The Meaning of Eating for Community-Dwelling Oldest Old who Live Alone: A Qualitative Study

Eating has a vital function to the body by offering many nutrients that are necessary for it to work. However, besides the biological factor [1], it is a part of a cultural behavior, performing an important role in the construction of the social organization of humanity [2]. So eating goes beyond the food being considered a process of choice. Eating behavior is composed of biological, economic, socio-cultural, psychological and anthropological factors that determine food choices and suit individual and social rules [3,4]. Therefore, food has symbolic meanings and values that interfere with the tastes and preferences of individuals [5]. 

The elderly people’s eating habits deserve special attention since they are influenced by changes that happen due to the body aging and external factors related to the environment [6]. The World Health Organization (WHO) with the plan called “Decade of Healthy Aging 2020-2030” establishes the food security of the elderly as the second objective, among the seventeen described [7]. However, eating habits developed in childhood and adolescence change just a little in adult life and, consequently, during the elderly stage of life, causing some cases of resistance in the acquisition of new habits, due to consolidated and valued practices [6,8]. In this context, we understand that knowing the meaning of food to oldest-old people that live alone, as well as its characteristics, can be the first step to create strategies that can surpass this resistance and allow eating habits behavior change.

Location 

São Paulo city, considered the financial center of Latin America [9], located in the Southeast region of Brazil, has an estimated population of 12,325,232 citizens [10], and data from the epidemiological study Health, Well-Being and Aging (SABE), showed that 16% of the elderly in this city live alone, with 7.8% nonagenarians [11].

Design

This qualitative research was done from January to June 2019 at Oldest-Old Outpatient Clinic of Federal University of São Paulo (UNIFESP), located in São Paulo city. This clinic was created in 2010 to assess and monitor lifestyle and survival factors in oldest-old people aged 80 years old and over. Of the 225 oldest-old people followed up, 20.4% live alone. The oldest-old people who met the selection criteria such as: living alone for at least 5 years and being cognitively preserved, attested by medical records, were invited to participate in this research. They received detailed information about the study and after signing the consent form (Research Ethics Committee of Federal University of Sao Paulo, register number 3.064.956) were interviewed, and the interviews were recorded. 

A semi-structured interview that allowed the oldest-old people to freely answer the questions was done, the nine questions were: 1) Since when do you live alone? 2) What has changed in your diet over the years? 3) Most of the time, do you eat at home or do you eat out? Justify 4) Do you enjoy cooking for yourself? 5) What does eating mean to you? 6) What do you understand as healthy eating? Do you consider your diet healthy? 7) Do you have any difficulties in following the nutritional recommendations that are given in your appointments? Justify your answer 8) Do you think that your diet was responsible for you reaching the age you are now? 9) If you could change something in your food, what would you do? 

We used the case study method, which aims to deeply analyze a certain phenomenon that will be investigated [12,13]. The qualitative approach allowed us to delve into the object of the study, acting in the field of meanings, values, attitudes, which are part of human social reality [14], and whose interpretation does not involve any numerical data, but rather an inference from the perspective of the studied population [15]. On the same day of the interviews, the oldest-old people received three sheets of paper for the food record so that they could write all the food consumed and ingested on two week days (non-consecutive) and one day on the weekend, allowing us to know the characteristics of their food. 

Analysis 

The interviews were fully transcribed and the material obtained was evaluated using the “thematic content analysis” method. In this modality, the theme is the unit of meaning that emerges from the text, and excerpts from the text whose repeated themes are grouped into thematic categories, here called thematic content [14]. Record units are the elements (such as word, phrase or sentence) extracted from the decomposition of the message, which can be used to analyze the content of the message, and the theme is the largest unit from which the conclusion will come [14]. The registration units were named as units of analysis and the themes identified as thematic content. The text was read thoroughly and excerpts that were common were grouped into thematic groups named at the authors’ discretion. These contents were constantly revised in order to certify that the entire text was being contemplated, as well as for the creation of new ones, in case they arise. From the results, logical deductions were made about the analyzed content and then the interpretation was based on the available theoretical material [14]. 

The sample was defined based on the filled information, which means, when there is complete and valuable information about what is wished to be investigated and new interviews are repetitive in their content the process of collecting data was concluded [16]. The food records were analyzed according to the “Ten steps to healthy eating for elderly people” which is presented in the food guidelines for elderly people from the Brazilian Ministry of Health. It is a manual for health professionals to guide the elderly population on appropriate eating practices to promote pleasure, comfort and food safety [17].

Sixteen oldest-old people were interviewed, 13 women and 3 men, aged from 82 to 96 years old, mostly widowed and living alone for an average of 18.7 years old. After analyzing the data, five thematic content and their respective units of analysis arose from the material explored (Table 1). 

Table 1: Theoretical categories.

Thematic content: Food is life 

When asked about the meaning of food, all the elderly people interviewed associated food with health and life, and did not mention feelings of affection, pleasure or taste: 

• “Food is life, right (...)?” [Interviewee 2]
• “(...) without eating, nobody can live.” [Interviewee 3]
• “(...) for me, it is not a pleasure, it is not about flavor, it is not that, and we need it to stay upright, for our health.” [Interviewee 11] 

The variety of foods was also associated with healthy eating, including with the interviewees claiming to practice this. 

• “So, we try to balance it, we look for a variety, never failing to consume vegetables, fruits, the essentials.” [Interviewee 2]
• “I think that's it, right? Rice, beans, that they are, right? They say that the best thing is rice and beans, isn't it?! That's it." [Interviewee 7] 

Food is important for health at any stage of life, whether acting in the prevention or in control of established diseases. There were changes in diet due to health problems: 

• “I used to eat everything then came a time in my life when I had a very serious problem, so the hematologist said some things like these that I shouldn't eat” [Interviewee 8] 

Physical limitations also promoted a change in eating habits. 

• “Now I'm not going to the open air market, because with this hot sun, right? I can't, because of my legs and dizziness, right? Before, I used to go to the open air market to buy vegetables (...). Yesterday I wanted to go, but I couldn't (...) I said, if I go I will fall down there (...)” [Interviewee 15] 

Thematic content: Genetics 

A part of the interviewees attributed the genetics inherited from their family members as the factor responsible for longevity. For them, food was not a factor that has contributed for them living longer. 

• “Look, to tell you the truth I have never thought about it (....) together with my mother's inheritance (...) and my father was a healthy man. So I think the family, right? My ancestors competed so that I was, had the age I am now (...)” [Interviewee 1]
• “(...) But I am from a family where everybody dies at eighty, ninety, ninety-five or more, around there, okay ?! (...) ” [Interviewee 13]
• “I think it is more genetic (...).” [Interviewee 16]

Thematic content: Culinary art 

The act of cooking is considered an ancient human habit which involves a set of actions that require knowledge, skills and it is influenced by social issues from their surroundings. Therefore, the fact of having to cook for just one person can cause demotivation, according to the statements below: 

• “(...) I am too lazy to do ... (...) because there are days I can't take it. The laziness speaks louder” [Interviewee 1]
• “Too lazy to do it for myself” [Interviewee 5]
• “I am too lazy to cook white corn, because more than cooking, you have to chew (...)” [Interviewee 13] 

Another important aspect to consider is the fact that living can only lead to simplification in the elaboration of the menu, since there is no one to share the preparations with: 

• “It changed a lot, when I was married I used to make more things, I made cakes, made desserts, I made a lot of things, now for me I am not going to make a cake, I made a dessert so I left it. I make dessert when the maid comes and she helps me eat it.” [Interviewee 9]
• “It has changed, I have simplified my diet more. I mean I had a variety of foods. And we alone try to do it as quickly as possible.” [Interviewee 10] 

The presence of other people during the meals promotes social interaction, and in the speech of our patient there is certain sadness for being alone at this moment: 

• “My children were at home, but now everyone has their jobs. When they were unemployed they were always there with me, eating with me. Now everyone has their jobs, I ended up being alone.” [Interviewee 5] 

Another thing observed was the act of snacking throughout the day, which could lead to improper eating. 

• “It has changed too much, it has changed a lot. I used to eat well (...). Now it's like that (...) I don’t eat right, I just snack (...) I don’t have any appetite for food, for beans and rice, right? This is what spoils, isn’t it?” [Interviewee 5]
• “After lunch later in the afternoon, I just snack here and there (...)” [Interviewee 6]
• “There are days when I have lunch, sometimes I have a snack, right? Sometimes I’m only going to cook in the afternoon, right? (...)” [Interviewee 15] 

In relation to cooking, the issue of learning in an advanced stage of life also stands out, since living alone elderly people had had to adapt to their new reality, being obligated to learn how to cook, in a stage of life where the habits were already established. 

• “It has changed because my wife used to cook, I let it to her (...) she died (...) I felt myself obliged (...) and to make my meals (...)” [Interviewee 6] 

Some elderly people have mentioned not enjoying cooking, implying that they did it due to obligation. 

• “Look, to tell you the truth, I don't like to cook. I don’t like cooking but I don't eat any kind of food (...)” [Interviewee 7]
• “I hate to cook, whether it's just for me or for anyone else. I don't like to cook. I really don't like it” [Interviewee 11] 

Thus, this content has brought up reflections about the changes that have occurred in the diet of the oldest-old people interviewed due to the fact that they live alone. 

Thematic content: Conservatism 

The interviewees in their speeches show resistance to changes, remaining faithful to their habits and traditionalism: 

• “Neither secrets nor news, it's always the same. (...) Everything is the same.” [Interviewee 3]
• “Look, almost nothing has changed. I'm used to eating that and it continues, right?” [Interviewee 7]
• “It hasn't changed, the quantity has decreased, but it has not really changed.” [Interviewee 13] 

The act of eating at home was also taken into consideration by all interviewees. Despite living alone, they preferred to maintain this habit, because they were concerned about the food preparation, hygiene of the place and health care. 

• “At home, really.” [Interviewee 3]
• “I eat at home. It’s hard for me to eat out” [Interviewee 5]
• “I don't like to eat out because these things always, ‘coxinha’, ‘esfiha’, all of these are things (...), and it makes me sick, there is a lot of fat, I don’t eat fried food, I eat only cooked or grilled, you know?” [Interviewee 8]
• “Only at home, I don't like to eat out.” [Interviewee 14]
• “No, I don't eat out. (...) I like to do everything at home, everything is clean, isn’t it?” [Interviewee 15] 

The nutritional recommendations prescribed in their outpatient appointments were also not entirely followed. 

• “Oh it depends on the orientation, right, it depends.” [Interviewee 3]
• “No, I don't follow everything.” [Interviewee 6] 

It is interesting the fact that these oldest-old people think it is unnecessary to make changes in their diet. 

• “Ah, I wouldn't change anything. No. I'm fine, I'm satisfied. It's great.” [Interviewee 4]
• “Change for what, girl? What is the suggestion? Eat beans? Eat lentils? Eat chickpeas? No, I don't like any of these things (...).” [Interviewee 11]
• “I don't think I would change a thing. The way it is, I think it's fine.” [Interviewee 16] 

Thematic content: Independence 

The oldest-old people interviewed appreciated the freedom assured by living alone, eating what they want to and to prepare meals according to their wishes: 

• “Oh it has changed a lot, right? Because now at least I'm free, I eat what I want (...)” [Interviewee 4]
• “It has changed that when I was a child nobody asked you if you liked it, or if you wanted it, the food was put on the table and you had to eat it (...). And nowadays, I eat what I like, especially living alone. I don't feel obliged to make food that I don't like and eat just because it's good (...).” [Interviewee 11] 

Analyzing the food records presented by the oldest-old people in our study, most of them do not have five meals a day. It was also observed a low consumption of vegetables and fruits, as well as a small consumption of beans and meat. The consumption of milk and dairy products and the intake of water was below the recommended quantity of eight cups, some of them had alcohol intake and daily consumption of industrialized products.

Longevity is an achievement for humanity and it is also a source of concern for society in how to live the “extra” years in a healthy way [18]. The present study explored the perception that the interviewed oldest-old people have regarding food and the influence of living alone. We have identified some thematic contents that are related to the meanings of food (food is life and genetics) and others that can be obstacles to change (culinary art, conservatism and independence). Although the value attributed to food by the studied public corresponds to the meaning of health and life, in real life it is observed that this knowledge is not always applied in their eating routine, where a low consumption of fresh food is shown. 

Perhaps one of the reasons for this situation is related to the physiological changes that occur in the body with aging [19], which can contribute to a reduction in food intake [20], letting the elderly people vulnerable to variations in their nutritional status, leading to risk of malnutrition or even malnutrition [21]. Our eating habits were acquired over time [22], so our choices are not determined only by a biological aspect [1], but rather by cultural influences that define the permissions and prohibitions that have kept and maintained these habits [22]. 

Eating behavior promotes a social identity, commensality (human sociability), which goes beyond food intake, it is related to cultural, symbolic habits, social organization, sharing of experiences and values, transforming these moments into remarkable moments [23]. Thus, the health of the elderly can be affected by their eating behavior, and this depends on factors that involve acquiring, preparing and eating food, in addition to social interactions, such as eating together, social economic and geographical factors [24]. 

Elderly people living alone is a matter of concern when there are situations of fragility and vulnerability, where the lack of companionship would allow undesirable practices in relation to health and lack of assistance, such as inappropriate eating habits and monitoring [25]. With the advance of age, there are sensory losses, such as gustatory and olfactory reductions and they can contribute to the decrease of the appetite, also visual problems reduce the ability to recognize food and the ability to prepare meals [26-28]. In addition, other factors such as social isolation, loneliness, widowhood, among others (chronic illness, use of medication, loss of autonomy, depression, anxiety, living in an institution and economic failure) influence eating behavior, inducing the purchase of industrialized products such as sweets and fast- foods (tea, cookies) [6,27,29]. 

“Eating alone” seems to be associated with the consumption of simpler and quicker meals [30]. Thus, human behaviors are influenced by the presence of others, providing in some situations an improvement in the amount of food consumed [31] in addition to a more variety of food consumed [24]. Eating together with other people can be a determinant of physical and mental health [32]. The benefits can go beyond, family meal standards add to the feeling of security and lead to a logical ordering in the lives of the oldest-old people, providing values and structuring a daily routine [33]. Perhaps the habit of “shortening” meals has to do with the fact that the oldest-old people eat no more than necessary to avoid feeling hungry, making the habit of eating meals of less importance [33]. The act of eating together with others favors the sharing of food knowledgement, contributing to the improvement of appetite, motivation, and also encouraging food diversity [24]. The association between eating alone and less food diversity was caused by a lack of motivation to prepare various types of food for just oneself [34], or also for tiredness and laziness for cooking [35]. 

The art of cooking requires skills, information and it is often passed on from generation to generation, showing the family’s identity [36,37]. Most of the time, cooking is a women’s task [36], but in some situations elderly men, due to widowhood, need to learn how to cook or they eat out, because they are unaware of how to make the food, or for considering cooking as a women’s task [38]. Papers have shown an irregularity in elderly people’s food who live alone, for instance, simplified preparations of dishes and less regular meals [39]. 

The study conducted by Whitelock & Ensaff [20] showed that the fact that the elderly people live alone can impact the habits of eating, shopping and cooking, which cooking for themselves resulted in simplified, ready meals and in the feeling of tiredness for having to do just for themselves. This practice of choosing more simplified meals could have impacted the food intake and, consequently, putting them under nutritional risk. Low weight, for example, is a risk factor for dementia and fractures in elderly people [32]. On the other hand, eating alone means more freedom, some have reported that they can act as they wish, decide for themselves [40], and the possibility of living alone makes them feel free, including in relation to food, giving them the chance to eat only what they want and in a way that suits them. 

The habit of snacking throughout the day can be a practical way for not wasting time, or possibly some meals make more sense when accompanied [41]. According to Kuwae et al., [41] being practical in cooking and reducing the time spent preparing meals were valued issues, especially among the elderly women who said that their time should not be “wasted” in cooking. Thus, the values of being practical and speed also interweave the elderly conceptions of eating, which could lead to the consumption of products that are easy to prepare or processed [35], facilitating the development of an inadequate nutritional status [33]. 

The interviewees showed conservative characteristics, referring to the fact that there were no changes in eating and not seeing the need to do so, always doing it at home, even without companionship and showing resistance to the nutritional recommendations received from the professionals. Eating out would be an interesting strategy in the attempt to improve consumption and food variety, but this did not happen in this study. Nutritional knowledge is related not only to the choice and consumption of food, but also to how the individual perceives and defines what is a healthy diet, and how this understanding is applied in a practical way in daily food choices [42,43]. 

Regarding following the nutritional recommendations, it should be highlighted that it is influenced by several factors such as: family, social and economic, besides the perception that the elderly people have in relation to their health problems, as well as the bond established with the services and health professionals [44]. Habits and beliefs are internalized in the individual, creating resistance to dietary changes, since the eating heritage that structured taste and habits became a persistent practice [37]. And every change creates an internal conflict, because they have to break a system in balance and establish a new one. Therefore, for the introduction of a change, it is necessary to reduce resistance to it through information to help them make their choices [45]. An important aspect to be considered, in relation to the diet of elderly people, refers to the nutritional behavior of the public that has been implemented throughout their lives, making this population keep their habits [8]. 

Some authors report that the habit of eating at home has to do with habits acquired in childhood and adolescence, where meals with the family were a form of integration among the family members [46]. In order to develop appropriate strategies that promote changes in eating behavior, we will need to know what factors motivate elderly people to choose certain types of food and these characteristics can be very individualized. We also realized that the oldest-old people analyzed were satisfied with their eating behaviors, that involve lower consumption of in natura food. Despite the recommendations they had received were very qualified, done by a nutritionist and individualized, they do not see the need for modification.

For oldest-old people who live alone, genetics were mentioned as responsible for contributing to for contributing to longevity, not eating, although the food has a meaning of life and health for them. They do not believe there is a need for change in their eating behavior because probably, in their perception, the food has the role to keep them alive.

We appreciate oldest old who were able to participate in this research.

This survey did not receive specific funding from any funding agency, commercial or non-profit sector.

The author RASA: Conceptualization, Methodology, Investigation, Formal analysis, Data Curation, Writing - Original Draft.

The author VAC: Conceptualization, Investigation, Data Curation, Writing - Original Draft.

The author CMAF: Methodology, Writing - Review & Editing.

The author NFDL: Conceptualization, Methodology, Formal analysis, Data Curation, Supervision, Writing - Review & Editing.

The author MSC: Conceptualization, Methodology, Data Curation, Supervision, Project administration, Writing - Review & Editing. All authors have approved the final article.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

“This study was conducted based on the guidelines of the Declaration of Helsinki and all procedures involving research study participants were approved by the Ethical Committee in Research of Universidade Federal de São Paulo, register number 3.064.956. All participants signed a written consent”.

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