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Margaret-Mary G. Wilson MD 1,2, Natasha Simmons B.Sc 1, Carolyn Philpot CGNP 1 Division of Geriatric Medicine, St. Louis University Health Sciences Center 1 and the GRECC, Veterans' Administration Medical Center, St. Louis 2. Corresponding Author: Margaret-Mary G. Wilson, MD Division of Geriatric Medicine, St Louis University Health Sciences Center, 1402, S. Grand Blvd, Rm M238, St. Louis, MO 63104. Tel No.: (314) 577-8462. Fax No: (314) 771-8575. E-mail: firstname.lastname@example.org
Objectives: To evaluate the effect of eating attitudes on body weight trends of African-American long-term care (LTC) residents. Design: Cross-Sectional study. The 3-factor eating questionnaire (3-FEQ) was administered to all study participants. Setting: Long term care geriatric facility housing only African American residents Participants: 53 African American residents Variables Measured: Cognitive restraint, dis-inhibition, and hunger dimension scores were analyzed for each subject. Body weight, height and body mass indices were obtained over the preceding year. Analysis: 3-factor ANOVA and Tukey's honestly significant difference test for post hoc comparison of means Results: Residents with weight loss had higher dis-inhibition and hunger scores (4.8±0.7 and 5.1±0.8) compared with residents who maintained or gained weight (3±0.4 and 2.4±0.6; p=0.01 and 0.003). Two and three-way interactions between gender, education and weight trend were not significant. Conclusion and Implications: Elevated dis-inhibition and hunger scores may indicate increased predisposition to weight loss among African-American LTC residents. Nutrition programs targeting this cohort should emphasize appropriate counter-strategies, such as limiting environmental regimentation, increasing social interaction and encouraging peer-directed activities. Key words: appetite, aging, weight loss
Nevertheless. in a notable number of cases. Missouri and surrounded by predominantly African-American communities that serve as the main source of referrals. namely. The facility has 84 residents all of whom are African American. This syndrome is highly prevalent in nursing homes occurring in 23 85% of all nursing home residents 1. despite available evidence indicating that culturally determined attitudes influence eating attitudes and behavior . Distinct patterns of abnormal eating behavior with characteristics of anorexia nervosa have been described in older undernourished adults. This theory is supported by the results of earlier studies that implicate inappropriate eating attitudes as a primary factor in the genesis of of weight loss in the elderly 4. renal failure. This questionnaire comprises 36 questions requiring a true/ false response and 15 multiple choice questions.EFFECT OF EATING ATTITUDES ON BODY WEIGHT TRENDS AMONG AFRICAN-AMERICAN NURSING HOME RESIDENTS Unintentional weight loss (UWL) in older adults is associated with adverse clinical outcomes and increased mortality. This study was designed to evaluate the eating attitudes of a cohort of African-American nursing home residents. iatrogenesis or adverse socio-economic events. cognitive dietary restraint.9. there is still limited data regarding the role of eating behavior and attitudes in the maintenance of geriatric nutritional health 8.3. dis- . which has been validated for the measurement of eating behavior was administered to all residents. resulting from medical illness. However. nephrotic syndrome or liver cirrhosis were excluded from the study. nausea or vomiting. Residents with a Geriatric Depression Score (GDS) > 14 or a Mini-Mental Status Examination (MMSE) < 18 were excluded from the study 12. Questionnaires were scored according to published guidelines. Additional exclusion criteria included malabsorption. "anorexia of aging" and involuntary weight loss in older adults pose major diagnostic and management challenges. 13. Patients with active congestive cardiac failure. Reduced energy intake. These findings and the results of more recent studies suggesting an association between abnormal eating patterns and increased morbidity in older adults warrant further exploration of the effect of eating attitudes on the health of this segment of the population 6. Abnormal eating attitudes and behavior have been proffered as possible explanations for some of these cases 4. cigarette smoking. Within the long-term care setting. chronic obstructive pulmonary disease and recurrent diarrhea. 11.7. a 51 item questionnaire. The effect of eating attitudes on the body weight trends of these residents was also assessed. All residents were approached for participation in the study. Available studies of eating attitudes among older adults focus on populations that are predominantly Caucasian 5.5. Furthermore. The term "anorexia of aging" has been proposed to describe this phenomenon 2. yielding three constructs scores each of which reflects one of three dimensions of eating behavior. METHODS The study site is a long term care facility (LTCF) located in the inner city of St Louis. little is known about the health effects of such differences within disparate cultures10. uncontrolled diabetes mellitus or thyroid disease. The 3factor eating questionnaire (3-FEQ). is frequently implicated as the major cause of UWL in nursing homes. a history of cancer in the past 5 years. the reduction in food intake can not be explained.
weight and Body Mass index of all participants was obtained over the preceding twelve months. 0. Dis-inhibition describes the tendency to increase food intake.1 and 0. The difference in dietary restraint scores between both groups was not significant. compared with residents who maintained their weight or exhibited weight gain. in the presence of enhanced hedonic stimuli during a meal or in the face of emotional challenge. Hunger refers to the subjective sensation that the individual perceives as signaling the need for food intake 14. Data are presented as means +/. the main psychiatric disorder associated with weight loss and undernutrition is anorexia nervosa. whereby the affected person thinks of herself as obese. educational level and weight trend on eating attitudes scores are shown in Table 2. Any statistically significant effects were further analyzed using Tukey's honestly significant difference test for post hoc comparisons of means.SEM.3 respectively). gender and weight trends were not significant.with no documentation of decrease in body weight below admission weight. educational level( <8years and > 8 years) and weight change ( loss or gain). in the absence of any clearly identifiable medical cause. For the purpose of data analysis. Dietary restraint refers to the tendency to consciously limit the type and amount of food ingested in an attempt to either lose weight or prevent weight gain. a negative weight trend was defined as > 10% decrease in the baseline body weight over a 12 month period. The three factors used were gender. Two way interactions between educational level and gender. Monthly height. scored significantly higher in the dis-inhibition and hunger domains of the 3-FEQ. namely dietary restraint. The three-way interaction between educational level. This theory has led to the misleading tendency to assume that high dietary restraint . The main effects of gender. DISCUSSION The The 3. with no documentation of return to baseline body weight within the 12 month period. Similarly. RESULTS Fifty-three (22M. Statistical analyses were performed using Statistica. Questionnaire scores were analyzed using 3-factor repeated measures analysis of variance (ANOVA). and educational level and weight trend were also not significant (p=0.05 was considered significant in all analyses. Overall.7. The demographic data for the study population are shown in Table 1. dis-inhibition and hunger.inhibition and hunger 14. A p value <0. In this study we found that residents who exhibited progressive weight loss .factor eating questionnaire (3-FEQ) used in this study is a psychometric instrument that has proven useful in enabling a more differentiated study of three domains of eating behavior. a positive weight trend was defined as a progressive increase in weight or weight unchanged over a 12 month period . although in reality she is underweight. This syndrome involves deliberate weight loss driven by a disturbed concept of body image. gender and weight trend. Our results also showed that neither gender nor educational level had a significant influence on eating attitudes in the study cohort. 31F) residents were included in the study.
in nursing home residents.is the major factor responsible for weight loss associated with abnormal eating attitudes. the majority of whom were Caucasian. Most studies examining pathological eating behavior have focused on Caucasian subjects and have resulted in the conceptualization of eating disorders as a disease of young white women within societies where there is a socio-cultural drive toward thinness. Notably. frequency of meals is more important than energy consumption in the definition of a dominant hunger trait. Studies establishing the presence of anorexia nervosa like syndromes in older adults with unexplained weight loss tend to validate such assumptions 15. while Japanese women resident in Britain exhibited moderate traits of emotional eating 22. Noninstitutionalized persons with a dominant hunger trait will often be observed to seek out food and eat at frequent intervals during the day. However. examined the eating attitudes of older veterans. They found a strong linkage between emotional stress and food consumption.16. further emphasize the need to explore cross-cultural influences on eating behavior and nutritional health. Additionally. This controversy remains unresolved due to the paucity of literature that objectively explores the relationship between ethnicity. Japanese women resident in Japan showed no association. the results of several descriptive studies have led to the assumption that non-Caucasians and men may be relatively resistant to eating disorders. which indicate an association between eating behavior in AfricanAmerican nursing home residents and significant weight loss.18. Data indicating that these sub-groups of the population may have less restrictive body weight standards lends credence to this assumption17. The inability of older adults to compensate for energy deprivation by increasing subsequent food intake may further compromise daily energy intake in such residents. The results of our study. the older adult with disproportionate representation of the hunger trait may eat relatively more meals. cultural variation and eating behavior 20. The lack of sufficient social . suggesting that dietary restraint may be the more prevalent attitude in older adults 5. studies indicating similar degrees of body dissatisfaction among Caucasians and nonCaucasians challenge the theory of cultural specificity of eating disorders 19. Conceivably. Miller et al in a previous study. Waller et al in a recent study demonstrated a cross-cultural difference in eating attitudes between Japanese and British subjects. loosely termed "emotional eating". Residents with high hunger scores often complain of "feeling hungry all the time". it is conceivable that persons with increased dis-inhibition may lack the stimulus to eat within the relatively regimented ambience of the NH. However. They identified inappropriate self-restraint around food in 60% of the cohort. limited access to meals on demand in the LTC environment may result in fewer meals. in British women. thereby decreasing daily energy intake. Thus. Although systematic cross-cultural prospective studies will be needed to adequately address a causal relationship. highlight the need for further systematic research in this area. The findings of our study indicating increased dis-inhibition among African American Nursing home residents with significant weight loss. Several hypotheses may be advanced to explain the tendency for subjects in our study with higher dis-inhibition and hunger scores to lose weight. while not necessarily consuming relatively greater amounts of energy. indicating shorter periods of satiety. thereby placing the resident at even greater risk of significant weight loss 21.
Thus. as occurs within the free-living community environment. They hypothesized that highly dis-inhibited eaters may have a greater intake of highly refined foods which may promote the development of disease. regardless of ethnic origin or cultural make-up.stimulation and the paucity of situations that induce abrupt changes in emotion. resident committees and special interest clubs affords the residents the opportunity to experience emotional stresses similar to those associated with independent living within the community. Outside meal-times. as the increased social interaction that occurs during such activities may enhance energy intake. Additionally. A mobile snack cart or food bar that circulates through the facility several times a day between meals would increase the availability of food to less ambulant and bedfast residents. Hays et al identified an increased risk of hypercholesterolemia and diastolic hypertension in community-dwelling older women with high dis-inhibition and hunger traits. in their study there was no association between dietary restraint and increased morbidity 23. may detract from the stimulus to consume food. This approach is particularly helpful to residents with elevated dis-inhibition traits. An innovative recreational dining program is critical to enhance energy intake in residents who are dis-inhibited eaters. Nevertheless. In disinhibited eaters. this study is unique in that it is the first to . are subjected to intervention that is directed mainly toward encouraging increased energy consumption and cognitive-behavioral techniques aimed at reducing meal related anxiety. Although our study suggests the potential for cross cultural variance in eating attitudes among nursing home residents. The results of our study suggest that a formal evaluation of eating attitudes may be a valuable guide to the development of an effective individualized nutritional intervention program for residents with significant weight loss. Additionally. Residents with increased hunger traits may benefit from more frequent meals and should be evaluated for satiety after each meal and offered second helpings. Thus. Handicapped accessible Vending machines that dispense pre-packaged "ready to eat " food snacks conveniently located within the facility would be helpful in this regard. residents should be encouraged to partake of snacks during routine recreational and rehabilitative activities. pet and music therapy are helpful adjuncts in this regard. these interventions may stimulate energy intake. Attention should be given to the dining ambience by enhancing the physical decor of the dining area and ensuring a pleasant dining atmosphere ( Table 3). Notably. This serves the additional purpose of recreational intervention. it is important that the resident is encouraged to participate in interactive programs. NH residents with anorexia and unexplained weight loss. Review of most LTC nutritional intervention strategies identifies reduction of high dietary restraint as the primary goal. Due consideration needs to be given to limitations of our study. Interdisciplinary involvement in nutritional intervention programs is critical to ensuring adequate nutrition in the NH. the identification of residents with high dis-inhibition scores is important as previous studies have identified an association between high dis-inhibition scores and increased morbidity. Inter-generational. the lack of a Caucasian control group precludes firm comment as to cross-cultural variance. Objective analysis of the association between eating attitudes and body weight trends may be confounded by the retrospective analysis of body weight. allowing only for historical comparison based on previous literature. Easy access and availability of food between meals is critical for this group of residents. the institution of peer-directed recreational activities. if desired. as it increases the opportunity for interpersonal contact for such residents.
7 3.9 6.with no documentation of decrease in body weight below admission weight.6 4.2 Dis3.8±0. Awareness of these issues warrant the development of nutritional intervention programs in LTC facilities that take into account differences in eating attitudes and behavior.7 0.0±0.4±0.8 6.55 -61 .1 5.01 inhibition Hunger 3. Our findings emphasize the broad spectrum of eating attitudes that may be found in older adults and highlight the adverse effects that such attitudes may have on body weight. b Positive: Progressive increase in weight or weight unchanged over a 12 month period .2 ± 0.4±0. 31F) Mean±SEM Range Age (yrs) Weight (lbs) Body mass index Weight change (lbs) 84±2.2 3. Table 3: Practical Recommendations to combat weight loss in nursing home residents with dominant hunger or dis-inhibition traits.7±0.examine eating attitudes among a cohort of exclusively African-American nursing home residents.6 0.8±0.7 4. Table 1: Demographics of study population.4 2.3±0.7±0. gender and weight trends on eating attitude scores Education (yr) Male N=22 Female p N=31 < 8> 8 p N=29 N=24 Weight trend negative positive p N=13 N=21 Restraint 6.4 4.3±3. N = 53 ( 22M.4 0. 3 72 .83. Further systematic studies are needed to investigate the full spectrum of eating behavior in older adults and to explore fully the effect of cultural variance.7 4.101 106 . .3 6.7 0.7 Table 2: Main effects of educational level.3±0.5±0.4 7.6 0.1±0.354 17 .9 26. with no documentation of return to baseline body weight within the 12 month period.2±0.7±0.6 0.7 7.7 0.5 0.8 2.6 0.2±0.003 a Negative weight trend : > 10% decrease in the baseline body weight over a 12 month period.0±0.3 158±5.4±0.9±0.0±0. Health professionals in LTC settings should be cognizant of the possibility that cultural differences may influence food intake and eating behavior.8 6.8 3.
attentive staff. recreational activities and resident committees Accessible snack vending machines • . cheerful decor and well lit. Positive ambience (music.Dominant hunger trait • • • • Offer option of six small meals daily Offer snacks during medication rounds Assess satiety after meals and offer second helpings Recreational circulating snack bar Dominant dis-inhibition trait • • • • • • • • • • Dining-specific Pleasant dining area. brightly colored. choice of dining companions) Combine social activities with dining General Inter-generational therapy: "adopt-a-granny" or Teen-connect" programs Pet therapy Music therapy Competitive games Peer-directed special interest clubs.
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