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A DESCRIPTIVE STUDY OF THE NUTRITION-RELATED CONCERNS OF CAREGIVERS OF PERSONS WITH DEMENTIA

 

J.G. Anderson, K.M. Rose, A.G. Taylor

 

Virginia, Charlottesville, Virginia, USA

Corresponding Author: Joel G. Anderson, PhD, CHTP, Department of Acute and Specialty Care, University of Virginia School of Nursing, P.O. Box 800782, Charlottesville, VA 22908-0782, Telephone: (434) 243-9936, Fax: (434) 243-9938, Email: jga3s@virginia.edu

 

Abstract

Objective: Family caregivers are the mainstay of caregiving support to persons with dementia, and often care for a family member with dementia for a decade or more prior to institutionalization or death. Malnutrition, including weight loss, is common among older adults with dementia, occurs throughout the disease process, and is associated with institutionalization and death. Nutrition education for caregivers is an important aspect of addressing the care needs of adults with dementia; however, nutrition education research in community-based persons and families experiencing dementia is minimal to non-existent. The need for tailored education resources ranks as highly important among caregivers; however, the nutrition concerns of caregivers in the home have not been identified. The purpose of the current study was to gather descriptive data about the nutrition-related concerns of family caregivers of persons with dementia. Design: A qualitative descriptive design using semi-structured interviews of caregivers of persons with dementia (n = 4) was used to collect the data. Thematic and content analysis was used. Results: Family caregivers experienced nutrition-related concerns and described a need for nutrition education to support the caregiving role. Four themes emerged: (1) meal preparation and food choices; (2) lack of appetite and eating behaviors; (3) making sense of existing nutrition information; (4) searching for reliable nutrition information. A discussion of each theme, including exemplars, is presented, along with suggestions provided by participants regarding how to address existing nutrition education resource needs.Conclusions: Issues surrounding care often are complex and require accurate and tailored information. Findings from the current study provide rich, valuable data regarding the needs of family caregivers with respect to nutrition concerns, allowing for the development, design, testing, and delivery of nutrition education resources and strategies.

Key words: Dementia, caregiving, nutrition education, eating behaviors.

 

Introduction

Over the past 50 years, the understanding of the impact of nutrition and dietary patterns on health has become increasingly important (1), facilitating a growing interest in the relationships between aging, nutrition, and cognition among both the public and researchers (2). Weight loss and malnutrition are common issues among older adults with dementia (3-6), occurring throughout the disease process and associated with death, muscle loss, loss of independence, and institutionalization (5, 7). Additionally, insufficient caloric intake is associated with reduced cognitive function, sleep disturbances, and fatigue (8, 9). Impaired nutritional status is associated with the severity of dementia, particularly the behavioral and psychological symptoms expressed by persons with dementia (10).
Providing care for a family member with dementia is recognized as a chronically stressful situation that may have a negative impact on the mental and physical health of the caregiver (11). Being a caregiver is not only linked with high levels of burden, depression, and anxiety (12), but also has a potentially negative impact on the nutritional status of the caregiver (11). Nearly a quarter (21%) of family caregivers of persons with dementia are at risk for malnutrition (13), and those with depressive symptoms are more likely to present with a poor nutrition status. Additionally, the nutritional status of the family member with dementia is inversely associated with the level of burden experienced by the caregiver (14).
The specific nutrition concerns and issues of caregivers in the home in the United States have not been identified. Given this fact, whether or not existing nutrition education resources adequately and accurately address the nutrition concerns of caregivers also is unknown. Studies are needed that identify topics and themes for potential interventions specific to caregiver needs and types, that incorporate data collection at sites convenient to the caregivers, and that are oriented toward maintenance or improvement of dietary habits during the caregiving process to decrease the risk of chronic disease and reduce caregiver burden (15). Thus, the aim of the current study was to identify the nutrition-related concerns and topics important to informal caregivers of persons with dementia.

 

Methods

Study Sample

Participants were recruited using study flyers placed in aging care clinics, assisted living facilities, inpatient clinical areas, and Web advertisements. Eligibility criteria of potential participants included individuals who (a) self-identified as an unpaid, informal caregiver for a person with a physician-confirmed chronic, dementing illness per standard neurological criteria for dementia, (b) were 18 years of age or older, (c) were able to speak and understand English, and (d) were willing to engage in a 30-45 minute semi-structured interview. All aspects of the study were approved by the Institutional Review Board for Health Sciences Research.

Interview Procedure

Demographic information including age, marital/partner status, education, ethnicity and race, income, employment status, and number of months in the caregiving role of the caregivers was obtained. A semi-structured interview, lasting approximately 45 minutes, was conducted using an interview guide and prompts adapted from Keller et al. (5) (Table 1). Questions focused on nutrition and eating issues of both the care recipient and the caregiver. Interviews were conducted either in person or via telephone. Detailed notes were taken in addition to audio recordings; these recordings were transcribed in full for qualitative analysis.

Data Analysis

Transcripts from the interviews were analyzed separately and in aggregate to gain the unique perspective of each interview and the overall results. Data from the interviews were organized, analyzed, and interpreted using content analysis (16) and supplemented by a thematic analysis approach (17). Dedoose software was used for the data analysis, and codes were ascribed. The lead author (JGA) used the analysis steps delineated by Weber: review the narratives, define coding units, define categories, test coding, assess accuracy or reliability, and revise the coding rules and assess the accuracy (16). Codes were created based on the verbatim words used by the participants in the interview. Definitions for codes were described in a coding manual to help the research team remember the exact meanings of the existing codes whenever a new code was created. Memos included expression of thoughts in words, sentences, diagrams, and symbols. The maintenance of analytic memos throughout the data analysis process helped research team members to identify the categories and themes as these emerged from the analysis.
Transcripts were analyzed multiple times in different orders and also simultaneously after the initial analysis to ensure that no codes were missed. The research team met and compared the data analysis results, including the emerging codes and categories. Coding was initially completed by the lead author and categories developed. Other members of the research team were asked to review the narratives independently and review the categories. Research team members maintained memos to draft both thought processes and their own individual assumptions and biases. The codes were then organized into a broader classification of categories. The groups of codes that expressed the same ideas or phenomena were classified broadly into categories. Major themes evolved that subsumed all of the categories, the defining properties, and the interrelationships. The research team discussed findings and reached consensus surrounding the themes that emerged from the data.  

 

Results

The sample (N = 4) consisted of Caucasian caregivers ranging in age from 27 to 83 years. Two caregivers were the children of a person with dementia, one was a grandchild, and one was a spouse. The amount of time spent in the caregiving role ranged from 10 months to 10 years. Three caregivers lived with their care recipients while one provided care to a family member who resided in an assisted living facility. Family caregivers experienced nutrition-related concerns and described a need for nutrition education to support them in the caregiving role. Four overall themes emerged from the analysis: (1) meal preparation and food choices, (2) lack of appetite and eating behaviors, (3) making sense of existing nutrition information, and (4) searching for reliable nutrition information.

Meal preparation and food choices  

Caregivers expressed concerns and issues related to the preparation of meals in the home, as well as food selection and food choices in the home, outside the home and, in one instance, assisted living facilities, which were described as “not so much focused on fresh fruits and vegetables.” Participants related instances in which meal preparation and food choices led to experiences of stress and burden, as in the following exemplar:
“…there’s this big stress about, ‘Oh, what are we going to eat now.’ And then it’s like, ‘Oh, we have to go the store for it.’ It’s not like…any sort of planned meals ahead of time. It’s always like, «Okay, it’s 12:00. We have to eat something. Let’s go to fast food or something like that,» which…isn’t…great obviously.”
Additionally, because all of the caregivers were interested in providing their loved ones with nutritious food choices and options, this desire increased the stress and burden experienced by the caregivers. One participant stated:
“You’ve got to fix the meals for her…I don’t go out and buy food at a restaurant cause [sic] I don’t know what they’re putting in it and I want to give her the healthiest options I can. So when I’m taking the food, I have to go do the shopping and then the preparation and then I take it over and then eat with her. So it’s a much more involved process.”
Caregivers also experienced stress when trying to engage a care recipient who at one time was the primary meal preparer for the family. Learning to step in the role and be more actively involved in meal preparation was a source of angst. One participant related the following:
 “…one of the things that the women in my family prided themselves on was being good cooks. You know Southern cooking. It’s…nurturing. It’s…comforting. So at the early stages you know we still tried to say, ‘hey, why don’t you cook this?’ And we would be kind of glancing to make sure that everything…was okay. But…[she] can’t do that now.”

Lack of appetite and eating behaviors

Caregivers spoke of issues related to feeding challenges, the most common being a lack of appetite. For instance, one participant stated that her family member with dementia was “…willing to eat what I put in front of her but there’s…no active participation. She’s not seeking anything.” Participants described their care recipients as “distracted” at meal times. For example, one participant stated “I will prepare a meal that I think is nutritious but…[she] doesn’t have the ability to sit still that long.” Another noted “…we’ll sit there for 10 [or] 15 minutes and then she’ll want to get up.”
With regard to a perceived lack of appetite, caregivers were frustrated by not knowing whether or not their loved one with dementia was simply not hungry or was unaware of their need or desire to eat. One participant stated “…she doesn’t seem to be aware of whether or not she’s hungry and she also doesn’t take it upon herself to eat.” Another said “…if you ask her if she’s hungry, she’ll ask someone else if they’re hungry.” This situation was described as “complex,” with one participant stating “…I don’t think [she] forgets to eat. But she does have to be prompted to eat.”
These eating behaviors were a source of frustration for caregivers, who were unsure how to approach these issues to provide quality care for their loved one. One caregiver expressed their frustration saying, “…sometimes she says she’s not hungry and…I know she hasn’t eaten since the morning and it’s like 5:00 [in the evening] or something.” Caregivers were uncertain if they “should be sort of saying, ‘Have you had three meals each day?’” or allow their care recipients to regulate meal times on their own. The level of uncertainty, frustration, and lack of knowledge related to whether or not their loved ones were capable of recognizing hunger is expressed in the following exemplar:
“[What is]…the best way to sort of handle that, whether or not it’s okay to just say, ‘Well, you need to eat something,’ or to actually listen to her when she says she’s not hungry,”
Caregivers also expressed concerns about their own health when dealing with erratic meal times, lack of appetite, and problematic eating behaviors that they experienced while caring for a family member with dementia, as depicted in the following:
“And also there’s the appetite problem,…she doesn’t want to eat and so in order to get her to eat, you have to eat with her. So, that’s a problem for me because I don’t eat that much. And when I do eat that much I gain weight and she wants me to be there eating the meals in the facility with her. And there is…nothing that they serve that I want to eat. But I’ve got to eat what she’s eating…she even compares amounts. Like you’re not eating as much as I’m eating.”

Making sense of existing nutrition information

Caregivers were very much interested in accessing and making use of nutritional information. This desire was fuelled by the question expressed by each of them–“what should I really be doing?” However, the participants expressed difficulty not only in finding information, but also making sense of the information that they located, as in the following example:
“…I don’t really ever get great answers. I sort of get mired in…what’s going on or where’s the reputable resource or where’s…the current…information…It would be nice to know…that I could go to the Alzheimer’s Association Web site and see…the general idea or consensus on a topic.”
Additionally, caregivers were frustrated by a lack of synthesis regarding existing nutrition information and resources, as well as the response by health care professionals to their requests for more information, as expressed in the following:
“I think there is just such a body of knowledge that it’s hard, nobody’s been able to…really synthesize what’s going on out there and new stuff keeps hitting the airways and so everybody is trying to digest it. And the answer of the health care provider seems to be a pill. And that has never been a favorite of mine. If you don’t have anything else for me,…I don’t have a lot of confidence in you as a health care provider if all you have to offer me is a pill.”

Searching for reliable nutrition information

The desire to locate and use reliable nutrition information and resources was expressed by each of the caregivers. The impetus of this search was most often led by the participants’ own interests in nutrition and providing nutritious, healthy food choices and meals that would enhance the health of their loved ones, potentially slowing the progression of the disease. One caregiver stated,
“I want to feed her and have her eat as healthy a diet as possible…if there was a way that I felt was possible to manipulate the diet to slow the [mental] decline, I would be interested in that. Or even to make her…clearer thinking, regardless of what level she’s at. Those are the kinds of things I’m interested in.”
Frequently, caregivers spoke of searching for resources that were “backed up by people who are experts in the field who should actually be able to interpret the results correctly of research studies.” One caregiver stated, “I wish that there was something that I felt confident was…evidence-based.”
In their efforts to uncover the sought after nutrition information and resources, caregivers described challenges in finding the information for which they were looking. One stated, “…I don’t think I ever find like, ‘oh, this is exactly what I was looking for. And this is the answer.’ I think I spend a lot of time looking.” Another caregiver expressed the following:
“I tend to find it difficult to find reputable sources…when you’re just looking on the Internet, there’s no clear indication that this is a worthwhile resource or…whether this study was…disproved like a month later or something.”
The level of frustration can be best summed up by one caregiver who said, “…I haven’t found anything…because I’m looking for the answer and nobody has the answer.”

 

Table 1 Interview questions and prompts

 

Discussion

In the current study the researchers identified four themes related to the nutrition concerns and issues experienced by caregivers of persons with dementia: (1) meal preparation and food choices, (2) lack of appetite and eating behaviors, (3) making sense of existing nutrition information, and (4) searching for reliable nutrition information. To the authors’ knowledge, this is the first study to explore the nutrition-related concerns of the family caregivers of community dwelling adults with dementia conducted in the United States. The findings of the present study point to a need for tailored, evidence-based nutrition education resources for the family caregivers of persons with dementia.
As family members with dementia experience a continued loss of autonomy and cognitive decline, caregivers must deal with an increasing array of challenges, including those involved in managing the diet and food preparation of their loved one (18). Caregivers in the current study described modifications and concerns related to meal preparation and food choices. In previous studies, caregivers have listed changes in the food preferences, as well as the loss of autonomy in meal preparation and food choices, as the main dietary challenges involved in caring for a family member with dementia (19-23). As the disease progresses, this loss of autonomy, as well as difficulties related to feeding, may lead to a poorer nutrition status for the person with dementia (19).
Informal family caregivers often have limited knowledge about the behavioral and psychological symptoms expressed by persons with dementia and may have difficulty interpreting behaviors, especially during mealtime (24). For example, Alzheimer’s disease is typically associated with changes in episodic memory, including an inability on the part of the person with dementia to recall whether or not s/he has eaten. Caregivers in previous studies identified decreased food intake and a lack of appetite as dietary challenges experienced while caring for a family member with dementia (19-23). This decreased food intake concomitant with progression of the disease may result from poor appetite, as well as depressed mood (23). Over time, inadequate food can lead to malnutrition, weight loss, and increased risk of mortality (7).
Apathy is a behavioral and psychological symptom of dementia that has been shown to be particularly burdensome for caregivers (25). Apathy on the part of the person with dementia often leads to a lack of participation in activities of daily living, including mealtimes and eating, and may require more intensive stimulation and engagement from the family caregiver (14). Apathy could weaken emotional and social exchanges between the caregiver and care recipient during mealtimes, decreasing the psychosocial function of eating with others (26). This is important given than mealtime quality recognized as essential factor to improve nutritional status of persons with dementia (27).
Family caregivers have been shown to possess poor nutrition knowledge and to be able only to recognize signs of gross malnutrition in the care recipient (28). Participants taking part in a study examining a caregiver education intervention scored lower on pre-tests for modules related to nutrition (29). Thus, nutrition education of caregivers is a potentially important aspect of addressing the care needs of adults with dementia. However, nutrition education research in persons and families experiencing dementia in the community is scarce, with caregiver education most often focused on the disease process of AD and dementia or general issues associated with the care recipient (5). Thus, family caregivers have been neglected in nutrition research, policy, and practice (15). Caregivers may benefit from nutrition education by enhancing their ability to provide nutritionally adequate diets for their care recipients, as well as helping them maintain their own health and well-being (15). Nutrition-related chronic diseases associated with aging and that increase risk of AD, including CVD, diabetes, pulmonary disease, and cancer, occur in up to 86% of adults ≥70 years of age (15). This is significant given that more than 30% of caregivers for the elderly are, themselves, age 65 years or older (30).
Many caregivers have cited a critical need for information (31) and identified educational support to be of more importance than additional task-oriented assistance (32). The need for tailored education resources ranks as highly important among caregivers, particularly in rural communities (31-36). Caregivers in international studies have indicated the need for nutrition education information specifically. In a Japanese survey study, Hirakawa and colleagues (37) found that almost 50% of respondents were interested in specific and tailored food and nutrition information, finding that an overabundance of such information can be overwhelming and complicate the care process. In a Swedish study (6), spousal caregivers expressed concerns about how they struggled “to be a good food provider in everyday life” as a result of changing food preparation roles and coping with becoming a caregiver. The participants expressed concerns of gaps between available nutrition education resources and the quality of information presented (6).
The most common sources of information for family caregivers of individuals with AD and dementia include the Alzheimer’s Association, allied healthcare professionals, family members, friends, clergy, and support groups (35). A previous study by Keller and colleagues (5) evaluating printed nutrition education resources provided by dementia society chapters found the need for development of better resources. In a recent study, half of the caregivers in the sample expressed interest in engaging in a nutrition education program (23). These same caregivers provided potential motivators for encouraging caregivers to take part in nutrition education programs, including the ability to feed and care adequately for a loved one with dementia, to learn more about nutrition, and to provide motivation for caregivers themselves to improve their eating habits (23).
Limitations of this study relate to the small sample size, which limits generalizability. However, while there were only four participants in the current study, saturation was reached with regard to the primary research question. Moreover, theoretical saturation in similar studies was achieved generally within in six interviews (38).
Issues surrounding care often are complex and require accurate and tailored information. By collecting descriptive data about caregiver needs, assessing current nutrition education resources, and critically examining the current evidence base, themes, and knowledge gaps can be identified. This study took a holistic approach to evaluating the problem and the findings provide information for future studies aimed at designing, testing, and disseminating new nutrition education materials tailored specifically to caregiver needs that address existing gaps in education resources while providing the most currently available evidence-based knowledge and dietary recommendations.

 

Conflict of interest: The authors have no conflicts of interest..

Ethical standard: The study was approved by the university’s Institutional Review Board.

 

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NUTRITION EDUCATION AND COOKING CLASSES IMPROVE DIET QUALITY, NUTRIENT INTAKE, AND PSYCHOLOGICAL WELL-BEING OF HOME-DWELLING OLDER PEOPLE – A PILOT STUDY

S.K. Jyväkorpi1, K.H. Pitkälä1, H. Kautiainen2, T.M. Puranen1, M.L. Laakkonen1,2, M.H. Suominen1

 

1. Unit of General Practice, Helsinki University Central Hospital and Department of General Practice and Primary Health Care, University of Helsinki, Finland; 2. Department of Social Services and Health Care, the City of Helsinki, Finland

Corresponding Author: Satu Jyväkorpi, Unit of General Practice, Helsinki University Central Hospital and Department of General Practice and Primary Health Care, University of Helsinki, Finland, satu.jyvakorpi@gery.fi

 

Abstract

Objective: To determine the impact of nutritional education combined with cooking classes on older people’s nutrition and psychological well-being (PWB). Design: Intervention study using pre- and post-test comparisons. Setting: Non-governmental organization’s cooking school facilities in Helsinki, Finland. Participants: 54 home-dwelling healthy older adults. Main Outcome Measure: Three-day food diaries, Index of Diet Quality (IDQ), and Psychological Well-Being scale (PWB) completed before and after the course were used to measure changes in overall diet quality, nutrient intake and, PWB. Analysis: Nutrient intake, IDQ, and PWB score were statistically compared using pre- and posttest analyzes with t-test paired bootstrap test. Results: Mean age of the participants was 69 years, and 90% were females. At baseline, 28 % had a diet with poor nutritional quality and 7% were at risk of malnutrition according to Mini-Nutritional Assessment. Participants improved IDQ (p=.013), vitamin C (p=.019) and fiber (p=.027) intakes, and PWB (p=.02). Effect sizes varied from small to moderate. Conclusions: Nutrition education and guidance combined with cooking classes may improve older adults’ diet quality, nutrient intake, and PWB. New innovative practices are needed to train older people about nutrition and to socially activate them to prevent future nutritional problems.

 

Key words: Nutrition education, diet quality, older people, life-style, nutrition intervention.

 

Introduction

Aging is associated with an increased risk of poor diet quality and malnutrition (1-3). Decreased food intake in older people often leads to insufficient intake of energy, protein, and other nutrients, causing a deterioration in nutritional status. Poor diet quality, and malnutrition are associated with aging and diseases, and they increase morbidity and mortality (1, 2, 4-8)

Various studies of home-dwelling older individuals’ dietary intakes have revealed that nutritional recommendations are not being met (3, 9-11). Furthermore, diet quality has been poor, nutrient intakes have been very low, and dietary patterns have been characterized as poor (3, 11).

Good nutrition and exercise promote healthy aging. Nutrition and good diet quality are associated with better health, reduced risk of cognitive decline, and they postpone frailty and disability (4, 12-15).

Numerous nutritional interventions have been targeted to specific groups of older people. A nutrition educational program directed at caregivers of older individuals with Alzheimer’s disease (AD) had a positive effect on AD patients’ weights and their cognitive function (16). Educational interventions may improve fruit and vegetable intake and fiber intake among colon cancer survivors (17-18). There have also been some lifestyle interventions, including nutrition education targeted at healthy home-dwelling individuals that have shown improvements in fruit and vegetable intakes, fiber intake, and general nutritional patterns (19-21). Although these interventions have improved nutritional intake or nutritional patterns, no study has examined detailed intakes of micronutrients and the psychological well- being (PWB) of nutrition education on home-dwelling older individuals.

Older individuals are often very interested in their health and nutrition. Healthy older adults have the motivation and capacity to make necessary changes. The importance of preventing deterioration of nutrition in older individuals is why we targeted this intervention to the home-dwelling healthy older individuals. Our hypothesis was that self-efficacy and nutrition knowledge would improve dietary patterns. The aim of this pilot study was to examine whether nutrition education combined with cooking classes consisting of 3 sessions would have an impact on diet quality, nutrient intake, and PWB of healthy home-dwelling older individuals.

 

Methods

Home-dwelling older individuals participated in nutrition education and cooking classes consisting of three sessions. The classes were held in Helsinki, Finland, and were carried out as a part of a larger project organized by a Non-Governmental Organization (NGO). The project’s goal was to spread information about nutrition of the older people, organize lectures, events, and to publish a book about nutrition of the older people among other activities. Participants were recruited through nutrition lectures, partner NGOs, and the project’s internet site.

Inclusion criteria comprised participants filling the required forms before or at the beginning of the course, and being of 60 years or older during the course. Study participants received by mail a 3-day food diary with written instructions, a validated Index of Diet Quality (IDQ) questionnaire (22), and a background information questionnaire, which also included a validated PWB scale (23). All questionnaires and food diaries were checked at the beginning of the course by a nutritionist. The subjects were weighed, body mass index (BMI) calculated, and nutritional status assessed using Mini-Nutritional Assessment (MNA) (24).

The IDQ consists of 18 questions scored from 0 to 15 points, including questions on fruit and vegetable intake, fat quality, use of whole grains, use of fish, sugary beverages, sweets, and meal spacing. The statistically defined cut-off point is set at 10, values below indicating non-adherence and scores of 10–15 points good adherence to dietary recommendations. It has been especially designed for Finnish diet. The IDQ shows relatively high sensitivity and specificity in validation against 7-day food records and is suitable for assessing the health-promoting properties of a diet (22).

The nutrient intakes retrieved from three-day food diaries were analyzed using the Nutrica program (1999) developed for this purpose. The nutritionist checked all diaries and interviewed the participants face-to-face to ensure, for example, type of fat, milk and bread and amounts of food. The Nutrica program provides a detailed analysis of food diaries, including intakes of energy, protein, fiber, vitamins, and minerals.

The background information questionnaire included six validated questions on PWB (23). The questions inquire about (1) life satisfaction (yes/no), (2) feeling needed (yes/no), (3) having plans for the future (yes/no), (4) having zest for life (yes/no), (5) feeling depressed (seldom or never/sometimes/often or always), and (6) suffering from loneliness (seldom or never/sometimes/often or always). We used a well-being score developed and well-validated by Routasalo et al. (2009) (23), where each question represented 0 (‘no’ in questions 1–4, ‘often or always’ in question 5 or 6), 0.5 (‘sometimes’ in question 5 or 6), or 1 (‘yes’ in questions 1–4, ‘seldom or never’ in question 5 or 6). The score was created by dividing the total score by the number of questions the participant had answered. Thus, a score of 1 represented the best well-being and 0 the poorest.

Each nutrition education and cooking course hosted between 8-14 participants, and in total, six courses of three sessions each were held. A nutrition education and cooking class session lasted four hours. The meetings started with an interactive nutrition lecture that lasted one hour, given by a nutritionist. The themes of the lectures were healthy nutrition and nutrition recommendations of older people, nutrition and brain health, and osteoporosis and nutrition. The participants were able to ask questions and make comments during the lecture. After the lecture, the cooking class started. The cooking classes were organized by a partner of a non- governmental organization (NGO) called the Martha Organization. Their professional cooking instructor taught the cooking classes. The meals prepared and the ingredients used were culturally familiar to older Finnish people. In each session a complete menu with various dishes was prepared and each of the participants prepared a part of the menu. The menus included salads, fish, meat and vegetable dishes, casseroles, healthy snacks, protein rich smoothies, deserts made from berries or fruits and home-made bread etc. The meals were healthy, easy to prepare, and nutrient dense. The participants were provided the recipes to take home after the classes. During the course the subjects received personal oral feedback consisting a face-to-face session with trained nutritionist. In addition the participants received written feedback on their diet. Subjects were given practical advice on how to complement possible inadequacies of their diet and how to improve their diet quality. The main focus of the nutritional advice was to increase diet quality of the participants. Good diet quality was considered to comprise generous servings of vegetables and fruits (≥5 portion, daily), sufficient energy and protein intake of fish, poultry, milk products, beans, nuts, or egg, good quality of fats, emphasizing the use of vegetable oils, good-quality spreads, nuts, seeds and fatty fish, whole grains, and low-fat milk products (14-15, 25). The dietary counselling was tailored according to each participants’ individual needs. For example, if participants consumed insufficiently fruits, and vegetables, they were encouraged to increase their consumption, or if fat quality in their diets was poor, they were encouraged to eat more nuts and seed, use vegetable oils, and good quality spreads instead of saturated fats. Whole grain product consumption was favored instead of processed carbohydrate use, and sufficient protein consumption encouraged. The participants were also advised to use 20 µg of vitamin D supplements daily (26). Some of the subjects used calcium supplements excessively, exceeding the upper limit (UL) for calcium. They were advised to reduce the use of calcium supplements when necessary. All subjects were given written information about healthy nutrition.

 

Table 1: Baseline Characteristics of the Participants in Nutrition Education and Cooking Classes.

 

At the end of the course, the participants were asked to anonymously give a semi-structured feedback on the course. They responded to a questionnaire that contained items using a scale as well as open-ended questions.

After a four-months follow-up, the subject received by mail a 3-day food diary, the IDQ (22), and the PWB scale (23).

 

Statistical analysis

The results were expressed as means with SD and 95% confidence intervals (CI). Statistical comparison of changes in outcome measurements was performed by using bootstrap type t-test. The effect size was used to measure the strength of dietary change. Effect size (“d”) was calculated by using the method of Cohen for paired samples (mean baseline scores minus mean follow-up, divided by the pooled standard deviation). Effect size of 0.20 was considered small, 0.50 medium, and 0.80 large. CIs for effect sizes were obtained by bias-corrected bootstrapping find trustworthy and reliable sites. (5000 replications). Correlations among the variables were tested (adjusted with BMI and age). No adjustment was made for multiple testing. We used STATA (release 13.1, College Station, TX) for statistical analyses.

All participants signed an informed consent. The study protocol was approved by the Ethics Committee of the University of Helsinki.

 

Results

Of the participants (n=54), 90% were female. Mean age and BMI were 69 years and 27.4 kg/m2, respectively. In total, 2 persons (3.6%) did not return the questionnaires after the follow-up time. Of the participants, 7 % were at risk of malnutrition, others had good nutritional status measured by the MNA (24). At baseline, 28 % of participants’ diets were of poor nutritional quality, as measured by IDQ (22). The baseline characteristics are shown in Table 1. Lower than recommended intakes of folate (n=32, 60%), iron (n= 26, 48%), vitamin E (n=12, 22 %), vitamin C (n=11, 21%) and fiber (n =37, 69%) were observed.

At baseline the IDQ was 10.6 points and at the end 11.1 points (estimated power of detected change was 0.75). After the four-month follow-up,the IDQ (p= .013) and vitamin C (p= .019), and fiber intake (p= .027) improved (Table 2). Intakes of other nutrients did not change significantly. PWB score also improved (p= .02). The effect size changes measured were small and were highest in vitamin C, fiber, and folate intakes. The effect sizes of change in IDQ and specific nutrients are shown in Figure 1.

Figure 1: Effect size of change in Index of Diet Quality (IDQ), energy and specific nutrients.

 

The proportion of participants using vitamin D supplements increased from 67 % at baseline to 80 % at the end of the study. Many of the subjects used calcium supplements excessively, the use of calcium supplements dropped from 51 % at the baseline to 42 % after the follow-up period.

According to the anonymous feedback of participants, 98.2 % of the participants gave the course an overall rating of very good (60.3%) or good (37.9%). Moreover,98.3 % rated the nutrition education part of the course as very good (62.1%) or good (36.2%) and thought they learned new things. Overall, 94 % were satisfied with the personal feedback that the nutritionist gave them of their diet and diet quality. All of the participants said they would recommend the course to their friends and acquaintances.

 

Discussion

Our pilot study showed that healthy older participants may improve their diet quality as well as vitamin C and fiber intakes. The intervention had a favourable effect on participants’ psychological well-being as a consequence of nutrition education, and cooking classes. Our results suggest that interventions tailored to everyday life, including food preparation and social activation may be effective in improving nutrition and psychological well- being in older people.

Our pilot study has several limitations. First, the lack of a control group does not allow us to rule out the Hawthorne effect. Second, it is impossible to interpret which part of intervention has effects on participants’ nutrition: learning about healthy diet, improving cooking skills or socializing with each other. However, our study suggests that as such this package of nutrition education and cooking classes with social stimulation may have favourable effects on older people’s diet quality. Third, our attempt to collect exact data on propecia doesn’t work food consumption is limited because the 3-day food diaries may be affected by under- or over-reporting of the foods consumed. However, we performed check-ups to improve the accuracy of the food diaries. For example, we attempted to clarify the type of fats, breads, milk- and meat products, and amounts of food eaten with the participants during the course, and later via phone interviews after the follow-up period. Due to lack of resources, we were only able to follow the participants for four months, although a longer follow-up would have allowed us to ascertain, whether the improved food habits would be retained. The power of our study is also fairly low. Therefore, we used effect sizes with confidence intervals to illustrate the size of the effect..

The effect of our intervention may be diluted by the ceiling effect. The fact, that our participants were healthy volunteers who already had a relatively good diet quality, nutrient intakes, and psychological well-being, and were still able to improve all of these, is encouraging. The effect sizes of the change were at best close to medium, due to the fact that the situation at the baseline was already quite good. The range of effect size changes seen here has also been observed in other intervention studies (20, 27).

Preventing the deterioration of nutritional status in older individuals is important. Previous interventions have been directed at specific groups, including older people with Alzheimer’ patients’ spouses (16) and cancer survivors (17). These interventions have been effective in improving participants’ nutrition. Nutritional and lifestyle change studies have also been successful in addressing some nutritional issues in healthy older individuals (19-21, 28). Most of these interventions have been performed by means of minimal intervention, e.g. through phone-calls, newsletters, or manuals. Also, dietary counselling of home-dwelling older people was successful in improving nutritional status and albumin values (29). We had a more hands-on approach; we combined practical cooking skills and nutrition education to socially activate older adults. This approach takes advantage of participants’ peer support and enhances their self-efficacy (23). In New Zealand, senior citizens have been offered nutrition and cooking classes free of charge in order to prevent future health problems and social isolation (30). No studies of the effectiveness of these courses have, however, been reported.

Nutrition education combined with cooking classes was a rewarding experience for the instructors as well as for the participants. Cooking and eating together created an enjoyable environment, where the participants willingly adhered. The enthusiastic atmosphere between instructors and participants led to a lively interaction, where participants felt free to ask questions, make comments, and share experiences with one another. The courses created a positive learning and social environment. Many participants commented that they would have wanted to attend more classes at the end of the course.

Policy interventions or merely spreading information have only weak effect on improving diets (31). Thus, we need a stronger focus on adult learning methods having effects on behavioural change (32-33). Nutrition education combined with cooking classes in a relaxed atmosphere with peer support is anticipated to benefit especially older widowers, male spousal care-givers and other specific groups of older people with limited nutrition knowledge and cooking skills (9, 34-35).

Nutrition education, cooking, and eating together may also increase self-efficacy and prevent social isolation in older people. Our study suggests that PWB improved among the participants. This may be due to socializing but diet may also have effect on depression (36). As the older segment of the population in Western countries is growing, new and innovative practices are needed to cost-effectively improve and maintain older individuals’ good nutrition and prevent the deterioration of nutritional status (37). More research on this approach is warranted. Our findings need to be supported in randomized controlled trials.

 

Acknowledgments: This project was funded by Finland’s Slot Machine Association and Finnish Medical Foundation. The authors thank the Society for Memory Disorders Expertise in Finland for hosting the project and the Martha Organization for their dedication in teaching the cooking classes and providing the recipes for the courses. The sponsors did not have any role in the study design, analysis or interpretation of data, nor in writing the report or the decision to submit this article. The authors were independent researchers not associated with the funders.

Conflicts of interest: The authors declare no conflict of interests.

Ethical standards: All participants signed an informed consent. The study protocol was approved by the Ethics Committee of the University of Helsinki.

 

 

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