effect of DF intake on laxation is not
directly proportional to the DF content of foods, more research is
needed to determine which foods are more effective in promoting
laxation and which constituents of dietary fiber are related to these
effects.

While the sample was generally a healthy group of women, a
large proportion of them (43%) said they were following some diet
restriction or special diet suggested by their physician. Others
reported making similar sorts of diet change on their own. Again,
the sample may have been biased, since nutrition education is offered
periodically at the Nutrition Sites. Many respondents may have been
exposed to new ideas about nutrition, and therefore more receptive to
suggestions from their physician for diet changes.

Fiber in food had become a topic of public discussion before
the study was conducted. This was evident in that nearly one-half of
the respondents understood the concept 'fiber' in food and could name
some sources of dietary fiber. On the other hand, there was no evi-
dence that knowledge about fiber had been translated into increased

fiber intakes, as DF intake and knowledge of fiber were not related.

115

Although many respondents had reported making health-related changes
in their diet, few of these changes were related to dietary fiber. On
the other hand there was a group of respondents with low fiber intakes
who were taking laxatives, who might have benefitted from increasing
the fiber in their diet.

Another finding of the study was that many of the respondents
went out to eat often, either at a Nutrition Site or at a restaurant
that offered a full selection of food. It is not clear if this is
characteristic of all healthy older women. Again, it may be that the
sample was biased in favor of those who enjoyed going out, since the
population was obtained from among those who had shown enough interest
in outside activities to come to a Nutrition Site and enroll in the

program there.

Conclusions and Implications

The findings of this study must be viewed with some caution
because of the limitations in the method of assessing DF intakes. The
method of estimating dietary fiber was subject to large error, empha-
sizing the need for standardizing the methods of determining dietary
fiber and incorporating DF values into tables of food consumption.
On the other hand, the relationships noted between DF intakes and
laxation suggest that more research is needed to clarify the rela-
tionship between laxation and the various components of dietary fiber.
Of more practical concern to physicians is the question of which, if
any, of the major plant food groups, or possibly individual plant
foods, is most effective in promoting soft, easy bowel movements in

those who are bothered by constipation. If future research shows that

116

low DF intakes are related to other disease processes, the answer to
this question will assume added importance.

DF is not considered an essential nutrient by the committee
responsible for establishing the Recommended Dietary Allowances (FNB,
1974), yet for certain nutrients the amount that will just prevent
failure of a specific body function is used by the committee in
assessing the requirement for that nutrient. Several studies including
the present one have concluded that laxation, a specific body function,
is unsatisfactory when DF intake is low. Experiments demonstrating
this relationship need to be undertaken, contingent on acceptable
methods of measuring DF.

Most respondents in the present study had satisfactory bowel
movements without the regular use of laxatives, suggesting that the
normal food intake of these subjects would provide sufficient DF for
satisfactory laxation for most peOple. This has important implications
for the nutrition educator who must address the problem of constipation
due to low DF intakes. Although increased fiber intake, especially of
cereal grains, has been associated with decreased blood levels of cer-
tain minerals, such as calcium and iron, the nutrition educator can
recommend with confidence normal eating patterns to those whose DF
intakes are low. The fruits, vegetables, and whole grains which supply
fiber in a normal diet also are rich sources of other nutrients.

Foods which are good sources of calcium and iron should also be
stressed, especially in light of the gradual loss of calcium from
bone seen in the elderly. For those who appear to require high DF

intakes for normal laxation caution should be exercised in making

117

recommendations for increasing DF intakes until interactions with
other nutrients have been clarified.

Most respondents in the present study enjoyed eating vegetables
and whole grain or dark bread. For those who do not eat dark breads,
the food manufacturers can contribute to the DF content of diets by
developing more palatable methods of preparing whole grain breads.

It is not clear that formulated high fiber baked products are normally
necessary or effective in preventing unsatisfactory laxation. Edu-
cation of the food industry concerning the nutritional implications of
food processing is needed.

Food expenditures were not related to DF intakes in the
present study. Documentation of the cost of high fiber foods may be
necessary to dispel myths about the high cost of whole grain breads
or certain vegetables. The finding that most vegetables as well as
whole grain breads were well liked by most respondents suggests that
stereotypes about the food preferences of the elderly should be
re-examined. While vegetables were generally well liked by respon-
dents and given an important place in the meal pattern by most,
methods of preparation which preserve the color and enhance the
flavor of vegetables should be stressed by nutrition educators in
guiding those who want to increase their DF intake. Suggestions for
the selection of restaurant meals that provide needed fiber could
also be given. The Nutrition Meals are a means of introducing older
persons to less familiar fiber foods as well as the use of herbs in
enhancing their flavor. Peer influence in this setting may encourage

individuals to try new foods.

118

The conclusions about the DF intakes of these women cannot be
extended to other groups of persons in the US. Documentation of the
DF intakes of older men and younger persons is needed.

The fact that a large proportion of the respondents had made
health related changes in their diet suggests that older women are
often willing to make adjustments in what they eat when health is a
motivation. For some groups of persons, consuming more vegetables
and whole grain breads may require additional motivation. The
selection of fruit and, in some cases, vegetables by nearly half of
these women as a special treat suggests that nutritious foods can
also be preferred foods. The question of whether the colorful food
cards stimulated this response deserves attention. Food advertising
as well as food use in magazine articles and television programming,
information channels which were the major sources of fiber information
in this study, could be used more effectively to influence the atti-
tudes of all people toward the consumption of fruits, vegetables,
and whole grains.

The present study did not show a relationship between DF
intakes and an attitude of willingness to change food behavior.
Better instruments are needed to document the relationships between
external influences, nutrition attitudes and food behavior change.
An understanding of these relationships must be the basis of all

nutrition education regardless of the age of the target group.

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Hoppert, C. A. and Clark, A. J. 1945. Digestibility and effect on
laxation of crude fiber and cellulose in certain common foods.
J. Am. Dietet. A. 21:157.

Jenkins, D. J. A., Hill, M. J., and Cummings, J. H. 1975a. Effect
of wheat fiber on blood lipids, fecal steroid excretion and
serum iron. Am. J. Clin. Nutr. 28:1408.

Jenkins, D. J. A., Leeds, A. R., Newton, C. and Cummings, J. H. 1975b.
Effect of pectin, guar gum, and wheat fibre on serum chole-
sterol. Lancet 1:1116.

Joering, E. 1971. Nutrient contribution of a meals program for
senior citizens. J. Am. Dietet. A. 59:129.

Jordan, M., Kepes, M., Hayes, R. B. and Hammond, W. 1954. Dietary
habits of persons living alone. Geriatr. 9:230.

124

Keys, A., Anderson, J. T. and Grande, F. 1960. Diet-type (fats
constant) and blood lipids in man. J. Nutr. 70:257.

Keys, A., Grande, F. and Anderson, J. T. 1961. Fiber and pectin in
the diet and serum cholesterol concentration in man. Proc.
Soc. Exp. Bio. Med. 106:555.

Kirwan, W. 0., Smith, A. N., McConnell, A. A., Mitchell, W. D. and
Eastwood, M.A. 1974. Action of different bran preparations
on colonic function. Br. Med. J. 4:187-189.

Kohrs, M. B. 1976. Influence of the Congregate Meal Program in
Central Missouri on Dietary Practices and Nutritional Status
of Participants. Human Nutr. Res. Prog., Dept. of Agr.
and Nat. Res., Lincoln Univ., Jefferson City, MO.

Kraus, B. 1975. The Barbara Kraus Guide to Fiber in Foods. New
Am. Libr., N.Y.

Kfihne, P. 1960. Home Medical Encyclopedia. Fawcett Publ., Inc.
Greenwich, CT. p. 265.

LeBovit, D. 1965. The food of older persons living at home. J. Am.
Dietet. A. 46:285.

Lyford, C., Fischer, J., Buess, B., Rhodes, R. and Rhodes, J.B. 1975.
Controlled clinical trial of bran in irritable bowel syndrome.
Clin. Res. 23:253A.

Lyons, J. S. and Trulson, M. F. 1956. Food practices of older people
living at home. J. Gerontol. 11:66.

Madden, J. P., Goodman, S. J. and Guthrie, H. A. 1976. Validity of
the 24-hour recall. J. Am. Dietet. A. 68:143.

Manousos, O. N., Truelove, S. C. and Lumsden, K. 1967. Prevalence
of colonic diverticulosis in general population of Oxford
area. Br. Med. J. 3:762.

MacQueen, C. 1978. Personal communication. Project director,
Nutrition Program for the Elderly, Oakland Livingston Human
Service Agency, Pontiac, MI.

Marr, J. W. 1971. Individual dietary surveys: purposes and methods.
World Rev. of Nutr. and Dietet. 13:105.

McCance, R. A. and Lawrence, R. D. 1929. The Carbohydrate Content of
Foods. Spec. Rep. Ser. Med. Res. Coun., London, N0. 135,
H.M.S.O., London.

McCance, R. A. and Widdowson, E. M. 1960. The Composition of Foods.
Spec. Rep. Ser. Med. Res. Coun. Lond. 297. IH.M.S.O., London.

125

McConnell, A. A., Eastwood, M. A. and Mitchell, W. D. 1974. Physical
characteristics of vegetable foodstuffs that could influence
bowel function. J. Sci. Fd. Agric. 25:1457.

McCormick, R. D. 1976. Added fiber - new breads spearhead direction.
Food Prod. Dev. 10(8):13.

MDPH. Undated. Snacks That Count. Mich. Dept. of Public Health and
Dept. of Soc. Serv., Lansing, MI.

Millard, P. 1971. In preparation. Cited in Exton-Smith, A. N. 1972.
Constipation in geriatrics. In Jones, F. A. and Godding, E. W.
(eds.) Management of Constipation. Blackwell Sci. Publ.,
Oxford, England. p. 156.

Moore, M. C., Judlin, B. C. and Kennemur, P. 1967. Using graduated
food models in taking dietary histories. J. Am. Dietet. A.
51:447.

Morson, B. C. 1975. Pathology of diverticular disease of the colon.
Clinics in Gastroent. 4:37.

Nie, N. H., Hull, C. H., Jenkins, J. G., Steinbrenner, K. and Bent,
D. H. 1975. SPSS - Statistical Package for the Social
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NNC. 1975. Nutrition Labeling - How It Can Work For You. Nat. Nutr.
Consortium, Inc., with R. Deutsch. Bethesda, MD.

NRC. 1945. Manual for the Study of Food Habits. Bull. No. 111,
Nat. Res. Council, Nat. Acad. of Sci., Washington, D.C. p. 26.

OED. 1971. The Oxford English Dictionary. Oxford Univ. Press, N.Y.

Ohlson, M. A., Jackson, L., Boek, J., Cederquist, D. C., Brewer, W. D.
and Brown, E. G. 1950. Nutrition and dietary habits of aging
women. Am. J. Pub. Health 40:1101.

Ohlson, M. A., Roberts, P. H., Joseph, S. A. and Nelson, P. M. 1948.
Dietary practices of 100 women from 40 to 75 years of age.
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Painter, N. S. 1969. Diverticular disease of the colon, a disease
of this century. Lancet 2:586.

Painter, N. S., Almeida, A. Z. and Colebourne, K. W. 1972. Unpro-
cessed bran in treatment of diverticular disease of the colon.
Br. Med. J. 2:137.

Painter, N. S. and Burkitt, D. P. 1971. Diverticular disease of the
colon: a deficiency disease of western civilization. Br. Med.
J. 2:450.

126

Painter, N. S. and Burkitt, D. P. 1975. Diverticular disease of the
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Painter, N. S., Truelove, S.C., Ardran, B. M., and Tuckey, M. 1965.
Segmentation and the localization of intraluminal pressures in
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Parks, J. W. 1943. M.D. Thesis, Cambridge Univ. Cited in Connell,
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Payler, D. K., Pomare, E. W., Heaton, K. W. and Harvey, R. F. 1975.
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Persson, I. 1976. Effect of prolonged bran administration on serum
levels of cholesterol, ionized calcium, and iron in the
elderly. J. Am. Geriatric Soc. 24:334.

Rankine, D. C. and Taylor, B. 1975. Are community nutrition programs
meeting the needs of the elderly? J. Home Econ. 67(11):37.

Rao, D. B. 1973. Problems of Nutrition in the aged. J. Am.
Geriatrics Soc. 21:362.

Reshef, A. and Epstein, L. M. 1972. Reliability of a dietary
questionnaire. Am. J. Clin. Nutr. 25:91.

Reuben, D. 1975. The Save Your Life Diet. Ballantine Books, N.Y.

Robertson, J. 1972. Changes in the fibre content of the British
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Rosow, I. and Breslau, N. 1966. A Guttman health scale for the
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127

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E. Lansing, MI.

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fibre. Nutr. Rev. 35(3):3l.

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Sdltoft, J., Gudmand-deer, E., Krag, B., Kristensen, E. and Wulff,
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new term for plant fibers in nutrition. Am. J. Clin. Nutr.
29:934.

Spiller, G. A., and Shipley, E. A. 1976b. New perspectives on dietary
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the Dietary of Elderly Women. King Edward's Hosp. Fund of
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Stein, J. and Urdang, L. (eds.) 1966. The Random House Dictionary
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128

Steinkamp, R. C., Cohen, N. L. and Walsh, H. E. 1965. Resurvey of an
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46:103.

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Trowell, H. 1972. Ischemic heart disease and dietary fibre. Am. J.
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Trowell, H., Southgate, D. A. T., Wolever, T. M. 3., Leeds, A. R.,
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129

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APPENDICES

APPENDIX A

INTERVIEW SCHEDULE

CKJ
FSHN
MSU
1977

130

EXPLANATION OF INTERVIEW SCHEDULE

The interview schedule has been designed to facilitate the recording
of the participants' responses to the questions, which are meant to
be open-ended, that is, the printed reSponses which follow most
questions will be checked if they represent the substance of the parti-
cipant's response. But if the participant's response differs in sub-
stance from the printed responses the actual response will be recorded.
The printed responses will not be shown or read to the participant
unless use of a RESPONSE AID is specifically stated.

General format of the interview schedule:

a. Instructions for the interviewer that are not to be read are
printed in capital letters and enclosed in parentheses.

b. All basic questions and their responses begin at the left margin
and should be asked of all participants.

C- Some questions have been marked with an asterisk (*). These
are questions related to functional activity level and optional
activity level, which are not a part of the main analysis.

(1. All contingency questions, which depend on the response to the
previous questions, and their responses begin at the first inden-
tation and are to be asked only if the reSponse immediately
above is checked.

Visual materials have been designed to be used with the interview
schedule to facilitate the conducting of the interview and also to make
it more interesting for the participant. While some of the materials
will be useless for those who are not literate, where possible the
materials have been designed with colors and pictures to have meaning
for the non-literate. For those who are visually handicapped, large
print visuals have been produced. For participants who are blind

it may be necessary to complete a short interview and exclude the
data from analysis, although the entire interview can be completed
without the visual participation of the participant if she is very coop-
erative and willing to take the additional time required.

CKJ
FSHN
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1977

131

EQUIPMENT FOR CONDUCTING THE INTERVIEW

Basket for carrying the supplies.

Complete Interview Schedule:

a.

1.

Introductory letter.
CONSENT FORM.

PARTICIPANT IDENTIFICATION FORM, for recording the
identifying information about the participant. It includes
CHECKLIST FOR COMPLETION OF INTERVIEW, for record-
ing the completion of each necessary step in the interview pro-
cedure.

INTERVIEW SCHEDULE, the form providing the schedule of
questions to be asked and space for recording of answers during
the interview.

SCHEDULE CARD A--USUAL MEAL PATTERN. the schedule
of questions for obtaining information on foods usually eaten,
for Item #19 of INTERVIEW SCHEDULE.

SCHEDULE CARD B—-USUAL MEAL PATTERN, the schedule
of questions for obtaining specific data about foods mentioned
in reaponse to SCHEDULE CARD A. To be used with FOOD
MODELS.

SCHEDULE CARD C--FOOD PREFERENCES, the schedule of
questions for obtaining food preference information in Item #20
of INTERVIEW SCHEDULE. To be used with COLORED BOXES
and FOOD CARDS.

FOOD CARD RESPONSE FORM, Used for recording information
obtained from Items #20 and #21 of the INTERVIEW SCHEDULE.

PROCEDURE FOR CONDUCTING THE INTERVIEW.

Visual Materials:

3.

FOOD MODELS, to be used by participant as required for esti-
mation of the usual serving size (Total of 20 items). Included are:

1. Three orange models (1/4 cup, 1/2 cup, and 3/4 cup)
representing fruits and vegetables. (Marked A, B, and C)

2. Three white models (l/Z cup, 1 cup, and l l/Z cup)
representing a hot dish or casserole. (Marked B. D, and E)

3. Three brown models (2 ounce, 4 ounce. and 6 ounce)
representing meat. (Marked A. B, and C)

4. Three yellow models (1 teaspoon, 1 tablespoon, and
2 tablespoons or 1 ounce) for estimating butter, cheese,
and condiments. (Marked l, 2, and 3)

132

EQUIPMENT, p. z

CKJ
FSHN
MSU
1977

5. Three saran-wrapped bowls containing 1/2 cup, 1 cup,
and 1 1/2 cup puffed rice for estimating soup and cereal. (Marked
6. Three glasses (4ounce, 8 ounce, and 12 ounce) for esti- 3’ D'E)

mating beverages. (Marked B. D. and E)

7. Two spoons (1 teaspoon and 1 tablespoon) for estimating
sugar, unprocessed bran. (Marked l and 2)

FOOD CARDS, 4" x6" laminated picture cards (total of 77 items)
of most fiber-containing foods, in the categories, Fruits,
Vegetables, and Miscellaneous (legumes, whole grains, nuts
and seeds, and certain starchy vegetables). Used for Item #20
of INTERVIEW SCHEDULE.

7 COLORED BOXES into which FOOD CARDS will be sorted,
with the following colors and labels:

Green--"Very often, more than once a week."

Yellow--"Often, about once a week."

1
2
3. Orange--"Occasionally, less than once a week."
4 Pink--"Cannot eat."

5

R ed- -" Dislike . "

6. Blue--"Other." 7. White--"Less than 5-6 times a year."

Categories l-3 are used for Fruits and Vegetables but not
Miscellaneous foods, about which more specific food frequency
information is obtained. Individual fruit and vegetable consump-
tion varies so widely that more detailed cateforization of fre-
quency would be of questionable validity.

Large print written materials for use by participant:

l. RESPONSE AID A--QUESTIONS FOR USUAL MEAL PATTERN,
used with SCHEDULE CARD B to remind participant of
information needed about each type of food eaten.

2. RESPONSE AID B--Weight categories, used
for Item #16 of INTERVIEW SCHEDULE.

3. RESPONSE AID C--STOOL CONSISTENCY, used with
Itém #26 of INTERVIEW SCHEDULE.

4. RESPONSE AID D, containing the three statements for
Item #45 of INTERVIEW SCHEDULE.

5. RESPONSE AID Eo-VIEWPOINTS ON EATING, containing
statements from Item #48 of INTERVIEW SCHEDULE.

6. RESPONSE CARD F. presenting the color-coded, S-point,
Likert-type scale used in responding to statements on
RESPONSE AID E. The scale consists of: Strongly agree
(blue), Agree (green), Undecided (graY). Disagree (orange),
and Strongly disagree (red).

133

EQUIPMENT, p. 3

4. Miscellaneous Supplies:
a. Clipboard.
b. Three sharpened pencils.
c. Three rubber bands to put around FOOD CARDS.

d. Ten 5" x 6" cards, folded to fit into COLORED BOXES, for
separating each category of FOOD CARD.

e. Gift for participant.

CKJ
FSHN
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l 977

134

MICHIGAN STATE UNIVERSITY mum- was”

 

DEPARTMENT OF FOOD some! AND HUMAN WON - W WY BUILDING

DEAR MRS.

SONE OF OUR HOST SERIOUS HEALTH PROBLEMS IN AMERICA ARE BEING
LINKED BY DOCTORS To THE KINDS OF FOOD NERICANS EAT. THESE NEH IDEAS
HAVE STIMULATED A GREAT DEAL OF RESEARCH. BUT MANY QESTICNS REMAIN TO
BE ANSNERED. I’D LIKE TO GIVE YOU AN OPPORTINITY AS A CONCERNE) CITIZEN
To BE A PART OF TT-E INPORTANT SEARCH FOR ANSWERS TO Tl-ESE DIET RELATED
I‘EDICAL PROBLEMS.

IN COOPERATION NITH DR. KATTRYN KOLASA I HAVE DEVELOPED A RESEARCH
PROJECT TO STUDY NHAT FOODS PEOPLE ARE EATING NON AND NHY THEY ARE
EATING THESE FOODS. YOU HAVE BEEN CHOSEN FROM AmNG THE W PARTICIPATING
IN THE OLHSA (OAKLAND LIVINGSTON HLMAN SERVICES AGENCY) NUTRITION PROGRAM
TO TAKE PART IN THIS STUDY. You CAN MAKE A VALUABLE CONTRIBUTION To THIS
RESEARCH EFFORT BY SITTING Dom NITH PE FOR ABOUT AN HOUR TO TELL IE
ABOUTWATYOUEATANDANSNERSO’EQUESTIGVSABOUTYOIRIENJHMDOTHER
THINGS THAT MAY INFLUENCE YOLR DIET.

NO SPECIAL KNONLEDGE IS REQUIRED TO ANSVER ANY OF THE QUESTIONS
BECAUSE THERE ARE NO CORRECT ANSWERS. THIS IS A CHANCE FOR YOU TO TELL
NE ABOUT YOURSELF AND YOLR OPINIONS ABOUT EATING AND ALSO ASK NE ANY
QUESTIONS YOU HAVE ABOUT EATING.

 

? 5 I"? O FRO“ HOME ECOVOMICS TO HL'\IAN ECOLOGY 0 [971-72

 

 

 

135

I HILL BE CALLING HITHIN TI-E NEXT WEEK TO ARRANGE A MEETING HITH
YOU. BESIRETOASKPEMYWESTIOVSYOJHAVEN-IEN I CALL. IFYOUNOULD
LIIG TO CHECK ON THE VALIDITY OF THIS STUDY. PLEASE FEEL FREE TO CALL
DR. KATTRYN KOLASA. (517) 353-1669, OR I’Rs. JANE NOVAK, 858-5197.
I TRULY APPRECIATE YOIR COOPERATION AND AM OONFIDENT THAT You HILL
BE WILLING To PARTICIPATE IN THIS IMPORTANT STIDY.
VERY SINCERELY.

KRIS JG-NSOV (I’RS. CARL N.)
COMIVITY NUTRITION RESEARCI-ER
(313) 338-1287

KJ/AP

CKJ
FSHN

1977

Date

136

Food Behavior of Older Women

PARTICIPANT IDENTIFICATION FORM

Participant code

 

Name of participant

 

Address

 

 

Phone

 

Title VII meal site

 

Is participant female?

 

Is participant living independently?

 

Is participant 60 years old or older?

 

CHECKLIST FOR COMPLETION OF INTERVIEW

 

Letter sent.
First telephone call made.

Second

Third

Appointment made:

Date Time Location Outcome

 

 

 

 

Interview completed.

FOOD CARD information recorded.

Information recorded on INTERVIEW SCHEDULE checked for
completeness and readability.

Record notes in Field Notebook.

137

CONSENT FORM

 

Name of Participant

I hereby agree to participate in a study being conducted by
Carolyn K. Johnson under the supervision of Dr. Kathryn Kolasa
of Michigan State University's Department of Food Science and Human
Nutrition. I understand that my participation involves an interview of
about an hour's length and that I am free to discontinue at any Mme.

I know that the purpose of this interview is to gather information
about food habits and diet-related health problems which will enable
dietitians and nutritionists to improve the diet counseling given to
patients.

I understand that my personal identity and information about
myself will be held in the strictest confidence. I further understand
that I have been asked not to discuss the interview with others until
the study is completed. I also know that I can receive additional
explanation of the study after the interview and that a summary of

the results will be made available to me at my request.

 

Participant

 

Address (if results are requested)

 

Interviewer

 

Date

CKJ

FSHN

1977

138

PC
Food Behavior of Older Women
INTERVIEW SCHEDULE

We know that there have been many changes in food habits in recent
years. I'm very interested in finding out what older women are

eating now and what factors influence their food habits. I'd like to

begin by asking you some questions about the things that influence
what you eat, such as where you live and how you fix your food.

 

 

 

1. Do you live alone?
Yes
No
Who else do you live with?
Husband
Family (SPECIFY RELATIONSHIPS )
Adult female
Adult male
Other
2. When you are at home do 222 usually prepare your meals?
No

 

a. Who does prepare your meals at home?

 

b. Do you prepare any of your own meals? Which?
No
Yes

 

 

c. Do you help with meal preparation?
Yes
No

Is there any special reason why you don't help fix the meals?

 

Yes

d. Are there certain of your meals that someone else often prepares?

No

 

e. Does any one help you with meal preparation?

No
Yes
Who helps you?

 

Yes
f. Who prepares these meals?

 

3. Which meals does he/she prepare?

 

h. Does he/she help you when you prepare a meal?

No
___ Yes

*

139

 

 

 

 

PC
2.
*3. Do you usually decide what you want to eat at home?
Yes
No
a. Who does plan your meals?
Sometimes
b. Which meals do you plan yourself?
Other
Question not asked, not appropriate
4. Do you feel that the food preferences of others influence what you
eat now? (Such as your husband.) In what way?
5. What kitchen facilities do you have? (IF ANY LISTED ITEM IS NOT
MENTIONED, ASK:) do you have (listed item)?

 

a. Stove/hotplate
How many burners does your stove/hotplace have?

 

 

b. Oven of any kind

 

c. Refrigerator
(IF N0:) Do you have access to any place where you
can keep food cold?

 

 

d. Space to store frozen foods
What kind of freezer space do you have?

 

 

e. Adequate workspace for preparing food

 

f. Adequate storage space for food and equipment

 

3. Equipment needed to prepare and serve food (pans, can opener,
electric appliances)

h. Other

 

 

 

6. Do you do your own grocery shopping?

Yes
a. How do you get to the store?

 

 

No
b. Who does do your grocery shopping (the relationship)?

 

c. Do you give them a list of what you want?

CKJ
FSHN ——-—- N°
MSU __________ Yes

1977

140

3' PC

nutrition site?
7. How often do you eat at the
multipurpose center?

times per week/month
Other

 

a. (IF PARTICIPANT VOLUNTEERS ANY OPINIONS ABOUT THE MEAL
PROGRAM, RECORD HERE)

 

 

8. How often do you eat somewhere else other than at home or at the
._ [hutrition site?

multipurpose center?
times per week/month

Never (GO TO QUESTION 10)
Other

 

 

 

9. Where do you go to eat?
To a friend's house
To a relative's house
To a restaurant
Does the restaurant offer a full selection of foods, including
salads and cooked vegetables?

 

 

 

 

Yes
No
Other
Other
10. How much do you usually spend for food for yourself each week, including

what you spend when you eat out? (HELP WITH ADDING UP TOTAL, IF NEEDED,
INCLUDING FACE VALUE OF FOOD STAMPS.)

3 per week

a. Does this include food for anyone else?
No
Yes
Who else?

 

b. Does this include paper products, cleaning items, and toiletries
at the grocery store?
Yes
No

 

Didn't know

Refused to answer
(ESTIMATE)

 

11. Have you lived on a farm at any time in your life?
No
Yes
CKJ
FSHN
MSU

1977

12.

13.

14.

15.

16.

17.

18.

CKJ
FSHN

1977

141

Another factor that influences the food we eat is our national background.
What country do you or your ancestors come from?

 

a. Were you born there?
Yes
No

 

b. Has your
influenced your cooking?
Yes
No

(country of ancestry) heritage

 

 

 

No answer

 

Would you mind telling me your age?
years old

 

Refused to answer
(ESTIMATE OF INTERVIEWER):

Is there any physical condition, chronic illness, or health problem
that bothers you now?
No
Yes
Describe the problem.

 

Do you feel that you have a weight problem?
No
Yes

 

§
9.
O
5‘

of these weight descriptions fits you the best?
A. Too thin

3. Just right

C. Slightly overweight

D. Moderately overweight

E. Very overweight

(INTERVIEWER AGREES DISAGREES )

 

 

 

Are you on a special diet prescribed by a doctor of given to you by
a dietitian?
No
Yes
What kind of diet?

 

In recent years have you made any changes in your diet because of your health
or because of other changes in your life (such as eating less because there is
no one to cook for or staying away from eggs.)
No
Yes
a. What changes have you made?

 

 

 

b. Why have you made this change?

 

 

C.

142

DIET, RECORD HERE.)

5.

PC

(IF PARTICIPANT MENTIONS ANY CHANGES IN HEALTH RELATED TO

 

 

l9

USUAL MEAL PATTERN.

(ARRANGE FOOD MODELS AND RESPONSE AID A ON TABLE.
DRAW A LINE
AFTER EACH MEAL OR SNACK AND INDICATE WHERE MEAL IS

INTERVIEWER USE SCHEDULE CARDS A AND B.

USUALLY CONSUMED.
BINATION FOOD INDENTED UNDER THE MAIN FOOD.

RECORD CONSTITUENTS OF A COM-
RECORD

FREQUENCY, SERVING SIZE AND DETAILS ONLY FOR MEAT
AND FOODS CONTINING FIBER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequency Number Serving Size
Meal per per of Common Food
Ifo_c_:gtion Food Item week month ServingsaMeasureModcl Detail:
i
. i '“‘
.__. ; i -
E I
.._--- -..-.. -... ._: ..... r - - -1“ H- -......_—-..-...._.__..-...--.--_.
-4; .._ ; __ __.._._
__ ! - ...__-_.
I 2
l I
CKJ
FSHN
MSU

 

 

 

 

 

 

 

1977

 

143

USUAL MEAL PATTERN. cont.

Meal
Location Food Item

 

CKJ "‘”"“'
FSHN —-—--——
MSU

1977-

u Number Servin Size
per per of Commo Food
week month Serving Measur Model

PC

Detail ‘.

 

 

 

 

CKJ
FSHN
MSU
1977

20.

21.

 

144

FOOD PREFERENCES
(USE PROCEDURE 0N SCHEDULE CARD C. FOLLOWING INTERVIEW
RECORD INFORMATION ON FOOD CARD RESPONSE FORM.)

(TAKE THE MISCELLANEOUS CARDS FROM THE WHITE BOX.)

Now I'd like to have you tell me how often you eat

the foods that you put into the orange box just now.

Tell me how many times per week or month you eat

(food from first card)? What size serving do you usually
have? Use the food models to make your estimate.

(RECORD INFORMATION BELOW. REPEAT QUESTIONS FOR EACH
CARD.)

Fr uen Servin Size COMMENTS
per per Common ood
Food Code week m onth Measure odel

(RETURN CARDS TO WRITE BOX.)

CKJ
FSHN
MSU
1977

 

145

8. PC
22. (TAKE ALL THE CARDS FROM THE PINK BOX.) These are the
Would you

foods that you cannot eat for some reason.

I
e lain to me why you can't eat them. Why can t you
3:: (food on card)? (RECORD INFORMATION BELOW

AND REPEAT QUESTION FOR EACH FOOD CARD FROM PINK BOX.)

 

Food Code Complaint COde C°mment Complaint Code
1. flatulence, gas
2. heartburn,belching
3. allergy
4. diarrhea
S. constipation
6. abdominal pain
7. doctor's orders
8. other (RECORD

No cards in pink box.

COMMENT)

(RETURN FOOD CARDS TO PINK BOX. NEST ALL BOXES TOGETHER

AND PLACE IN BASKET.)

23. (IF PARTICIPANT VOLUNTEERS UNUSUAL FRUITS AND VEGETABLE

NOT ON FOOD CARDS RECORD HERE;)

CKJ
FSHN

1977

24.

25 .'

26.

27.

28.

146

9.
PC

Now I'd like to ask some questions about your food shopping.

How often do you buy or get fresh fruits and vegetables?

Rarely/never (CROSS OUT ANSWER THAT DOES NOT APPLY.)

a. Is there any special reason why you rarely/never get
fresh fruits and vegetables?

 

Other

 

times per week/month

b. Where do you get your fresh fruits and vegetables now during
the winter?

 

 

c. Where do you get them in the summertime?

 

(ARE CEREALS PART OF HEAL PATTERN?)
NO
YES
There are many kinds of cereals in the store so we have to
make a decision about which kind to buy. How do you decide
which kind of cereal to buy? What factors do you consider?

 

Now we're going to shift gears and talk about a health problem that bothers
many of us, which may be related to the food we eat. I'd like to ask you
some questions about your bowel movements. How would you describe the
consistency of your normal bowel movements, that is, without having taken
a laxative? ( USE RESPONSE AID C.)

a. Hard

b. Soft, well formed

c. Soft, fluid

Other

 

 

 

Would you say that you usually move your bowels easily, or only with
considerable straining?

Easily

Considerable straining

Other

 

How often do you usually have a bowel movement?
(1) More than 2 times per day

(2) l-2 times per day

(3) Every 2-3 days

Variable , usually

 

 

Other

 

29.
30.
31.
a32.
33.
CKJ
FSHN
MSU

1977

147

10. PC

Would you say that you often are bothered by constipation
or diarrhea? How often?

 

 

Consti-
pation Diarrhea
No
Yes. times per week/month

 

Yes, all the time.
Sometimes, less than once a month
Other

 

Have you ever been told by a doctor that you have diverticulosis
or any other bowel problem?
No
Yes, diverticulosis
Yes, other
Describe the problem.

 

Do you take laxatives or any other medicine for your bowels?
No
Yes
How often? (IF ANSWER IS INCONSISTENT WITH # 29
QUESTION FURTHER FOR REASON.)
times per week/month
Answer inconsistent with t 29
a. When do you decide to take a laxative?

 

 

Other

 

b. What laxative/medicine do you take?

 

Constipation seems to mean different things to different
people. Would you explain what you mean by constipation?
How would you describe being constipated?

 

Question not asked

Some people have their own special ways of avoiding or
relieving constipation without the use of laxatives. Is
there anything special that you would recommend for
constipation? (Do you feel that certain foods help to
avoid constipation? Which foods?)

 

CKJ
FSHN
MSU
1977

34.

35.

36.

37.

38.

39.

148

11. PC

Now I'd like to talk about a topic that I am interested
in--fiber. Do you remember reading or hearing anything
about fiber in the food we eat?

No

Yes

a. Where did you hear about fiber?

 

b. Can you tell me briefly what you read/heard about
fiber? Why did you mention that? In what way?
What difference does make?)

NO
Yes

 

 

 

 

c. Have you ever bought a book about fiber?
No
Yes
What book?

 

What comes to your mind when I mention fiber? (Why did you
mention that? In what way? What difference does
make?)

 

 

Tell me what you know about bran. (Why did you mention
that? In what way? What difference does make?)

 

 

Do you find that you have to pay attention to the amount of
roughage or bulk in your diet?

No

Yes

 

In what way?

 

 

Do you ever eat bran in any form?
No
Yes

Is there any Special reason why you 3:3.2rggz bran?
No
Yes

Would you explain your reason.

 

 

 

40.

149

12. PC

What kind of bran do you eat? How often? What size
serving? How do you use it?

Fr ue Servin Size
per per per Common Food
da week month Measure Model

 

e41.
442.
843.
$44.
$45.

CLK

FSHN

MSU

1977

Another thing that affects what people eat is how active
they are and what they are able to do physically. Are you
physically able to do heavy work around your house/a part-
ment, like scrubbing the floors?

No

Yes

 

Do you do the ordinary work around your home yourself, like
vacuuming and changing the bed?

No
Are you able to do light housework?
No
Yes
Yes

 

Can you walk up and down stairs without assistance?
No
__”_Yes
Do you ever go for a walk when the weather is nice or engage
in other outdoor activity?

 

 

NO

a. Do you have difficulty walking?
No
Yes

Yes

 

b. _EOw often do you get out for a walk or other out-
door activity?

times per week/month
Other

 

Which of these statements fits you best? (RAND PARTICIPANT
RESPONSE AID D.)
A. I cannot keep house at all now because of my health.
3. I have to limit some of the work or other things
that I do.

C. I am not limited in any of my activities.

CKJ
FSHN

1977

s46.

‘47.

48.

49.

50.

150

13. PC

How often do you get out of the house for other activities
besides eating out, and shopping for food?

times per week/month

I don't go out if the weather is bad
How often do you get out when the weather is better?

 

Other

 

What are these other activities?

Other kinds of shopping
Visiting friends or relatives
Regigious services

Club meetings

Volunteer work

Part time job

Full time job

Other

 

 

 

 

(SEE NEXT PAGE)

Now I'd like to close with one more question.
If you decided to buy a special treat at the grocery
store what food would you buy?

 

I really thank you for your cooperation, Mrs._;i
It's hard work to answer so many questions. To show my
appreciation I'd like to give you a little gift.
(PRESENT CHOICE OF GIFT BOOK)

Cooking for TWO

Nutrition Labeling

CKJ
FSHN
MSU
1977

49.

151

14. pc
VIEWPOINTS ON EATING

(LAY OUT RESPONSE AIDS EAND F.) To close I'd like to get some
of your vieWpoints about eating. (POINT TO RESPONSE AIDE.)
These statements have been made by other people about eating and
learning about food. After I read each statement will you tell me
what your vieWpoint is, using this scale of responses (POINT TO
RESPONSE AIDF): strongly agree(SA), agree (A), undecided (UN),
disagree (D), and strongly disagree (SD).

 

Statement SA A UN D

SD

 

1. Learning something new about
nutrition will probably not lead me
to change what I eat.

 

2. I have found it worthwhile to
watch my calorie intake.

 

3. It is fun to try out new foods and
old foods fixed in a new way.

 

4. I like to stick with my old favorite
meals rather than experiment
with new kinds of foods.

 

5. I like to eat fruit for dessert.

 

6. In actual practice, my nutrition
knowledge has little influence
on what I choose to eat.

 

 

 

7. When I decide what food to buy,
nutritive value is a major
consideration.

8. I try new recipes frequently.

9. Food selection is a personal matter,

people shouldn't try to persuade me
to change.

 

 

10. I am willing to eat foods I don't
like very much if.I know they are
good for me. i

 

 

 

 

 

(GO BACK TO PREVIOUS PAGE.)

 

CKJ
FSHN
MSU
1977

FOOD CARD RESPONSE FORM--VEGETABLES

152

PC 1.

 

Box Color and Designation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gre. Yel. ' Crawl/lib Blue Red Pink

>l/wk wl/wk (Wk S/yr 'aher'Dislik Canaan Vegetable
V1. Asparagus ‘
V2. Broccoli
V3. Beans, green or wax
V4. Cabbage, sauerkraut
V5. Carrots
V6. Celery
V7. Collards, chard
V8. Corn
V9. Cucumber, pickles
V10. Lettuce
VII. Okra
V12. Onions, leeks
V13. Peas, green
V14. Peppers, green or hot
V15. Squash, summer, zucchini
V16. Squash, winter, pumpkin
V17. Sweet potatoes, yams
V18. Tomatoes
V19. Beans, lima
V20. Bean sprouts
V21. Beets
V22. Cauliflower
V23. Chinese cabbage
V24. Brussel sprouts
V25. Eggplant
V26. Greens, mustard, beetjale
V27. Mushrooms
V28. Radishes
V29. Rutabaga, turnips, parsnips
V30. Spinach

‘ V31. Mixed vegetables

V32. Vegetable soup

 

 

 

 

 

 

 

 

 

153

FOOD CARD RESPONSE FORM--FRUIT PC 2.

Box Color and Designation
CTre. Yel. Ora. is Blue Red Pink
>l/wk l/wk Kl/wk S/yr Gher DislileCam: Fruit

F1. Apple with skin

 

 

 

 

 

F2. Pears

 

F3 . Banana

 

F4. Blueberries

 

 

F5. Cantaloupe or melon

 

F6. Fruit Cocktail
F7. Grapefruit

 

 

F8. Grapes
F9. Orange

 

--. -_—q _.—<.—_.

 

F10. Peaches
F11. Plums

 

 

F12. Prunes

 

F13. Raisins, currents

. .-_. -._ . .m...—-— e

 

F14. Apricots
F15. Avocado

 

 

 

4...-) ..

F16. Raspberry, boysenberry

 

F17. Strawberries

 

F18. Cherries

 

F19. Cranberries

 

F20. Dates
F21. Figs

 

 

 

5 F22. Pineapple

 

i F2 3 . Papaya. Mango

 

3 F24. Tangerine, mandarin orange

E F2 5 . Waterm elon

 

 

 

 

 

 

 

 

 

i ~ 1 F26. Applesauce or peeled aPPle

 

CKJ
FSHN
MSU
1977

154

PC 3.

FOOD CARD RESPONSE FORM--M.ISCELLANEOUS FOODS

 

Data from Ques. 21

 

Freguency

Serving Size

Box Color & Designation

 

 

per
week

per
mon.

 

m'

Meas

 

 

 

Food
Morbl

 

White

(S/Yr

Blue Red
Qter Dslike

($334

 

l l

 

l

I

1

M1.

Beans , dried white

 

M2.

Bean, dried red

 

M3.

Peas, dried

 

M4.

Garbanzos, chick peas

 

M5.

Lentils

 

M6.

Soybeans

 

M7.

Peanut butter

 

M8.

Salted peanuts or other nuts

 

M9.

Potatoes with the skins

 

M10.

Potatoe 5 without skins

 

M11.

Whole wheat baked products

 

M12.

Rye bread

 

M13.

Bread containing added fiber

 

M14.

Brown rice

 

M15.

Fruit pie

 

 

 

M16.

Whole grain cereals, as

Wheaties, Shredded Wheat,
Oatmeal

 

M17.

Blackeye peas, crowder peas

 

 

CKJ
FSHN
MSU
1977

 

 

 

 

 

 

 

 

M18.

Popcorn

 

155

SCHEDULE CARD A--USUAL MEAL PATTERN (#19)

(TAKE OUT FOOD MODELS AND EXPLAIN PROCEDURE WHILE
SETTING UP FOOD MODELS.) Now I'd like to find out about what you
usually eat and drink every day. I'd like to have you tell me the kinds
of food you eat at each meal. To help you estimate how much of a
particular food you usually eat I have some food models here for you

to look at, and then tell me which model is about the same size as

your usual serving. (EXPLAIN MEANING OF MODELS.)

(IF PARTICIPANT INDICATES THAT SHE HAS TEMPORARILY CHANGED
HER DIET FOR ANY REASON, SUCH AS SICKNESS, ADD:) I want to
know what you usually eat under normal circumstances. (RECORD ALL
RESPONSES ON PAGES 5 &6 OF INTERVIEW SCHEDULE.)

(KEY QUESTIONS. USE DETAIL QUESTIONS TO GET COMPLETE
INFORMATION ABOUT EACH MEAL OR SNACK.)

1. What do you usually have to eat or drink when you get up in the morning?
2. Do you have anything to eat later in the morning? What do you have?
3. What do you usually have to eat or drink in the middle of the day?
4. What do you usually eat at noon when you eat at the nutrition site?
5. Do you usually have anything to eat or drink later in the afternoon?
What do you have?
6. What do you usually have to eat in the evening? r ,-
. . ,do out
7. Is your usual evening meal different on days when youn‘ ea .
. . . . . 610 not Lat the;
nutrition site. Describe your usual evening
meal on these days.
8. Do you usually have anything to eat or drink later in the evening?
What do you have?

(DETAIL QUESTIONS.)

1. (IF ANSWER IS SOMETHING LIKE, "ALL KINDS OF THINGS", ASKz)
Tell me what you eat on a typical day, for example yesterday.

What else do you have to eat at this time?

What do you have to drink?

Do you have anything else with this meal?

(FOR EACH FOOD THAT INCLUDES FRUITS, VEGETABLES, OR
CEREAL GRAINS, ASK QUESTIONS ON SCHEDULE CARD B.)

01-th

 

 

 

 

6. (IF A FOOD ON CHECKLIST HAS NOT BEEN MENTIONED. ASKz)
You didn't mention eating (food on checklist).
Do you ever eat ?
How often do you eat ? W
What size serving do you have? Salads
What kind of do you have? Vegetables
Fruit
Cereal
Thank you. You've given me a good picture Bread
of the foods you usually eat. Soup
(GO TO SCHEDULE CARD C.)

156

SCHEDULE CARD B--USUAL MEAL PATTERN

(RECORD LOCATION OF MEAL. IF LOCATION IS NOT CLEAR,
ASK:) Where do you usually eat this meal?

How often do you have (class of food mentioned)?

What size serving do you usually have?
OR

How many (class of food mentioned) do you usually have?
(IF SERVING SIZE 15 NOT CLEAR FROM RESPONSE TO #3, ASK:)

Which model represents your usual serving the best?

(IF FOOD OF THIS CLASS 13 NOT EATEN EVERY DAY, ASK:)
What do you eat on other days?

(FOR THESE SPECIFIC FOOD CLASSES, ASK:)

(SOUP, CEREAL,SANDWICH, BREAD, SALAD, SNACK FOOD)
What kind of do you have?

(SANDWICH, CASSEROLE) How do you make your ?
What do you include in it?

 

157

#20. SCHEDULE CARD C--FOOD PREFERENCES

 

(WHILE EXPLAINING PROCEDURE, GIVE VEGETABLE CARDS TO
PARTICIPANT AND ARRANGE GREEN, YELLOW, ORANGE, AND
WHITE BOXES WHERE SHE CAN SORT INTO THEM.)

Now I'd like to find out in more detail the kinds of vegetables that you
like to eat. I have here some cards with pictures of each vegetables
on them. I'd like to have you s ort them into these boxes according to
how often you eat them. If there is any vegetable you don't recognize
feel free to ask me. Into the green box put those vegetables that you
eat very often, that is more than once a week. Into the yellow box
put those vegetables that you eat often. that is about once a week.
Into the orange box put those vegetables that you eat occasionally,
that is less than once a week on the average. If you eat the vegetable
less than five or six times a year put it in the white box. (IF PARTICI-
PANT HESITATES WITH SEASONAL VEGETABLES, LAY OUT THE
"VERY OFTEN IN SEASON" CARD AND EXPLAIN.)

(HAND FRUIT CARDS TO PARTICIPANT.) Now I'd like to have you
do the same thing with these fruit cards. Sort the cards into these
boxes according to how often you eat them.

(NEST AND PUT ASIDE ORANGE, YELLOW, AND GREEN BOXES.)

(SET OUT PINK, RED, AND BLUE BOXES. GIVE PARTICIPANT
THE CARDS FROM THE WHITE BOX.) Now would you sort these
cards according to why you don't eat them. If the fruit upsets you or
you cannot eat it for some medical reason, put it in the pink box.

If you dislike it, put it in the red box. Those you don't eat for any
other reason, such as expense or not being familiar with them, put
in the blue box. Things you do eat once in a while put back in the
white box.

(ADD "I EAT THESE" CARD TO THE WHITE BOX. GIVE PARTICI-
PANT MISCELLANEOUS CARDS.) Now I'd like to have you sort these
cards into these boxes to show me which of these foods you eat and
why you don't eat the others. Remember the pink box is for foods you
cannot eat, the red box for food you dislike, the blue box for foods
you don't eat for other reasons, and the white box for food that you

do eat.

(GO TO #21 of INTERVIEW SCHEDULE.)

APPENDIX B

FOOD DEMONSTRATION

II.

III.

Outline of the Food Demonstration

Problem of thinning bones in older people
A. Presentation
1. OsteOporosis and peridontal disease
2. Calcium in bones
3. Calcium balance - calcium cube demonstration
4. Sources of calcium - poster
B. Demonstration
1. Make Peach Milk Shake
2. Distribute samples
Other Factors in calcium balance
A. Presentation
1. Bones as storehouse of calcium
2. Vitamin D, the sunshine vitamin
3. Intolerance of milk
B. Demonstration
1. Make Banana Yogurt Shake
2. Distribute samples
Exercise and strong bones
A. Presentation - astronaut experience
B. Demonstration
1. Make ‘Brown Bear', molasses peanut butter milk drink

2 . Distribute samples

158

APPENDIX C

CONVERSION FACTORS

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161

 

 

 

 

 

 

 

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APPENDIX D

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