Research in Gerontological Nursing

Theory 

The Theory of Compromised Eating Behavior

Ellen Furman, PhD, RN, GCNS-BC

Abstract

The purpose of this inquiry was to develop substantive theory that describes the social process that influences the eating behavior of hospitalized older adults. Undernutrition contributes to negative health outcomes, such as increased morbidity and mortality in hospitalized older adults. Despite the availability of vast nutritional resources within the hospital environment, hospitalized older adults often have inadequate dietary intake. A grounded theory methodology was used to explore this phenomenon. The Theory of Compromised Eating Behavior describes the process of compromise that older adults experience related to eating behavior while hospitalized. The theory has four stages: self-indication, joint action, negotiation, and action. The meaning of hospital food and mealtimes differs from at-home food and mealtimes for the older adult, resulting in compromise. Intervention, which enhances the meaning of food and mealtimes for the older adult during hospitalization, may improve dietary intake and nutritional outcomes.

[Res Gerontol Nurs. 2014; 7(2):78–86.]

Dr. Furman is Associate Director of Graduate Nursing, and Assistant Professor of Nursing, American International College, Springfield, Massachusetts.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Ellen Furman, PhD, RN, GCNS-BC, Assistant Professor of Nursing, American International College, 1000 State Street, Springfield, MA 01109; e-mail: ellen.furman@aic.edu.

Received: March 11, 2013
Accepted: September 18, 2013
Posted Online: October 04, 2013

Abstract

The purpose of this inquiry was to develop substantive theory that describes the social process that influences the eating behavior of hospitalized older adults. Undernutrition contributes to negative health outcomes, such as increased morbidity and mortality in hospitalized older adults. Despite the availability of vast nutritional resources within the hospital environment, hospitalized older adults often have inadequate dietary intake. A grounded theory methodology was used to explore this phenomenon. The Theory of Compromised Eating Behavior describes the process of compromise that older adults experience related to eating behavior while hospitalized. The theory has four stages: self-indication, joint action, negotiation, and action. The meaning of hospital food and mealtimes differs from at-home food and mealtimes for the older adult, resulting in compromise. Intervention, which enhances the meaning of food and mealtimes for the older adult during hospitalization, may improve dietary intake and nutritional outcomes.

[Res Gerontol Nurs. 2014; 7(2):78–86.]

Dr. Furman is Associate Director of Graduate Nursing, and Assistant Professor of Nursing, American International College, Springfield, Massachusetts.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Ellen Furman, PhD, RN, GCNS-BC, Assistant Professor of Nursing, American International College, 1000 State Street, Springfield, MA 01109; e-mail: ellen.furman@aic.edu.

Received: March 11, 2013
Accepted: September 18, 2013
Posted Online: October 04, 2013

Eating or lack thereof can be a determinant between wellness and poor health. Lack of eating contributes to inadequate dietary intake, which is a risk factor for undernutrition. Undernutrition contributes to negative health outcomes such as increased morbidity (Mudge, Ross, Young, Isenring, & Banks, 2011) and mortality (Gariballa & Forster, 2006) in older adults. An environment in which undernutrition is especially problematic is acute care hospitals, where the prevalence of undernutrition in older adults is reported to be 36% to 45% with an additional 41% to 50% at risk for undernutrition (Kaiser et al., 2010).

Despite the availability of vast resources within the hospital environment, hospitalized older adults are at risk for inadequate dietary intake (Heersink, Brown, Dimaria-Ghalili, & Locher, 2010). Adequate dietary intake is especially important for older adults within the hospital environment since acute illness necessitates adequate, if not extraordinary, nutrition. Eating behavior defined as, “the thoughts, actions, and intents that an organism enacts in order to ingest solids or liquids” (Elsner, 2002, p. 18) influences dietary intake. Further inquiry of hospitalized older adults’ eating behavior is warranted and will provide theoretical insight as to why dietary intake remains inadequate. Thus, the aim of this study was to develop substantive theory that describes the social process that influences the eating behavior of hospitalized older adults.

Background

The Quality Health Outcomes Model (QHOM, Mitchell, Ferketich, & Jennings, 1998) provided a guide to organize what is known about undernutrition in hospitalized older adults. The QHOM was developed as a framework to guide outcomes research and suggests that multiple factors, such as patient characteristics, interventions, system characteristics, and the relationships between these concepts, all affect patient outcomes. The outcome considered in this review was undernutrition.

Known patient characteristics that contribute to undernutrition in hospitalized older adults include admission nutritional status (Heersink et al., 2010), age (Kagansky et al., 2005), appetite and morbidity (Mudge et al., 2011), gender (Chen, Bai, Huang, & Tang, 2007), mood (German et al., 2008), medication use, and functional status (Chen et al., 2007). Nutritional interventions include the use of nutritional supplements (Gariballa, Forster, Walters, & Powers, 2006), feeding assistance (Tsang, 2008), and use of congregate dining areas (Wright, Hickson, & Frost, 2006). System characteristics that affect nutritional status include nutritional assessment (Volkert, Saeglitz, Gueldenzoph, Seiber, & Stehl, 2010), surveillance of dietary intake by health care providers (Xia & McCutcheon, 2006), and health care provider nutritional knowledge, attitudes, and behaviors (Ross, Mudge, Young, & Banks, 2011). Negative health outcomes related to undernutrition include short- and long-term mortality (Kagansky et al., 2005; Stratton, King, Stroud, Jackson, & Elia, 2006), functional dependence (Oliveira, Fogaça, & Leandro-Merhi, 2009), increased length of hospital stay, increased discharge disposition to nursing homes, and increased hospital readmission rates (Stratton et al., 2006). Yet, the relationships among these concepts and the social process involved in these interactions that contribute to undernutrition had not been described and represent the phenomenon of interest.

Method

Study Design

This study used Glaserian grounded theory methodology. Symbolic interactionism provides the philosophical basis of grounded theory methodology (Glaser, 1992). Symbolic interactionism suggests that all behavior, whether individual or systemic, is based on the individual’s or group of individuals’ interpretation of objects and the meaning they assign to those objects (Blumer, 1969). Understanding the meaning of older adult eating behavior from the participant perspective, as well as based on participant actions and interactions, provided insight into the social process that influenced eating behavior in hospitalized older adults. This study was approved by the University Institutional Review Board and the Institutional Review Board of the participating institution.

Setting and Participants

The study setting was a medical unit of a large, acute care hospital in the northeastern United States. Purposeful sampling was used to recruit initial participants, followed by theoretical sampling. The sample consisted of (a) consenting older adult inpatients who were 65 and older, English speaking, and had an oral diet order, and (b) consenting health care providers, who were English speaking and had direct interaction with older adults relative to eating behavior. The total number of participants was 12: eight older adults and four health care providers (one dietician, two RNs, one nurse aide). The phenomenon of interest was eating behavior, which occurred during mealtimes. Participants were observed over 30 mealtimes.

It is important to note that in addition to a therapeutic diet prescribed based on older adult participants’ morbidities, the hospital used two types of diet ordering options: room service and non-select diet. The room service option offered designated patients the option to order a meal from a menu at any time, thus allowing for varied mealtimes and a variety of food choices. The non-select diet ordering option had standardized mealtimes and a prescribed menu. The patients’ diet ordering option was at the discretion of the nurse on the basis of an informal assessment of the patient’s functional ability (room service) or inability (non-select diet) to order a meal independently. Seven older adult participants had a prescribed therapeutic diet, and one had a regular diet. Of the eight, four had the non-select option, and four had the room service option.

Procedure

Observation, interview, and document review were used to ensure collection of rich data. A total of 56 hours of observation, including 30 mealtimes; 12 interviews, lasting 30 to 60 minutes; and review of eight medical records were conducted. Prior to each observation, the researcher met with unit health care staff to describe the method of observation and to identify potential older adult participants who met inclusion criteria. Health care provider participants volunteered to participate or were recruited by the researcher.

Observation involved complete observation, which allowed for an understanding of system dynamics pertaining to eating behaviors within the setting. As insight was gained, participant observation was used to observe actions and interactions of participants related to eating behavior while engaging in informal, unstructured interview. Participant observation occurred during and around patient mealtimes. Mealtimes included breakfast, lunch, and dinner on weekdays and weekends. Although the room service diet ordering option allowed for the ordering of a meal at the patient’s discretion, it was found that older adult participants who had this ordering option would nonetheless order meals at standard mealtimes (i.e., breakfast, lunch, dinner). All participants were formally interviewed using a semi-structured interview schedule wherein the general question, “Tell me about eating here in the hospital,” was followed by more probing questions. Documents reviewed included patient medical records and dietary menus.

Data Analysis

Data from interviews, field notes, and memos were uploaded into a qualitative data analysis program, Atlas-ti version 6. Data were simultaneously collected and analyzed using the constant comparative method (Glaser & Strauss, 1967) to identify codes and themes derived from the data. Once the basic social process was identified, analysis involved the comparison of select codes that pertained to that basic social process.

Observation of eating behavior was extensive, and data collection and analysis continued until no new codes were identified (data saturation). Once data saturation had been reached, the researcher returned to the setting to recruit one additional participant. Data collection and analysis from this participant failed to identify any new codes. Additionally, the researcher returned to the setting after data saturation had been reached to continue complete observation to assure that theoretical thinking was indeed consistent with the data and the developing theory. Thereafter, theoretical saturation with relevant literature and extant theory was determined.

Trustworthiness of the Data

Credibility, dependability, and confirmability were established according to the criteria described by Lincoln and Guba (1985). Persistent and prolonged engagement enhanced credibility. Triangulation of methods and sources included the use of observation, interview, and documents, as well as inclusion of the perceptions, actions, and interactions of the hospitalized older adults and health care providers. Peer debriefing occurred weekly, wherein the researcher would meet with another nurse researcher to discuss theoretical thinking. Review of schematics that were indicative of the emerging theory was discussed, allowing for greater insight. Member checks were conducted whereby the researcher would reiterate prior statements made by participants at subsequent observations for accuracy of interpretation. Dependability and confirmability were established using an audit trail and reflexive journaling.

Results

The basic social process discovered was compromise. Major theoretical concepts identified included the concepts of compromise, foodways, and health. Compromise (n.d.) is defined as “to come to terms by mutual concession; to come to an agreement by the partial surrender of position or principles.” Despite stating that eating during hospitalization was important for health, the older adults surrendered this position if they did not eat adequately or, alternatively, surrendered their acculturated foodways if they did eat adequately, resulting in compromise. Older adult participants were found to have inherent foodways. Foodways (2013) are defined as “the eating habits and culinary practices of a people, region, or historical period.” The older adults described various food preferences and meal expectations based on their acculturated foodways. Health was identified by participants as the reason to eat during hospitalization, suggesting a positive relationship between eating and health. The theory developed herein is referred to as the Theory of Compromised Eating Behavior.

The Theory of Compromised Eating Behavior (Figure) has four stages: (1) older adult self-indication, (2) older adult-health care provider joint action, (3) older adult negotiation with the self, and (4) older adult action. The theory is further described as follows:

The older adult is admitted to the hospital with acculturated foodways, as well as a disease or condition warranting hospitalization. Theoretical antecedents such as physiological characteristics related to the older adults’ medical diagnosis and functional status at the time of admission to the hospital, as well as environmental characteristics related to the hospital setting, are present. The process of compromise occurs with each meal and involves older adult self-indication, older adult-health care provider joint action, older adult negotiation with the self, and concludes with older adult action.

The Theory of Compromised Eating Behavior.Note. OA = older adult; HCP = health care provider.

Figure.

The Theory of Compromised Eating Behavior.

Note. OA = older adult; HCP = health care provider.

Stage 1: Older Adult Self-Indication

Based on the Theory of Compromised Eating Behavior, older adult self-indication begins the process of compromise. As each meal tray is delivered, hospitalized older adults begin a process of self-indication in which they judge or assess whether the hospital food and meal meets their food preferences and meal expectations given their acculturated foodways. For example, one older adult participant stated, “At home you know what you’re making, you know what it is, you know if you like it or not. Here you look at it [meal] first, if it doesn’t look good, you stop right there.”

Food preferences described by older adult participants included food flavor, temperature, choices, and quantity served. Food flavor was especially noteworthy. The majority of older adults expressed the lack of flavor associated with the hospital food. For example, an older adult participant stated:

It’s flavorless [food]. I would rather have a half of a cup of tasty pasta than to have something that tastes lousy. Flavorless—If I don’t like it; I’m not going to eat it [food] so it’s not doing me any good. Give me something that at least I’m going to eat.

This perception was further described by a health care provider participant:

People lose their sense of taste as they grow older so food doesn’t taste the same and if at home you’re used to drowning your food with salt and all of sudden you’re on a cardiac diet and there is not salt or sugar delivered with your meal or because you have diabetes we’re not going to give you sugar [this factors into whether older adults eat or not].

Older adult participants indicated they had certain meal expectations. The ability to choose food items to eat for the meal, the timing of meal, the ability to perform traditional meal rituals, and the availability of familiar foods were identified. The availability of familiar foods was a meal expectation, as one health care provider participant stated:

We have a meatloaf but it’s turkey meatloaf and it’s not really distinguished to me. It doesn’t look like meatloaf to me either and these fancy dishes like the shrimp Provencal. It [the menu] describes it with these fancy descriptions. I think people are afraid to order it because they’re not sure what it is. Sometimes they just don’t know what it is.

Another health care provider participant stated that, “The hospital serves a lot of cold sandwiches; most of them [older adults] won’t eat the sandwiches. They want something hot. The wraps were terrible today for the older people.” This sentiment was also shared by an older adult participant as she stated, “We had those little sandwiches [for lunch]…what do you call those sandwiches…wrappeds? [sic] I didn’t even touch those.”

Stage 2: Older Adult-Health Care Provider Joint Action

Older adult-health care provider joint action is the second stage of the Theory of Compromised Eating Behavior. Since the older adult has already made indications about the meaning of the hospital meal to themselves in Stage 1, these indications about the meaning of the meal were then fit together with those of the health care provider. Joint action was exhibited by the older adult’s eating behavior during the meal and health care provider facilitation and surveillance throughout the meal.

Health care provider facilitation was identified as helping the older adult access food items on the meal tray, assistance with eating, cueing or reminding the older adult to eat, physical positioning of the older adult to eat, timing of medication administration in relationship to eating, assessing the availability of prostheses or assistive devices, and promoting dietary changes. Having difficulty accessing food or the meal tray was common. Many food items or utensils were commercially packaged, which proved to be challenging for the older adults to access independently. For example, during observation it was noted that an older adult participant was trying to open the packaging on his utensils with his teeth. This was substantiated further by a health care provider participant who stated: “Sometimes they’re too tired [older adults] to go through pulling off covers, cutting things up…by the time they’re through with all that they’re just so exhausted they don’t want to eat.”

When asked what influenced whether she ate or not, an older adult participant indicated:

It depends where they leave it [meal tray] and how my bed goes. If my bed goes up a little maybe I can reach it or if it goes down a little, maybe I can reach it. If I can’t; maybe I’ll ask someone. If they [health care providers] come in [to the room] I’ll eat; if they don’t I won’t. I won’t even look at it, so that’s another factor.

Whether health care providers provided surveillance over older adults’ eating influenced the meaning of the hospital meal for the older adults. Lack of surveillance indicated lack of meaning, whereas health care provider surveillance would indicate the food and meal had meaning. Health care provider surveillance involved identifying missing meals, missing food items or utensils, and monitoring dietary intake. One health care provider participant stated:

Now if…patients and their families aren’t orderin [sic], we’ll say he’s a regular diet but we’ll say he’s unable to call and not all the time are the nurses or the PCTs [aides] able to call for him, so the whole day will go by and this poor man will not get anything unless you’re [health care provider] alert and notice, so that’s why we put in non-select [rather than room service], so he could get his meals.

During an observation, it was noted that an older adult participant did not receive a meal tray, despite having the non-select diet ordering option. Initial thought was that the meal had been delayed due to nutrition education being provided by the dietician; however, during participant observation with the older adult and the dietician, it was realized that the meal tray had been missed. Had a question about the participant’s meal not been asked, it is questionable whether this older adult would have had the opportunity to eat as he did not question his missing meal. During another observation, an older adult participant received dry cereal without milk for dinner. The older adult pushed the meal tray away, stating in a loud voice, “They gave me cereal without milk. How am I supposed to eat cereal without milk?” During several observations, missing food or meal tray items caused the older adults great distress.

Throughout this study, health care provider surveillance of dietary intake was limited. Many older adult patient meal trays were collected by health care providers uneaten or with little eaten; yet, the provider rarely commented on lack of dietary intake. During one observation, an RN suggested an older adult participant “try the soup,” stating, “They say the soup here is good.” Yet the nurse neglected to note that with his significant hand tremor, the older adult participant would not be able to get the soup from tray to mouth without spilling. The nurse did not offer assistance, nor did the older adult ask for assistance. Total dietary intake for this meal consisted of a cracker, which the older adult participant struggled to access, in addition to sips of milk consumed during medication administration.

Older adult participants identified negative influences related to their eating behavior yet did not proactively seek to remedy these influences. For example, if food flavor was not to their liking, they would not ask for an alternative but rather would not eat, or if they needed help accessing their meal tray, they would struggle or “give up” rather than ask for assistance. This conveyed the meaning of the hospital food and meal from the older adult participant perspective to the health care provider. Likewise, when health care providers did not facilitate the meal or provide surveillance for the meal, this conveyed meaning from the health care provider perspective to the older adult. Thus began a cycle of older adult-health care provider interactions (joint action) wherein the hospital meal had little meaning for both the older adult and the health care provider.

Stage 3: Older Adult Negotiation With the Self

All participants indicated the importance of eating while hospitalized to maintain health. Additionally, all but one older adult participant indicated they were hungry prior to meals. This disparity between the older adults’ perception about the importance of eating while hospitalized and their hunger, versus the lack of meaning assigned to the hospital food and meal required older adult participants to negotiate between hospital foodways and their health. Based on Stage 3 of the Theory of Compromised Eating Behavior, the older adult negotiates with the self in a decision to eat or not, or what to eat.

Negotiation had variable outcomes based on the degree to which the older adult could reconcile the meaning of the hospital food and meal. One older adult participant could more readily accept differences, which ultimately affected her decision to eat in a positive way, whereas others had more difficulty, thus affecting their decision to eat in a negative way. This became apparent in the older adult participants’ affirmation or reticence to assume hospital foodways. Affirmations indicated a willingness to negotiate acculturated foodways for hospital foodways, thereby accepting the meaning of the hospital food and meal and the importance of health and hunger. Reticence was indicative of an unwillingness to negotiate acculturated foodways for hospital foodways, despite the importance of health and hunger. Affirmation was demonstrated by one older adult who stated, “It’s enjoyable [the food], very enjoyable. The food is good. Sometimes when it arrives of course it’s cold,” or she stated, “The night I got here they had meatloaf. It’s dry. The outside top is hard. I make meatloaf but my niece said Aunt _____ don’t be so gosh darn critical. Your meatloaf is delicious but this is not home.”

However, the majority of older adult participants displayed reticence or an unwillingness to accept the differences in meaning between hospital foodways and their acculturated foodways. Older adult participants would eat select food items from the meal tray. These food items tended to be familiar such as coffee, juice, crackers, toast, fruit, and dessert items. Total dietary intake was most oft en limited and inadequate. For example, when asked about eating in the hospital, an older adult participant stated: “If I don’t like it, I’m not going to eat it…give me something that at least I’m going to eat…let me tell you something, when I die I’m going out happy and full.” He further demonstrated his reticence when asked during observation if he had consulted the dietitian about his dissatisfaction with the food, he responded negatively, indicating, “[The dietitian] only tells me what I can’t eat, not what I can.” He and other older adult participants were unwilling to negotiate their acculturated foodways for hospital foodways, despite the importance of health and hunger, thereby affecting their decision to eat or not, or what to eat.

Stage 4: Older Adult Action

Older adult action or dietary intake is the last stage of the Theory of Compromised Eating Behavior. Adequate dietary intake required older adult participants to compromise their acculturated foodways, whereas inadequate dietary intake required older adult participants to compromise their health. During this study, the researcher quantified dietary intake based on the assessment method described by Berrut et al. (2002). Using this method, individual food items were assessed for percentages eaten. These percentages were then averaged for a total overall percentage of meal consumed. Quantification of dietary intake was established to determine adequate versus inadequate intake. Inadequate intake was determined to mean less than 75% (Peterson, Sheean, & Braunschweig, 2011). In the current study, one older adult participant chose to compromise her acculturated foodways by eating 100% of observed meals, whereas seven older adult participants chose to compromise their health by eating 0% to 50% of their meals. Dietary intake remained consistent (adequate or inadequate) for those participants observed during multiple mealtimes.

Theoretical Relevance

The social process, not previously described in the literature, is that of compromise. The stages of the Theory of Compromised Eating Behavior, although somewhat arbitrary, represent a continuous process, which occurred during each mealtime (Figure). Findings from this study are consistent with current literature in that dietary intake was oft en inadequate. Additionally, findings from this study indicate that food and mealtimes represented more than solids or liquids to ingest or a time and place to ingest them. Food and mealtimes have been known to be associated with both personal and social identity, as according to Murcott (1988), “as we eat we not only survive corporally, we express ourselves socially…the symbolic significance attached to foods can thus demonstrate the human ability to construct a world of ideas that imbues the material environment with meaning” (p. 5).

The food choice literature further substantiates the meaning of food and mealtimes to older adults and what constitutes proper food and meals as these ideals, oft en established in childhood, become more poignant with age (Falk, Bisogni, & Sobal, 1996). In the current study it was found that older adult participants had particular food preferences and meal expectations based on acculturated foodways or what they considered proper food and meals. Food choice literature also suggests that people demonstrate repetitive food behaviors such as types of food and drink consumed; context for consumption; as well as time, location, activity, social setting, mental processes, and physical condition for mealtimes (Jastran, Bisogni, Sobal, Blake, & Devine, 2009). Again, this signifies the influence of acculturated foodways on eating behavior and suggests hospitalization challenges these behaviors. Furthermore, Connors, Bisogni, Sobal, and Devine (2001) found that people use negotiation when values related to food choice are in conflict. This act of negotiation is consistent with Stage 3 of the Theory of Compromised Eating Behavior in which older adults negotiated whether to eat, or not or what to eat.

The Theory of Compromised Eating behavior is also consistent with aging theory. Continuity Theory posits that as people age, they use adaptive strategies to cope with changes associated with aging (Atchley, 1999). In doing so, they preserve internal and external structures from their past to provide continuity in their psychological and social being wherein elements of themselves and their experiences are preserved. Continuity Theory is supportive of the Theory of Compromised Eating Behavior in that as older adult participants coped with changes in their health as well as being hospitalized, they called on past patterns of behavior, such as their eating behaviors. Therefore, maintaining acculturated foodways was an adaptive strategy used by participants to cope with changes in their personal and social selves during illness while hospitalized. Furthermore, participants’ adaptive capacity or degree to which they could deal with discontinuity or significant departure from past patterns of behavior was demonstrated by affirmation or reticence to accept hospital foodways.

The Theory of Managing Personal Integrity (Jacelon, 2004) suggests that older adult independence and control are jeopardized during hospitalization due to changes in health status as well as characteristics of the hospital environment and that older adults demonstrate autonomy to preserve their personal integrity to survive hospitalization. Based on Jacelon’s theory, it is conceivable that older adults used eating behavior as a strategy to increase their autonomy whereby they decided to eat, not eat, or what they would eat.

The Theory of Compromised Eating Behavior is also supported by biological theories of aging such as the Free Radical Theory, which suggests aging results in cellular, organic, and systemic changes (Harman, 1956) that may influence eating behavior relative to the flavor of foods. During the current inquiry, older adults did not have an appetite for available food as they indicated hospital food was flavorless. Studies suggest that detection and recognition of tastes change with age such that increased concentrations of certain flavors (i.e., salty, sweet) are needed for detection (taste thresholds) in older adults compared with younger adults (Methven, Allen, Withers, & Gosney, 2012; Nordin, Razani, Markison, & Murphy, 2003). These findings are further compounded when the older adult has chronic disease or takes multiple medications. Therefore, as the older adult ages, acquires more chronic disease, and consequently takes more medications, therapeutic diets prescribed to manage these diseases limit salty or sweet flavors, thus affecting the older adults’ perception of food flavor.

The prescription of therapeutic diets for older adults’ remains controversial since dietary restriction of some nutrients can help prevent complications of disease, especially important during hospitalization for an acute exacerbation of disease. Yet, these same dietary restrictions can contribute to inadequate dietary intake (Darmon, Kaiser, Bauer, Seiber, & Pichard, 2010). In the current study, older adult participants had chronic disease and were taking multiple medications. These older adults were prescribed therapeutic diets, which restricted either salty (cardiac) or sweet (calorie restricted) flavors or both. Although some older adult participants indicated they followed a therapeutic diet at home, the stringency to which they adhered to that diet at home versus within the hospital setting is unknown. As one participant stated:

There is no flavor to the food here. It’s bland. They don’t give you any salt and pepper…well they give you pepper but no salt, which I can understand but…you’ve gotta have some salt…even my own doctor told me that.

Thus, based on the Theory of Compromised Eating Behavior, if food was not traditional in flavor, consistent with the older adult participants’ acculturated foodways, the meaning of the food and meal was compromised, thereby influencing dietary intake.

Nursing Implications

The Theory of Compromised Eating Behavior suggests that the meaning of food and meals to older adults is challenged during hospitalization. Therefore, nursing education should include the importance of continuity and the personal and social significance of food and meals to older adults, changes in physiology that occur with aging and how these changes affect eating behavior, as well as the effect of autonomy on eating behavior.

Patient-centered care is designed to alleviate patient vulnerabilities related to physiological state and threats to identity within the acute care setting (Hobbs, 2009). Based on the Theory of Compromised Eating Behavior, development of a plan of care wherein acculturated foodways are considered would enhance patient-centered care. Family involvement should be considered when developing the nutritional aspects of care due to the diverse cultural foodways of older adults. Additionally, risks versus benefits of a therapeutic diet need also be considered on a patient-by-patient basis as health care providers weigh the potential for disease complications due to the intake of various nutrients versus inadequate dietary intake or undernutrition.

Nursing assessment should also be considered. Ongoing formal assessment of functional status would inform the plan of care relative to eating behavior and allow for changes consistent with acuity and environment. Valid assessment of dietary intake is also warranted so nutritional intervention can be implemented whenever intake is inadequate. The assessment of dietary intake is subjective, and as one health care provider participant indicated:

The nurses are writing down adequate but Mr. so and so ate all of his fruit and ate his desert. That’s not adequate. He left his entrée and this is the third meal in a row he’s left his entrée and he only went for the sweet stuff. So it [these assessments] can be misleading.

Qualitative inquiry into each stage of the Theory of Compromised Eating Behavior, as well as interventional research that would reduce the need for nutritional compromise, would be beneficial (Table). Although further research is needed, during the current inquiry, health care provider participants experienced compromise when older adults did not eat, as they also indicated the importance of eating during hospitalization yet facilitation and surveillance of dietary intake was minimal. Lastly, additional research and analysis would allow for progression toward formal theory in which the concept of compromise is considered whenever health care is not patient centered.

Interventions Requiring Further Study Related to the Theory of Compromised Eating Behavior

Table:

Interventions Requiring Further Study Related to the Theory of Compromised Eating Behavior

Conclusion

The Theory of Compromised Eating Behavior describes the social process of compromise that influences the eating behavior of hospitalized older adults. This occurs at a time in the older adults’ life when disease requiring hospitalization becomes more prevalent and prescribed diets become more restrictive, yet traditional food and mealtimes become more meaningful. Enhancing the meaning of food and mealtimes for the hospitalized older adult is imperative if negative outcomes associated with undernutrition are to be ameliorated.

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Interventions Requiring Further Study Related to the Theory of Compromised Eating Behavior

Incorporate acculturated foodways into plan of care

Involve family members in meal planning/mealtimes as appropriate

Consider liberalizing therapeutic diet if dietary intake is inadequate

Formally assess functional ability to eat and assistance needed, and provide assistance as needed

Emphasize the importance of mealtimes/eating

Increase presence and interaction during mealtimes

Accurately assess dietary intake using a validated method

Make dietary changes/referrals readily

Offer diet options/alternatives, as indicated, including flavor enhancements

Assure assessment is ongoing based on patient acuity/ functional ability throughout length of stay

10.3928/19404921-20130930-01

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