key: cord-0718868-xq9z6pqt authors: Ellis, Amy; Jung, Seung Eun; Palmer, Frankie; Shahan, Mackinsey title: Individual and interpersonal factors affecting dietary intake of community-dwelling older adults during the COVID-19 pandemic date: 2022-03-23 journal: Public health nutrition DOI: 10.1017/s1368980022000696 sha: afcfae9ae28cc6f5e116709d5a46017396ead421 doc_id: 718868 cord_uid: xq9z6pqt OBJECTIVE: As older adults are at higher risk for severe illness and mortality from SARS-CoV-2 infection, social distancing has been a primary means of mitigating risk. However, this lifestyle change may impact eating habits and food choices. The aim of this study was to explore individual and interpersonal factors affecting the eating behaviours and dietary intake of community-dwelling older adults during the COVID-19 pandemic. DESIGN: Semi-structured individual interviews were conducted. All interviews were audio-recorded and transcribed verbatim. Qualitative data were analysed using a deductive content analysis approach to identify themes. SETTING: Southeastern United States PARTICIPANTS: Twenty-three men and women, 60 years of age and older (mean age 71·9 ± 7·7, 22 % male), completed both the interview and questionnaire. RESULTS: Themes that emerged at the individual level included changes in eating habits and foods eaten, with most participants reporting healthier food choices during the pandemic. Participants also reported more frequent cooking, improved cooking skills and cooking as a form of stress relief. Although some older adults described increased snacking and consumption of ‘comfort foods’, others noted no influence of mood on food choices. At the interpersonal level, an increased use of technology for social interaction and the importance of social support were identified as influencing factors. CONCLUSIONS: Findings provide insight on how to help older adults maintain good nutrition amidst lifestyle changes imposed by social distancing. Nutrition educators may capitalise on positive behaviour changes that occurred during the pandemic such as increased cooking and increased use of technology for social interaction. Social isolation is a well-recognised risk factor for poor nutrition status (9, 10) . In turn, poor nutrition status can lead to further decreases in immune function as well as increased susceptibility to infections, poor wound healing, impaired mobility and loss of independence (11) . Consequently, the Gerontological Society of America's COVID-19 Task Force has identified understanding the impact of social distancing precautions on nutritional status of older adults as a research priority (2) . Researchers from other countries have reported differences in responses to pandemic lockdowns between younger and older adults. For example, among a nationally representative sample of adults from the Netherlands, researchers found that older adults were more likely than younger adults to report no changes in food-related behaviours (12) . In another study from Japan, younger adults were more likely than older adults to increase time spent cooking at home (13) . Most studies to date from the USA have focused on older adults in nursing homes or other congregate living facilities, but community-dwelling older adults are a vulnerable population, too. In addition to increased risk for severe disease from SARS-CoV-2, independently living seniors experience many age-related barriers to good nutrition such as poor dentition, decreased sense of taste and smell, and polypharmacy (14) . Community-dwelling elders are also prone to the psychosocial effects of social distancing on nutrition status (11) . Understanding factors influencing community-dwelling older adults' eating behaviours due to the COVID-19 pandemic will provide insight on how to help older adults maintain good nutrition amidst lifestyle changes imposed by social distancing. Thus, the aim of this study was to understand individual and interpersonal factors affecting the eating behaviours and dietary intake of community-dwelling older adults during the COVID-19 pandemic. To explore the impact of the COVID-19 pandemic on community-dwelling older adults' eating behaviours at the individual and interpersonal levels, the semi-structured individual interview guide was developed based on a review of the literature and those constructs of the social ecological model. The social ecological model is a theoretical framework that incorporates multiple levels of influence on health behaviour. The individual level of the model focuses on personal factors, while the interpersonal level considers an individual's relationships with others such as family and friends (15) . Because a previous study based on the social ecological model identified individual-and interpersonal-level factors as the strongest barriers and facilitators to behaviour change during the COVID-19 pandemic (16) , we focused on these levels of the model in the development of the interview guide. Open-ended questions with probing questions are shown in Supplemental Table 1 . A panel of two experts in the area of older adult nutrition, food choice behaviour and qualitative research reviewed the interview guide to establish the content validity of the interview questionnaire. A pilot interview was conducted with one older adult who met the inclusion criteria for the study. Based on feedback from the pilot interview, verbiage for the interview questions was revised slightly for clarity. Additional questionnaire data Participants also completed an online survey that included demographic questions and the Questionnaire for Assessing the Impact of the COVID-19 Pandemic on Older Adults (QAICPOA). The QAICPOA was introduced as a standardised tool to understand the effects of the pandemic and social distancing guidelines on behaviours and well-being of older adults (17) . The QAICPOA questionnaire included questions about communication with others during the pandemic, difficulty obtaining food and the threeitem loneliness scale (18) . Purposive sampling (19) was used to recruit communitydwelling men and women aged 60 years and older. Participants were recruited in September 2020 from the Osher Lifelong Learning Institute (OLLI) at The University of Alabama. The OLLI marketing department posted recruitment flyers to their social media websites and email distribution list. In addition to the age of 60 years or older, inclusion criteria required participants to have internet access and be living independently. Participants were provided with a $10 incentive upon completion of the individual interview and questionnaire. Individual interviews were conducted by Zoom (Zoom Video Communications Inc., 2021). The effectiveness of Zoom videoconferencing as a means of conducting interviews for qualitative research has been previously documented (20) . Individual interviews were conducted during September and October 2020. At this time in the pandemic, lockdowns were no longer imposed, but masks and social distancing guidelines were mandated. One of the two principal investigators conducted each interview, while a research assistant took written field notes. The interviewer and research assistant debriefed after each interview to add additional reflections to the field notes. Sessions were recorded, and interviews were transcribed verbatim by an automated transcription service. A research assistant verified each transcript for accuracy. Design and implementation of this study followed the Standards for Reporting Qualitative Research (SRQR) and the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (21) . Each participant was given an unidentifiable indicator, and each individual interview was transcribed verbatim. After each individual interview was transcribed, transcripts were cross-checked by two members of the research team for accuracy. Finalised transcripts were imported into NVivo 12 software (version 12, NVIVO, QSR International) and analysed using deductive content analysis, with the social ecological model theory constructs acting as predetermined themes (22, 23) . Two researchers coded transcripts independently and compared results through Zoom meetings to reconcile any discrepancies, reorganising any overlapping themes and subthemes (24) . Themes and subthemes were discussed with another research team member to ensure high reliability. Supporting quotations were chosen with agreement between all research team members. Trustworthiness of the data was addressed by conducting member checking (19) , peer debriefing and an audit trail to determine the validity of the findings and accuracy of the identified themes and subthemes (25) . Descriptive statistics from the online questionnaire were calculated using SPSS version 26.0. (IBM Corp.). Questionnaire data were aggregated across the entire sample without categorising participants based on their responses or matching individual interview data to questionnaire responses. Eighteen women and five men aged 60-87 years (mean age 71·9 þ 7·7 years) completed both online questionnaires and individual interviews. Additional participant demographics are reported in Table 1 . From the interviews, three main themes with several subthemes were identified at the individual level, and two main themes with associated subthemes emerged at the interpersonal level (Table 2) . Those themes and aggregated results from the QAICPOA questionnaire are summarised as follows. Theme A: Changes in eating habits and foods eaten Healthier food choices emerged as one of the changes in eating behaviours among the study participants during the COVID-19 pandemic. Some participants stated that less frequent eating out was a facilitator for healthier food choices at home such as more vegetables and fruits and fewer fried foods. For example, one participant noted: Since I'm at home a lot more than I used to be, I can spend more time cooking, like, like preparing vegetables and fresh vegetables, and that I think has helped us as far as eating healthier, because we don't eat out. Participant 119, female, 66 years Some participants also perceived healthier food choices as a way to take charge of their own health and relieve health anxiety related to the pandemic. For instance, one participant said: Yes, well, I'm trying to eat, you know, I've been reading a lot and I know that vitamin D and zinc and, and vitamin C is supposed to help your immune system. So, I've been trying to eat more vegetables and fruits. Yeah. I had, five tomato plants, so we ate a lot of tomato sandwiches and a lot of salads this summer. I had three of the cherry-sized tomato plants and two of the larger-sized tomatoes. And, I also grow my own garlic, so I had harvested my garlic earlier and I had I think seventeen or eighteen garlics that I harvested. And, oh let's see, I now have planted in my garden two rows of mesclun lettuce, a row of black-seeded Simpson lettuce, a row of arugula, and three collard plants : : : If you've never eaten lettuce out of a garden, boy, you have missed something. It's fantastic. The lettuce you get in the grocery store is old. It's not fresh. Participant 125, female, 62 years However, a few participants did describe unhealthier food choices due to the pandemic. One participant told of increased caffeine consumption, stating: Notably, among this cohort of older adults, food insecurity was not a barrier for healthy food choices. Per the questionnaire, only five participants reported difficulty obtaining food because of the pandemic or social distancing rules. Of these, no one reported 'much difficulty' or 'an inability to obtain food' (Table 3) . Changes in cooking habits emerged as a theme as many older adults reported cooking more since the beginning of the pandemic. For example, one participant stated: I would cook, I would say a couple of nights a week and then : : : I didn't cook every night. I have cooked more since I've been at home. That's, that's a given, yes. Participant 118, female, 62 years In addition to increased frequency of cooking, a few participants described improved cooking skills. One person noted: Others used cooking as a stress reliever. This was illustrated in one person's comment, 'That's the way I cope with when I'm getting sad or depressed Interestingly, loneliness did not emerge as a major barrier to healthy eating among this cohort of older adults. Included in the QAICPOA questionnaire is the three-item loneliness scale (17) . According to the questionnaire data, approximately half of the participants noted feeling isolated from others at least some of the time. However, of these, only two participants said they felt left out or that they lacked companionship (Table 3) . Although some participants associated changes in mood with changes in eating behaviours, other participants denied any impact of mood or emotion on dietary intake. As one participant noted, 'I don't think it does anything. I've never wanted to comfort myself with food. Music is my thing, but not food. And my husband doesn't either'. Participant 127, female, 83 years Theme A: Alterations in social interaction At the interpersonal level, alterations in social interaction emerged as a prominent theme with influences on eating behaviours. As described above, loneliness was not commonly reported among the older adults we interviewed. Nonetheless, participants did universally report less faceto-face interaction with others. However, despite less face-to-face interaction, questionnaire data showed that only four participants reported communicating with close friends and family less often than before. The vast majority of participants reported communicating with others at least several times per week ( Table 3 ). The most frequently cited methods of staying in touch with others were phone calls, texting, video calls, email, and social media. During the interviews, many participants described the increased use of technology for social interaction. In some cases, technology was used to adapt to less frequent eating with others. One participant described how she and her husband adapted their usual practices of eating with others to a virtual format, saying: We were used to eating out twice, three times a week with friends. We're retired. My husband had breakfast with a group of men. I had coffee every Thursday with a group of women. We ate dinner with a group every Wednesday night faithfully. Usually went out with a group after church on Sunday. All of those things. Our social life went to zero. What we have done is both of us instituted Zoom meetings with our friends. My husband got, the men all go and they meet every morning, every Wednesday morning at 9 o'clock on Zoom. They don't, several of the men in that group have health issues and the restaurant they went to is a little hole in the wall in downtown [location name]. They just can't go there. I mean, it's just not safe. But there are 15 men that meet Wednesday morning at 9 o'clock on Zoom. And, I have a, you know, I have a group of about 6 or 8 women who meet every Thursday morning and we have coffee. We're on probably hour and a half to chat every Thursday morning, which is what we would have done ordinarily, but we would have done it at the local coffee shop. Participant 113, female, 70 years Despite less face-to-face interaction overall, some participants described creative ideas for socially distanced gatherings that included food and beverages. One participant provided a vivid example, saying: When COVID first hit and everybody was isolating, we would have gatherings on our driveway with anywhere from 4 to 12 neighbours that would come over. And we would just socially distanceeverybody would bring their own lawn chair and we had chairs all overand I had an ice cream party. I made homemade ice cream for one of them. And I served it so everybody wasn't getting their hands on things, they'd come up one at a time and I served them whatever they want. And another time we just put out just some, just some finger food type of stuff. And then the heat hit and we just stopped having it, so we're gonna probably start up doing something -I just ordered a little fire pit for our backyard. What I hope to do is be able to start inviting 2 to 4 people at a time where we can just sit out there, and I'll put out some finger foods or something. Participant 115, female, 70 years Food sharing was also identified by a few participants as a way of staying socially connected with others. As one participant said, 'People are less reluctant for you to bring something to share. So, yes, I would say yes, that's a different food behavior'. Participant 108, female, 74 years Theme B: Importance of social support Finally, for older adults who described positive changes in dietary intake and food-related behaviours, social support was acknowledged as a facilitator. Several participants spoke of social support from family, and some commented about how more time at home had led to more meals together with immediate family members. For example, one person said: So COVID really, if anything, in a sense, we stay home more, which I love. I mean now we don't have the, the need or the ability to go places, which, so, it sort of forces us to stay home to be safe. But we're happy at home. Participant 115, female, 70 years Other participants described social support from friends and neighbours. For example, one participant who lives alone described the importance of her friends as a social network. She explained: My family is in Chattanooga and Nashville and Memphis. And I'm here, but I have a close support of friends here. And we don't we may not see each other except maybe once a couple, every couple of weeks or so, but we talk every day. And I have two groups of people that I speak with every morning just to make sure that everybody is still living. And not laying on the floor. Participant 117, female, 68 years Another participant told of food-related social support from a neighbour, stating: We have a neighbour next door who's a bachelor and he likes to cook and he knows a lot about food, so he's our primary go-to person once or twice a week that does our shopping for us. Participant 106, male, 87 years A few older adults also reported social support from church friends specifically. They explained that even though their faith communities were not meeting face to face for congregate worship, their friends from church remained important social contacts. For instance, one person noted, 'The home fellowship group with our church that we were very, very close to, went to Zoom when the virus came in'. Participant 128, female, 69 years Similarly, another participant said: I have a lot of church contacts. My friends from church, they keep in touch with us and, you know, in case we have an emergency need for anything, they're very good about helping us if we can't get our neighbour. Participant 106, male, 87 years This study explored the effects of the COVID-19 pandemic and associated social distancing requirements on the eating behaviours and dietary intake of independent, communitydwelling older adults in the southeastern United States. By describing their personal experiences, participants provided valuable insights that may help nutrition educators promote positive adaptive coping strategies to maintain good nutrition. Multiple themes emerged at the individual The COVID-19 pandemic and diets of older adults and interpersonal levels that may guide future nutrition interventions. Although a few participants reported more unhealthy food choices such as increased caffeine consumption and decreased intake of fresh vegetables, most older adults among this cohort said they had eaten healthier since the pandemic began. This is consistent with research from Spain that found healthier eating patterns and diet habits among younger adults during pandemic confinement (26) . For some participants in our study, the threat of illness from the virus motivated them to consider their previous eating habits, and they perceived choosing to eat more fruits and vegetables as a preventative measure to remain healthy. Previous literature supports the notion that an internal locus of control is associated with healthier food choices as well as other positive health behaviours (27) (28) (29) . However, previous research has also reported a declining sense of control over one's own health with advancing age (30) . Our results suggest that by talking with older adults about food-related behaviours and choices within their control, health care providers may help seniors improve nutrition status while fostering their autonomy. Gardening was also identified by some participants as a facilitator for the consumption of more vegetables. A review of gardening intervention studies among older adults revealed that most studies to date have examined the effects on energy expenditure and physical function (31) . Although studies of those outcomes have produced equivocal results, future studies should consider effects of gardening on dietary intake along with other potential physical and psychological benefits. Changes in cooking habits emerged as a strong facilitator for healthier food choices. Studies worldwide have similarly reported increases in home cooking since the beginning of the pandemic (32) (33) (34) (35) . In different countries and across various age groups, the increase in home cooking has been associated with greater intake of fruits and vegetables and less consumption of processed foods and fast foods (35, 36) . In the current study, participants described a sense of satisfaction and accomplishment from improved cooking skills. Some participants also described cooking as stress reliever and a form of entertainment. Another qualitative study similarly reported that cooking reduced boredom and negative feelings related to COVID-19. The authors concluded that cooking may provide an 'escape' from pandemic-related stress (32) . Considering reported declines in home cooking in the years preceding COVID-19 (37) , nutrition educators may seize the opportunity to encourage this behaviour change among community-dwelling older adults post-pandemic. At the individual level, some participants noted that stress, anxiety and boredom posed challenges to healthy eating. Particularly, these older adults reported a tendency to consume more sweet foods and energy-dense snack foods that are often categorised as 'comfort foods' (38) . Other studies with younger adults have likewise described emotional eating in response to perceived stress (33, 39) and boredom (40) from the pandemic. However, it is important to point out that among our cohort, several older adults denied any influence of mood or emotions on their food choices. A few even described a staunch resilience against allowing mood or emotion to impact their eating behaviours. These individuals identified other strategies they used to cope with pandemic-induced stress and boredom, for example, sewing, music or online activities. Again, these ideas present an opportunity for nutrition educators to encourage alternative behaviours that may counteract stress-induced emotional eating. Interpersonal-level themes At the interpersonal level, alteration in social interactions emerged as a theme associated with changes in foodrelated activities. Social isolation is a well-known nutritional risk factor (9) , and we hypothesised that the social distancing restrictions imposed by COVID-19 would compromise nutrition by worsening social isolation. To the contrary, although the older adults did report less face-to-face interaction with others, many also described the increased use of technology for social interaction. Phone conversations and text messages were the most frequently used methods of staying in touch with others, but many participants also used video calls, email and social media for social contact. Use of technology for social interaction also helped some participants compensate for the inability to eat with others as they described virtual happy hours and other food-related get-togethers. Eating alone has been associated with nutrition risk (10) ; however, social contact may take many forms, and alternatives to in-person contact have not been widely examined in nutrition research. This offers an opportunity for future intervention studies. Although all participants acknowledged fewer in-person gatherings due to the pandemic, some described creative and resourceful socially distanced face-to-face interactions. For example, participants described eating with others outdoors with chairs spaced out. These gatherings took place at parks, on driveways and in backyards with careful attention to food safety and COVID precautions. A few participants also identified food sharing as a means of social contact. To our knowledge, food sharing has not been explored as a facilitator for social contact or adaptive coping by previous studies, but our results suggest that further investigation is warranted. Social support was recognised as a facilitator for healthy eating by several participants. Social support has been defined in different ways in the literature, but most definitions consider social support to include both emotional support and instrumental, hands-on assistance (9) . The older adults in this study described emotional support from immediate family members in their households. However, even those who did not live with family could identify friends, neighbours and church members who provided both emotional and instrumental support. Benefits of church-based social support for overall health (41) and fewer depressive symptoms (42, 43) had been described prior to the pandemic. Before the pandemic, social support from religiousbased fellowships often involved physically going to places of worship to be with others. Findings from the current study provide unique insight into ways older adults adapted and maintained a sense of community even when they were unable to physically get together with their congregations. These strategies could be adapted beyond religious settings to help older adults find social support from various civic organisations and social groups. When conducting nutrition assessments, Registered Dietitians should inquire about support networks and help older adult clients identify resources for social support. Results of this study suggest multiple ideas for clinicians and researchers to help community-dwelling older adults maintain good nutrition status when faced with major life stressors such as the pandemic. However, results may not be widely generalisable as the older adults in this study were all relatively well educated, from the same geographic area, and predominately White and female. Findings may be much different among those with food insecurity, lower socio-economic status or among those with more physical limitations. Indeed, a recent review article described discordant results among studies that evaluated the impact of the COVID-19 pandemic on psychological symptoms of older adults in Canada. The authors highlighted that older adults represent a very heterogeneous group, so different segments of the population may be impacted differently (44) . Because all interviews for this study were conducted by Zoom, all participants in this study were somewhat tech savvy. Results may differ among older adults without access to computers, tablets or smartphones. However, policy changes during the pandemic opened internet access to some communities that did not previously have access, expanding the potential for technology-based communication to under-served areas (45) . This provides an opportunity for practitioners and agencies that serve older adults to educate seniors about how technology can be used for social connectedness. Despite these limitations, the study was strengthened by rigorous qualitative methods and a research team that was trained and experienced in the methodology. Member checking also revealed no discrepancies between the researchers' interpretation of the results and that of the participants themselves. According to WHO estimates, one in six people worldwide will be 60 years of age or older by 2030 (46) . Results of this study demonstrate the resilience of older adults amidst the worst pandemic in more than 100 years. By relating participants' first-hand experiences during the COVID-19 pandemic, these findings have implications for clinicians and future research. When working with community-dwelling older adults, health care providers should inquire about cooking skills, mood and social contacts of their clients. Some of the same strategies for adaptive coping to maintain healthy eating that were described in our interviews may be helpful to other seniors. Multiple opportunities exist for nutrition researchers to further explore positive changes in food-related behaviours such as cooking and use of technology for social contact. Research into facilitators of good nutrition status is imperative to meet the Healthy People 2030 developmental objective to 'increase the proportion of older adults who engage in preparedness activities for a widespread outbreak of contagious disease' (47) . Why does COVID-19 disproportionately affect older people? 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