Social and Cultural Aspects of Food

Although at its core the role of food is simply that of providing energy and nutrients for bodily functions, few individuals view food from this perspective. Over the course of history, different types of foods have served as poisons, potions, or panaceas for health, potency, long life, and love. Hippocrates (460–377 bc), the “Father of Medicine,” reflected his commitment to the importance of diet in a statement from the Hippocratic Oath: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice” (Tannahill, 1988). Cato the Elder (234–149 bc), a Roman statesman, ate large amounts of cabbage in the belief it had special healing properties. A later Roman scholar, Pliny the Elder (23–79 AD), ate the foot and snout of the hippopotamus to enhance sexual potency, whereas a Chinese physician of the sixth century bc prescribed certain foods for clients to stimulate the yin (female principle) and the yang (male principle) to keep a person healthy (Tannahill, 1988).

The public has grown increasingly interested in complementary and alternative medical therapies, including consumption of herbal teas, vitamin therapy, and a variety of touch therapies such as massage therapy. This has encouraged the clinician and practitioners of Western medicine to gain a thorough understand of the underlying concepts and mechanisms of Eastern medicine. Research is beginning to emerge on the efficacy of each therapy in relation to a particular physiologic problem. Nurses should use this evidence-based support to guide their patients on the use of complementary and alternative therapies in the treatment of any disease or condition. The use of vitamin and mineral supplements, ergonetic aids, and herbal teas can affect drug or nutrient interactions or both. Therefore, careful assessment of a patient’s diet and supplement intake is important in understanding the patient’s overall medical picture. A nursing referral to a registered dietitian (RD) can be very helpful for patients with complex dietary and medical conditions.

In present societies food and diet are manipulated to enhance athletic performance, carbohydrates are avoided to force the body into ketosis in an effort to burn fat for weight loss, and supplements are taken to replace the vitamins and minerals missing from the “fad diets” many Americans try. Comfort foods are now a designated and popular category, particularly after September 11, 2001, when purchases of donuts and pastries increased significantly (Balon, 2002; Comforted but unfattened, 2002).

Food is much more than fuel for the body; food in our society is a social centerpiece, a source of comfort, and a symbol of celebration. Consider the monthly calendar:

In addition to these holidays, there are birthdays, anniversaries, and other personal holidays. Life, death, and everything in between is celebrated with food. Culturally, food is a symbol of heritage, land, and environment, and religiously food is abstained from, eaten only on certain days, and certainly blessed by a higher power for the energy it provides to the body. Religious practices also specify prohibited foods and beverages (see Cultural Awareness Boxes).

Nutritional interventions that do not take into account the social, cultural, and emotional aspects of food are rarely effective because few individuals “eat to survive”; most of us “survive to eat.” For the nurse, understanding a patient’s social, cultural, and emotional ties to food can be a great asset in working with nutrition and health issues. This is especially true with geriatric clients, who hold strong ties to their culture, need social interaction to enhance functional status, and may be emotional labile when different foods are presented. For some, food can be a private and delicate point, which the health care practitioner must be sensitive to during conversation. The nurse is unlikely to influence basic beliefs about foods and their religious significance and should attempt to make recommendations that are consistent with religious beliefs.

Overall, within the medical field and compared with fields like biochemistry, chemistry, and biology, the field of nutrition

Nursing professionals should be encouraged to work with an RD, who is constantly updated on the latest nutritional applications for patient care. This collaborative relationship can optimize patient outcomes and enhance work efficiency for each practitioner. Both dietitian and nurse can thus bring a higher quality of health care to the patient and grow as practitioners. Allied health researchers and practitioners perceive dietary intake as one of the most significant, controllable tools for wellness, disease prevention, rehabilitation, and treatment or therapy for a wide range of disorders. To make changes in patients’ poor dietary choices, the entire team needs to work together and have an appreciation for the social, cultural, and emotional significance that food has to the vast majority of the population.

Demographics of the Aging Population

The “graying of the American population” can be considered one of the most far-reaching medical and nutritional issues of the millennium. Medically, this is a population that has served its country, worked hard, and now faces a health care system that views patients in terms of cost. Some of the individuals in this population are survivors of deadly bacterial diseases that plagued the world in the early 1900s. With the development of antibiotics and a growing pharmaceutical industry, these individuals who helped to automate this country are not only living longer but also are hearty souls capable of overcoming many adversities.

Nutritionally, the aging population comprises individuals who, for the most part, believe in a home-cooked family meal with fresh foods and cultural connections. Older adults are less comfortable with the food choices being made in today’s fast-paced world, and they are not as comfortable with the high-tech cooking gadgetry of the new millennium. As some of the younger baby boomers progress through their retirement (65–70 age group), this aversion to technology is less pronounced. The food choices and cooking habits in this age group are more erratic, and many prefer the use of technology in their methods of cooking to allow time for other activities; however, this age group may need support and guidance in their food choices to more positively enhance the aging process.

It is no secret that the aging population is growing. The 85 and older age cohort, which represented 3.4 million of the total population in 1993, is the fastest growing segment and makes up 10% of the older population. In the 120-year period between 1870 and 1990, individuals older than age 65 grew from 1 million to 32 million. In 2030 those older than 65 years of age are expected to reach 71 million individuals (American Dietetic Association [ADA] position paper, 2005b). Chronic diseases are compromising health status at later stages of life; these chronic diseases have repeated and direct correlates with dietary intake, exercise, stress management, and locus of control and include cardiovascular disease, cancer, stroke, osteoporosis, and diabetes. More often, the diagnoses of such diseases occur among the old-old (ages 85 or older), closer to the period of dying and death (the ninth and tenth decades of life).

Life expectancy has increased, but life span has not. Today’s average life expectancy at birth is about 75.7 years, whereas the life span is still considered to be 115 years, although a record of 128 years appears to have been set in January of 2009 by a woman in Uzbekistan who has provided documentation to the BBC that she was born in July of 1881 (BBC News, January 29, 2009). The old-old will continue to be the fastest growing group, and it is predicted (by the U.S. Census Bureau) to be 8.6 million by 2030. By 2050 this group may be 25% of the population age 65 or older (AARP, Administration on Aging, 2005).

The social and economic consequences of America growing older, coupled with lower birth and mortality rates, are vast, including a heavy demand on the health care industry. Nutrition, exercise, and engagement in other activities such as lifelong learning and education will enhance the functional capacity of this generation of individuals and their families, as well as reduce the incidence of depression, found to be increasingly prevalent, especially in older U.S. women (Stadler & Teaster, 2002; McGuire, Strine, Vachirasudiekha, et al, 2008).

Physiologic Changes in Aging that Affect Nutritional Status

Aging produces physiologic changes; however, assumptions about the aged are often generalizations without merit. A distinction should be made between the healthy aging person and the aging person with acute or chronic disease. For the healthy aging person, exercise and the resulting maintenance of muscle mass are emerging in research as one of the greatest determinants of maintaining vitality (Campbell, Johnson, McGabe, & Carnell, 2008). Loss of lean body mass, which is essentially loss of skeletal muscle, can lead to decreased strength and mobility, predisposing aging adults to falls and affecting (although minimally) metabolism. Exercise is effective in maintaining skeletal muscle mass, and it enhances functional status and fitness levels for aging adults by 10 to 20 years (Campbell et al, 2008).

Functional impairment often leads to malnutrition. Older adults with functional impairments may have difficulty performing, or be unable to perform, activities of daily living (ADLs) related to eating. They may be unable to shop for groceries, prepare food, or eat. Conditions that result in shortness of breath, pain, or limited mobility affect an individual’s ability and desire to eat. In addition, some medications further alter sensory receptors, resulting in greater differences in taste or smell. Changes in flavor, taste, and odor perception generally decline with age and can become quite exaggerated with some medications. For many of the elderly, foods that were once cherished and enjoyed as part of their culture now smell very different and are simply avoided. A report published by the AARP found that almost 22% of aging adults who live at home have health-related impairments in ADLs (AARP, 2005).

Physiologic changes that are common in older adults can lead to problems with nutrition. Organ function declines with age; this can affect digestion, metabolism, absorption of nutrients, and the ability to eliminate waste products via the kidneys (Keithley, 1996). The gastrointestinal system slows with age, resulting in less efficient absorption of nutrients (Zulkowski & Albrecht, 2003). Changes in the oral cavity include tooth loss or ill-fitting dentures, mouth dryness, and decreased esophageal motility. Satiety triggers are diminished in older adults, yet given the increased risk for skin breakdown and the likelihood of a compromised immune, circulatory, and respiratory system, the majority of the elderly populations have increased protein requirements (Zulkowski & Albrecht, 2003).

Delayed gastric emptying, hiatal herniation, and decreased secretion of gastric juices may cause bloating and discomfort. Changes in the pH of the gastrointestinal tract can lead to the malabsorption of B vitamins. Hepatic and renal reserves are decreased, which makes it harder to metabolize medications and alcohol and to conserve water or excrete nitrogenous wastes. Thirst regulation is often affected, making dehydration a prime risk among older adults (see Evidence-Based Practice Box).

Older adults are at risk of dehydration caused by a decreased intake of fluids, loss of sodium, and increased fluid losses. Physiologically, the decreased intake can be related to altered thirst; older adults may not feel thirsty even when hypovolemic and often do not compensate for fluid losses during illness. Confusion, depression, and dementia also contribute significantly to reduced food and fluid intake. Dehydration can take three main forms. Isotonic dehydration results from the loss of sodium and water, such as during a gastrointestinal illness. Hypertonic dehydration results when water losses exceed sodium losses. This type of dehydration is the most common and can occur from fever or limited fluid intake. Hypotonic dehydration can occur with diuretic use when sodium loss is higher than water loss (Weinberg & Minaker, 1995).

Psychosocial and Socioeconomic Factors Related to Malnutrition

Poverty is a significant problem for older Americans, particularly as individuals age. The U.S. Census Bureau reports that 10.1% of adults ages 65 or older were below the poverty level; in the 75 or older subgroup, 43% fell into a substandard level (AARP, 2005). When individuals have a fixed income to cover housing, clothing, utilities, food, health care, medications, and other expenses, food may be sacrificed, especially as the percentage of income required for health care rises. It is estimated that 61% of women and 31% of men older than 65 live on annual incomes less than $10,000. The cost of medication for the elderly has significantly compromised many already low-income budgets, forcing individuals to choose between food or the medication (Zulkowski & Albrecht, 2003). Food may initially be limited in quality as a transition to high-fat, high-carbohydrate convenience foods occurs, followed by a limitation in quantity.

Social isolation is another factor contributing to malnutrition. Older adults may skip meals completely when they live alone and have no one with whom to prepare and share meals. Grieving over the loss of a spouse or friends also affects diet quality and intake. It is important to keep in mind that as individuals age their loss of friends and family members can be significant and overwhelming. These psychosocial factors, such as isolation and depression, and economic issues, such as poverty or the limitations of a fixed income, can affect food purchases and, ultimately, total intake. Approximately 8% to 16% of older adults do not have access to a nutritious, culturally acceptable diet, and federal programs to combat hunger and malnutrition reach only about one third of the population they are intended to benefit. Many of those who receive home-delivered meals have two or three chronic health conditions. While those that receive home-delivered meals have most likely been hospitalized within the previous year (Ponza, Ohls, & Millen, 1996), the lack of companionship during mealtime can result in home-delivered meals being left uneaten. Both older women and men report eating more when with others, including family and friends, than when alone (ADA position paper, 2005b). Meals-on-Wheels programs and congregate dining arrangements can

Nutritional screening is an abbreviated assessment of nutritional risk factors that determines which clients are in need of a more comprehensive assessment and nutritional interventions. A variety of tools have been developed to conduct nutritional screening. Perhaps the most widely used of these tools is the “Determine Your Nutritional Health” screening tool developed as part of the Nutrition Screening Initiative (NSI) (Fig. 10–1).

The NSI (Dwyer, 1991), a 5-year, multifaceted national effort to promote routine nutrition screening, began in 1990 under the direction of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on the Aging. As part of the initiative, a nutritional health checklist was developed to be used by older adults or caregivers to determine risk factors associated with nutrition and health. A score of 3 or more indicates moderate to high nutritional risk and triggers the need for a more comprehensive nutritional assessment. The Level II Screen is a tool that health care professionals use to conduct a more in-depth assessment of nutritional status (Fig. 10–2).

The importance of nutritional screening is emphasized in the standards and guidelines developed by the Health Care Financing Administration (HCFA) (now the Centers for Medicaid and Medicare Services [CMS]) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The Outcome and Assessment Information Set (OASIS) implemented by CMS includes data elements relating to food intake and nutritional status (HCFA, 1998). This massive project is designed to collect and measure client care outcomes for home care clients. Nutrition-related outcomes for OASIS in home care include “improvement in eating and stabilization in light meal preparation.” The focus of the OASIS project is to develop outcome measures that lead to performance improvement.

A variety of studies have shown that nutrition affects immune status and length of hospital stay (Feldblum et al, 2008). Outcome management attempts to identify critical interventions that produce a positive clinical outcome at lower cost. Because nutrition is an integral intervention in many diseases, disease state management programs or clinical pathways often incorporate nutritional interventions. Malnourished, hospitalized clients have more infections and other complications, which significantly increase the costs of hospitalization and care (Feldblum et al, 2008).

Standards developed by the JCAHO require nutritional screening of all hospitalized and home care clients who receive clinical services (JCAHO, 1998). The standards also require referral for a comprehensive assessment if the client is found to be at moderate to severe nutritional risk.

Nutritional Assessment

A nutritional assessment is a comprehensive evaluation of a client’s nutritional status and typically includes data collection in each of the following areas: demographic and psychosocial data, medical history, dietary history, anthropometrics, medications and laboratory values, and a physical assessment. Nutritional assessment may be performed as a result of an identified risk on a nutritional screening or when the risk status is obvious without a preliminary screening. The American Society for Parenteral and Enteral Nutrition (ASPEN) published standards that identify nutritionally at-risk clients (Box 10–1) (ASPEN, 1995). ASPEN also identified the goals of a nutritional assessment as follows:

BOX 10–1   NUTRITIONALLY AT-RISK CLIENTS

• Involuntary loss or gain of 10% or greater of usual body weight within 6 months, or

• Loss or gain of 5% of usual body weight in 1 month

• 20% over or under ideal body weight

• Presence of chronic disease or increased metabolic requirements

• Altered diets or diet schedules

• Inadequate nutrient intake for more than 7 days

Data from the American Society for Parenteral and Enteral Nutrition, Board of Directors: Standards for nutrition support: hospitalized patients, NCP 10:208, 1995.

• Establish baseline subjective and objective nutrition parameters.

• Identify specific nutritional deficits.

• Determine nutritional risk factors.

• Establish nutritional needs.

• Identify medical and psychosocial factors that may influence the prescription and administration of nutritional support.

Diet History

In addition to a complete history and physical assessment, clients who are found to be at nutritional risk require a more specific evaluation of their dietary intake patterns. Information that is typically part of a diet history includes number of meals and snacks per day; chewing or swallowing difficulties; gastrointestinal problems or symptoms that affect eating; oral health and denture use; history of diseases or surgery; activity level; use of medications; appetite; need for assistance with meals and meal preparation; and food preferences, allergies, and aversions. A diet history may also include a food recall. For accuracy and relevancy, the food recall must include specific information about the type of food ingested, the preparation method, and an accurate estimate of the amount. The client should also be cautioned to select days for recording that are typical of his or her intake patterns. Clients should be instructed about how to estimate portion sizes and should be given samples from which to estimate their intake (e.g., 3 oz of meat is the size of a pack of cards; a serving of vegetables is usually ½ cup). The purpose of the food recall is to estimate the average number of calories and amount of protein ingested daily and to detect any deleterious food intake patterns, such as overuse of fried foods or lack of vegetables or fruit. Some clients may need assistance from another person, if available, to complete the food recall.

For a more detailed picture of a client’s diet and food patterns, a 3- to 7-day food intake history is obtained. Clients are asked to keep a detailed record of everything they eat, the time at which they eat, and the amount of each type of food item that is consumed. In addition to recording eating habits, clients are also asked to record activities and feelings, which allow the health care professional to determine whether there are emotional issues or activities that may either interfere with or enhance eating pleasure.

The final means of assessing dietary patterns is to look at food frequency. Food frequency questionnaires allow a health care professional to assess a particular nutrient category, such as calcium intake, or the adequacy of an individual’s entire diet. A food frequency questionnaire is completed either by a medical assistant or by the patient during his or her wait in a health professional’s office. Food frequency questionnaires are recommended for new clients because they allow the practitioner to collect reasonable dietary data without compromising the patient’s sense of privacy about food intake and diet.

Anthropometrics

Height and weight are the mainstays of anthropometric measurements. Ideally the client is weighed in the morning while wearing light clothing. Height is measured, if possible. For clients who are unable to stand without assistance, height can be estimated by measuring the distance from the heel to the top of the knee (knee height) with the use of a broad-bladed caliper. This measure can be used to estimate height with the following formula (Nutritional assessment of the elderly through anthropometry, 1988):

Knee Height as an Estimate of StatureStature for men=(2.02×knee height in cm)−(0.04×age)+64.19Stature for women=(1.83×knee height in cm)−(0.24×age)+84.88

In comparing weight and height, the nurse can use instruments such as the Metropolitan Life Insurance Table of Weight for Height as a reference. Surveys of weight changes with age reveal that the young-old are more likely to be overweight, whereas the old-old tend to be underweight (Andres et al, 1985). With age there is a loss of lean body mass and an increase of body fat; therefore body weight alone can be misleading. Older adults should be cautioned against extreme leanness. Andres et al (1985) report an increased mortality risk in lean older adults compared with older adults who have 10% to 15% more body weight. With this information, Andres et al created a table of heights and weights (Table 10–1).

TABLE 10–1

A WEIGHT TABLE FOR OLDER ADULTS

This age-adjusted weight chart, devised by Johns Hopkins University gerontologist Dr. Reubin Andres, indicates medically sound weight ranges for people in their 50s and 60s. The ideal weight for most people is around the midpoint for each person’s age and height. Those in the lower ranges are probably heavy enough to maintain good health, as long as there is no sudden or unexplained weight loss. Weights in the upper ranges may also be acceptable, but if a client finds himself or herself on the high side, he or she should talk with a physician about the possibility of losing weight. A physician makes recommendations based on where the client tends to store fat and his or her general health.
HEIGHT	WEIGHT (LB) AGES 50 TO 59	WEIGHT (LB) AGES 60 TO 69∗
4’10”	107–135	115–142
4’11”	111–139	119–147
5’0”	114–142	123–152
5’1”	118–148	127–157
5’2”	122–153	131–163
5’3”	126–158	135–168
5’4”	130–163	140–173
5’5”	134–168	144–179
5’6”	138–174	148–184
5’7”	143–179	153–190
5’8”	147–184	158–196
5’9”	151–190	162–201
5’10”	156–195	167–207
5’11”	160–201	172–213
6’0”	165–207	177–219
6’1”	169–213	182–225
6’2”	174–219	187–232
6’3”	179–225	192–238
6’4”	184–231	197–244

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