5 BARRIERS TO OLDER PEOPLE MEETING THEIR NUTRITIONAL REQUIREMENTS
This chapter discusses the barriers older people living in the community in Scotland have in meeting their nutritional requirements and includes issues around:
- Their social situation
- Money worries
- Geographical differences across Scotland
- Physical and mental health factors including grief and depression
- The impact of medication
- Food safety issues
5.1 Reviews by Schenker (2003) and Denny (2008) identified a number of factors which affect the ability of older people, living in the community in the UK, meeting their nutritional requirements. These factors are summarised in table 5.1. These along with problems specific to the Scottish population (in particular geographical differences) are discussed below.
Table 5.1: Summary of factors influencing dietary intake
Poverty and economic uncertainty
Poverty can affect food choice and dietary diversity.
Foods that are integral to a healthy diet (e.g. fruit, vegetables and fish) may be perceived as a luxury.
Healthier alternatives to everyday foods can carry a price premium (e.g. wholemeal bread, spreads low in saturates).
Food preparation facilities and skills may be limited in poorer households.
Immobility may lead to difficulties with shopping, preparing, cooking and eating foods.
Mental health and well - being
Depression can lead to loss of interest in food.
Dementia can impact on appetite and food intake.
Social isolation or emotional trauma can result in disinterest in food.
Social interaction may encourage eating.
Other health problems
Illness and medications can result in reduced appetite and difficulties with shopping, preparing and eating food.
Malabsorption conditions (i.e. gastritis & pernicious anaemia) reduce ability to absorb B 12 from food.
Problems with incontinence may stop individuals eating and drinking normally.
Some medication can contribute to constipation.
(Denny, 2008; Schenker, 2003)
Socio-economic factors (social and financial issues)
5.2 Currently 25% of the population in Scotland are living in poverty and although the level of older people living in poverty has fallen in the past decade, 16% of pensioners continue to live in poverty (Palmer et al., 2008).
5.3 The Low Income Diet and Nutrition Survey ( LIDNS) (Nelson et al., 2007) collected data on dietary habits and nutritional status of the low income population and includes data from older people with 33% of the sample population aged >50 years. The survey found that in poorer households:
- the average consumption of fruit and vegetables was half of the recommended five portions per day.
- saturated fat intake was above the (maximum) UK recommendations.
- intakes of non-starch polysaccharides (fibre) fell below the (minimum) UK recommendations.
- there was evidence of inadequate nutritional status for iron, folate and vitamin D.
5.4 Further analysis of the LIDNS data found that older men and in particular those who live alone may be at even more risk of an inadequate diet (Holmes et al., 2008).
5.5 All these findings are of critical importance as most of the nutrients highlighted are of concern for older adults and have specific recommendations set for them (see Chapter 3).
5.6 The Scottish Health Survey (Scottish Executive 2003) found significant differences in dietary intake between socio-economic groups. Those in lower income homes ate less fruit and vegetables, were more likely to have non-diet drinks, have savoury snacks daily and ate more chips and processed meats more frequently than those in higher income households. These poor dietary habits are related to an increased prevalence of overweight and obese people, increase in cardiovascular disease, hypertension and some forms of cancer and these risks continue into later life.
5.7 The Welsh Consumer Council (2006) have identified key characteristics of food poverty (summarised in table 5.2) with food poverty being defined as: 'the inability to obtain healthy affordable food' ( http://www.sustainweb.org/page.php?id=187, accessed 24.11.2008). In addition they also identified potential solutions including assisted shopping schemes and door-to-door shopping services.
Table 5.2: The three main characteristics of food poverty
Influence of food intake
Low/limited incomes may restrict ability to afford healthy food.
Proximity and ease of travelling to supermarkets.
Smaller retailers offer a limited range of healthy foods.
Poor and high cost of transport.
Lack of home delivery services.
Particularly older men, may lack the skills/or equipment to prepare healthy meals.
Welsh Consumer Council (2006)
5.8 In the past 20 years there has been a decentralisation of supermarkets to sites out of town centres. This has resulted in many older people experiencing difficulty in accessing food retailers (Wilson et al., 2004). These stores generally require people to have access to a car and in low income groups this is not always available. Although there are still small numbers of local convenience stores available they are generally more expensive and have a poorer variety of fresh produce compared to larger supermarkets.
5.9 In Scotland there is a high degree of variation in access to retail food provision but all inhabited areas do have access to a food store. Those areas with larger food stores have access to a wider range of healthy foods at more affordable prices (Dawson, 2008).
5.10 Current trends show that as people age, they make less use of private cars and increased use of public transport (Scottish Executive 2007). Access to reliable and convenient public transport is therefore essential to provide older people access to among other things goods, services, and amenities and this enables them the ability to maintain their independence.
5.11 As most of the major food retailers now offer an on-line shopping service access to food has become easier in recent years for some. However, the convenience of on-line shopping may not be available to older people and particularly those in low income households. As there is generally a delivery charge for this service, the cost of the food bill is increased and more fundamentally the shopper requires access to a computer. The Scottish Household Survey found that, in 2007/8, 33% of the Scottish population did not use the internet at all (Scottish Government 2009c). Of the 60-74 age group 55% of men and 66% of women do not use the internet at all and this increased further to 83% men and 93% women aged 75 and over (Scottish Government 2009c).
5.12 The Scottish Government have acknowledged the need to support older people to improve access to, and use of, information technology. Information technology can impact positively and the Digital Inclusion Strategy is designed to help make Scotland a digitally inclusive society. It has been shown that when older people are educated to increase skills of internet use, online shopping is an area which is popular (Ward et al., 2008).
Geographical differences across Scotland
5.13 There are diverse population densities across Scotland but the difference in dietary intake between people living in urban and rural areas in Scotland is poorly defined. Those people living in rural Scotland have access to a smaller variety of foods, in particular fresh produce, have inconsistent food deliveries and the food which is available generally costs more (Skerratt, 1999). Whether this translates into a poorer nutritional status is not known.
5.14 Rural Scotland also has a higher percentage of 'older smaller' households, that is, with one or both adults of pensionable age (Scottish Government 2009d). This may be cause for concern for older people in rural areas for the reasons discussed in section 5.13.
5.15 In addition Levin & Leyland (2005) reported greater health inequalities in remote rural Scotland than urban areas for both males and females. How much of this can be attributed to differences in diet is unknown. As there is a paucity of data regarding differences in food intakes between rural and urban areas further research is required in this area.
Social and physical factors
5.16 The social and physical factors which affect food choice and eating patterns and thus nutritional status include: budgeting skills, cultural and religious beliefs, education, nutritional knowledge, cooking facilities, food preferences, time, previous food experiences, social isolation, depression and bereavement (Schenker, 2003). These are relevant to older people and have to be considered when devising interventions to improve nutritional status.
5.17 The presence of chronic illness and disability increases significantly with age and the Scottish Health Survey reports that two-thirds of people aged 75 and over have a longstanding illness (Scottish Executive 2003). For many this will result in a reduced ability to complete normal activities of daily living, and this is a particular problem for those living alone or with an ill or disabled partner. Specific individual needs should be taken into account and addressed with appropriate interventions, as provision of food and nutrients alone may not be adequate if a person has a limited ability to shop, prepare, cook or even chew the food provided.
5.18 The "Recipe for Life" project (Jones et al., 2005), a project which aimed to find better ways to support older people in Scotland to eat well, found a number of social and psychological factors which had an impact on dietary intake. These are shown in table 5.3.
Table 5.3 Social and psychological factors which impact on dietary intake
Social and psychological factors impact on dietary intake
- eating with others
- cooking for others
- having a good quality meal cooked by someone else
- eating food that looks appetising
- smelling food as it is being cooked
- getting out of the house
- being active
- having exposure to foods and food ideas
- having a varied and suitable diet
- being supported to be spontaneous with food
- support to address losses, low mood or depression
(Jones et al., 2005)
5.19 This project also found that services may often be poorly set up to address the social and psychological factors contributing to an older person's ability to eat well. If these factors are not considered they can provide significant barriers to older people's ability to eat well. In addition to this, the report highlighted a need for further work to be undertaken to explore how services and communities can address these factors more systematically. Prioritising the physical needs of older people over their social and psychological needs may lead to inappropriate targeting of resources with little positive benefit (Jones et al., 2005).
Mental health problems
5.20 Mental health problems are not an inevitable part of ageing but are common in the older population. They include depression, anxiety, dementia, schizophrenia, bipolar disorder and alcohol and substance abuse. The impact of depression and dementia on nutritional status is discussed below.
5.21 Depression is the most common mental health problem seen in Britain and it affects up to one in seven people over the age of 65. The causes in older people are often multi-factorial and may be as a result of biological, psychological or social factors including chronic diseases, functional disability, personality traits, inadequate coping strategies and stressful life events such as bereavement (Vink et al., 2008).
5.22 There are a number of symptoms associated with depression and these may be physical, psychological and/or social. These symptoms include apathy, anorexia, inability to make decisions and refusal of food and fluid ( NHS Choices, 2009). As a result depression may significantly impact on activities of daily living and thus dietary intake which can then result in deterioration of nutritional status.
5.23 A number of nutrients have been linked with depression including vitamin B 12 and folate. Low levels of these, in combination with low homocysteine (an amino acid found in the blood) levels have been associated with depression in older people. In addition, poor nutritional status has been cited as a cause of depression (Rogers, 2001) but there is limited evidence to support this.
5.24 Cognition is the process of thought and understanding. Cognitive decline increases with age, is almost universal, and can be expected in the majority of the oldest old (Park et al., 2003). It ranges from mild cognitive decline to dementia. Clearly as cognitive decline progresses there will be a resultant impact on a person's ability to fully participate in activities of daily living. Cognitive impairment is a major cause of disability in old age and thus has the potential to have a significant detrimental effect on nutritional status.
5.25 A number of nutritional deficiencies have been associated with cognitive impairment, in particular B vitamins and antioxidants, but the studies cannot determine whether a nutritional deficit is the cause or the consequence of impaired cognition (Del Parigi et al., 2006).
5.26 Dementia is a collective term for a number of pathologies which affect the brain and is more common in older people than younger people. It is estimated that currently there are between 59,000 and 66,000 people in Scotland with dementia and this figure is expected to rise by 75% to between 102,000 and 114,000 by 2031
(Alzheimer Scotland http://www.alzscot.org/pages/statistics.htm accessed 28.11.08).
5.27 Although clinically the types of dementia vary considerably many of the effects which impact on dietary intake and nutritional status are the same. Early stages of dementia impact on nutritional intake through difficulty in shopping and storing food, forgetting to eat and changes in food preferences. As dementia progresses the consequences for dietary intake may include food being hoarded in the mouth but not swallowed, increased activity levels and mealtimes being interrupted due to poor concentration levels. In very advanced stages problems may include food not being recognised, refusal to eat, inability to ask for food or drinks and an inability to swallow food and drinks safely due to a deterioration in the swallowing reflex.
5.28 All types of dementia therefore impact on dietary intake and weight loss and undernutrition are common. The cause of undernutrition is as a result of inadequate intake rather than the disease itself so it may be possible to correct this by providing adequate nutrition.
Other health problems
Impact of medications
5.29.1 Over the counter and prescribed medications have the potential to cause side effects which can impact on dietary intake. These side effects include altered sense of smell and taste (Brownie, 2006) fatigue, constipation, diarrhoea and anorexia. In addition a number of medications also interact with food (known as drug-nutrient interactions) and result in a reduction in absorption of nutrients. Both these problems have the potential to adversely effect nutritional status (Santos & Boullata, 2005). These problems are exacerbated in the presence of malnutrition or in people who have gastrointestinal tract dysfunction (Genser, 2008).
5.29.2 As older adults generally take more medications than younger adults the impact of medications on dietary intake and nutritional status could be significant.
5.30.1 Poor food hygiene practice can impact on dietary intake and nutritional status. Food poisoning often results in severe diarrhoea and vomiting which impacts on dietary intake and results in depletion of nutritional status. In extreme cases food poisoning can be fatal. It is therefore important to consider food hygiene in the over 65 year age group as this group of the population are consider to be one of the at risk groups for developing food poisoning.
5.30.2 A significant proportion of the population aged 65+ are prepared to eat food which is past its use by date ( FSA 2009b) increasing the likelihood of developing food poisoning. Part of the problem lies in the fact that only 25% of older people aged 65 -74 and 17% of people aged 75 years and over said that food hygiene was important to them when deciding what to buy to eat at home. This is of concern as the number of cases of Listeria poisoning (the number one food poisoning killer) has increased dramatically in the over 65 age group over recent years. Ensuring good food hygiene practice will contribute towards maintaining health and nutritional status in the over 65's.
- A number of factors impact on older people meeting their nutritional requirements which include financial, physical, social and psychological influences.
- 16% of pensioners live in poverty in Scotland. People with low incomes have a poorer diet than more affluent people.
- Changes to the location of food stores results in a need for access to private or public transport and thus can result in more limited shopping opportunities for older people.
- There is a high degree of variation in access to retail food provision in Scotland. Areas with larger food stores have access to a wider range of healthy foods at more affordable prices.
- There are limited data available on the differences in dietary intake and nutritional status between the older urban and rural community populations in Scotland.
- Those people living in rural areas have access to a smaller variety of foods and have inconsistent food deliveries which may result in poorer dietary intakes.
- Chronic illness and disability impacts on a person's ability to source and eat foods.
- The social and psychological needs of older people should be considered alongside their physical needs to optimise nutritional intake.
- There is limited evidence to support the link between diet and mental status.
- Poorer mental health impacts on a persons ability to meet their nutritional requirements.
- As older adults take more medications than younger adults there is the potential for this polypharmacy to exacerbate a poor nutritional status.
- As the over 65 year age group are considered to be one of the at risk groups for developing food poisoning it is important to ensure good food hygiene is practised.