Corporalidad

2.4.4.1 Living Arrangements

Social factors play an important role in promoting optimal nutrition status. Food contributes to enhanced quality-of-life and well-being, and meals may give a sense of security, meaning, independence and structure to an older person’s day (Amarantos et al., 2001). Eating is a social activity and the opportunity to share meal preparation and dining increases food intake; older adults have been found to consume 23 percent more food when dining with others (American Dietetic Association, 2005). Four other factors that may increase food consumption in the presence of others include meal times being extended

37 when others are around, the guest eating more and this being subconsciously mimicked, an expression of gratitude for a meal if the deliverer eats with them, or by being provided encouragement to eat (Locher, 2005). Those who live alone may therefore be more likely to have inadequate dietary intakes, and consequently a compromised nutrition status. A study of 250 older adults in Australia found that people who lived alone were 1.5 times more likely to be ‘not well nourished,’ than those who lived with others (Visvanathan et al., 2003). Another study among 201 hospitalised older adults in the United Kingdom found that on admission to hospital, patients who lived alone had poorer nutrition status than those who lived with others (Gariballa et al., 1998).

The 1996 New Zealand Census found around 30 percent of adults aged 65 to 75 years lived alone, with the proportion twice as high for adults aged over 85 years (Statistics New Zealand, 2000). Therefore the association between living alone and poor nutrition is likely to significantly affect older adults in New Zealand. Gender differences were seen among the living arrangements of older New Zealand adults in 2001; of adults aged 65 to 74 years, 80 percent of men and 59 percent of women were living with partners. By their late 80’s around half of men and almost 90 percent of women were not partnered, largely attributable to women experiencing greater life expectancy than their male counterparts (Statistics New Zealand, 2004). This was similar to a British study (n=369) where the odds of women living alone was twice that of men (Donkin et al., 1998). The rates of poor nutrition status may therefore be higher among women.

A prevalence study of 152 community-living older adults in Christchurch, New Zealand found that 72 percent in the ‘at high nutrition risk’ group ate alone, compared to only 33 percent of those in the ‘not at nutrition risk’ group (Watson, 2010). Similarly, in another New Zealand study (n=112), 60 percent of adults who were at significant nutrition risk lived alone, compared to 29 percent of adults with normal nutrition status (Wham, 2011). This was supported by a third New Zealand study (n=473) that found older people who lived alone were 3.5 times more likely to be at nutrition risk, than those who lived with others (McElnay et al., 2012). Living alone is therefore a significant risk factor for poor nutrition status among older adults in New Zealand.

38 Eating alone may lead to poor nutrition status due to lower food intake, as older adults who eat in the presence of others have been found to have significantly larger meal sizes (de Castro & de Castro, 1989). Not only has living alone been associated with lower food intake, but also poorer dietary variety. Bernstein et al. (2002) suggested that a diet of little variety is associated with worse nutrition status, and that increased food intake with meal sharing is positively correlated with nutrition quality. Living alone may negatively affect nutrition status of older adults through decreased enjoyment and motivation, forgetting to eat, inability to buy or prepare food. (Johansson, 2009; McCormack, 1997; Teo, 2001; Walker, 1991). Living alone may also lead to feelings of loneliness and depression which can decrease willingness or desire to eat. This was found in a study in the United States (n=837) where the Geriatric Depression Scale score was significantly higher in malnourished participants compared to those at risk of malnutrition (Thomas et al., 2002; Visvanathan et al., 2003).

Living arrangements are generally influenced by partnership status, and being married has been associated with better health (House, 1988). Older adults who are married may have a better nutrition status as they are less likely to skip meals and may be better able to afford food (Locher et al., 2005). Conversely, older adults who are widowed have been found to be at increased risk of weight loss, likely due to decreased appetite and enjoyment of food (Shahar, 2001). Men who are widowed may be less confident with shopping or cooking for themselves, if they have rarely completed these tasks previously. A study of 2195 older adults in Australia showed that men living alone, when compared to married men, were less like to eat fruit and vegetables and more likely to have a restricted diet, made up of high fat and high salt convenience foods (Horwath, 1989). Although women are more likely than men to consume fruit and vegetables, the issue for women who lose their spouse may be higher levels of food insecurity and difficulty accessing food (Baker & Wardle, 2003; Locher et al., 2005). A lack of social support, living alone or being divorced or widowed are therefore important risk factors for poor nutrition status in older adults.

2.4.4.2 Education and Income

39 socioeconomic status and better health and diet quality (Elia & Stratton, 2005; Lantz et al., 1998; McKay, Houser, Blumberg, & Goldberg, 2006; Muennig, Sohler, & Mahato, 2007; Shahar, 2005). A lower level of education has been associated with poorer health and nutrition status (National Health Committee, 1998). This may be through its relationship with subsequent occupation and income, or that adults who are better educated are better informed about the nutritional quality of their diet and how this effects their health (Callen & Wells, 2003). Furthermore, nutrient intake and thus, nutrition status, is affected by food skills. A lack of education around practical cooking skills may also limit food choices and the ability to improve dietary behaviours. Older adults with better cooking skills are not only able to prepare meals, but may also have a greater knowledge about ready-prepared meal options (Caraher, Dixon, Lang, & CarrǦ Hill, 1999). Furthermore, it has been suggested that more highly educated people may have greater access to health resources within the community that may assist in improving nutrition status (Locher et al., 2005).

Income is the most important modifiable determinant of health; a lower income may be associated with poorer nutrition status. The NZANS08/09 revealed that over 92 percent of people aged over 71 years could always afford to eat properly (University of Otago and Ministry of Health, 2011). This suggests good food security among older adults in New Zealand. However, those with a lower socioeconomic status may be more vulnerable if they are unable to afford transport to purchase food, unable to purchase enough or nutrient-dense food, or forced to choose foods they would rather not eat because they are cheaper (Locher et al., 2005). Older adults with less income may therefore have smaller meals or skip meals, and consequently have significantly lower energy and micronutrient intakes (Guthrie & Lin, 2002; Smithers, 1998). This was found in data from the NHANES 1999 to 2002 which analysed the association between income, food choice and nutrition status; intakes of macronutrients and many micronutrients increased from low- to medium- to high-income groups (Bowman., 2007). Additionally, those in the low-income group generally consumed less fruit, vegetables, milk, meat, poultry and fish than the high- income group. Therefore older adults with a higher socioeconomic status may consume a greater variety of highly nutritious foods, making socioeconomic

40 status an important indicator of nutrition status.