Introduction
Since the 1990s, when malnutrition and under-nutrition amongst elderly populations in the Western world was documented as a societal problem, nutritional and gerontological studies have dealt with the prevalence and consequences of malnutrition among both self-reliant and frail home-dwelling older people (Nyberg et al. Reference Nyberg, Olsson, Pajalic, Örtman and Andersson2015). A majority of these studies have used quantitative or mixed-method approaches either to map intake and consumption patterns or to define determinants of healthy eating in old age and thus understand or predict their correlation with a variety of health and wellbeing parameters (Anyanwu et al. Reference Anyanwu, Sharkey, Jackson and Sahyoun2011; Clarke and Bennett Reference Clarke and Bennett2013; Conklin et al. Reference Conklin, Forouhi, Surtees, Wareham, Nicholas and Monsivais2015; Hansen et al. Reference Hansen, Nielsen, Biltz, Seidelin and Almdal2008; Keller Reference Keller2006; Klebak Reference Klebak2014; Maitre et al. Reference Maitre, Van Wymelbeke, Amand, Vigneau, Issanchou, Sulmont-Rossé and Issanchou2014; Munk et al. Reference Munk, Beck, Holst, Rosenbom, Rasmussen, Nielsen and Thomsen2014; Olin et al. Reference Olin, Koochek, Ljungqvist and Cederholm2005; Payette and Shatenstein Reference Payette and Shatenstein2005; Quandt et al. Reference Quandt, Vitolins, DeWalt and Roos1997; Rurik Reference Rurik2006; Sahyoun and Vaudin Reference Sahyoun and Vaudin2014; Sørbye et al. Reference Sørbye2008; Sorensen et al. Reference Sorensen, Holm, Kondrup and Bom2012; Torres et al. Reference Torres, Féart, Samieri, Dorigny, Luiking, Berr, Barberger-Gateau and Letenneur2015).
In recent years these primarily quantitative studies have been complemented by a range of qualitative studies discussing the importance of understanding both individual and societal practices, such as meal services, eating habits, as well as meal practices and preferences among older people, providing more in-depth insights into actual eating situations.
In Scandinavia, studies investigating how eating situations are influenced and shaped by a range of features specific to the Scandinavian welfare states have, for instance, pointed to how home-dwelling and institutionalised older frail people depend upon others, persons as well as state provision systems, to maintain previous and more healthy eating patterns (Edfors and Westergren Reference Edfors and Westergren2012; Sydner and Fjellström Reference Sydner and Fjellström2005, Reference Sydner and Fjellström2007). These studies thus emphasise the importance of structural conditions and inter-personal relations to older people's sense of ownership over meal situations, highlighting how the possibility of participation in the shaping and arrangement of the eating situation affects older people's sense of pleasure and appetite in meal settings.
Other studies have focused on the importance of gendered practices and perceptions to older people's sense-making of food and eating situations. A main area of study has thus been on food perceptions and practices among older home-dwelling women (Andersson et al. Reference Andersson, Nydahl, Gustafsson, Sidenvall and Fjellström2003; Gustafsson and Sidenvall Reference Gustafsson and Sidenvall2002; Gustafsson et al. Reference Gustafsson, Andersson, Andersson, Nydahl, Sjödén and Sidenvall2002, Reference Gustafsson, Andersson, Andersson, Fjellström and Sidenvall2003; Sidenvall, Nydahl and Fjellström Reference Sidenvall, Nydahl and Fjellström2000, Reference Sidenvall, Nydahl and Fjellström2001; Sidenvall et al. Reference Sidenvall, Fjellström, Lumbers and Raats2007). These studies have mainly focused on self-reliant women who cook their own meals, stressing the importance of the women's prior experiences with food preparation and cooking to their food perceptions and practices in old age.
That gendered patterns of perception and behaviour exist and are important to the ways in which older people make sense of their eating situation is supported by an American study of frail men and how their relationship to cooking shapes their eating practices (Moss et al. Reference Moss, Moss, Kilbride and Rubinstein2007). The study identifies that the men generally associated food with physical strength and as a way to maintain their body. This was, however, found to be most pronounced amongst widowed men because they, in contrast to married men, did not associate food and eating with pleasure but instead regarded it merely as a means to stay alive. Another important insight from the study was that the men saw food as a way to maintain control over their lives. Several of them thus described themselves as being in control in situations involving food, even though they received help from several women, such as their daughters or home helpers. Other studies also accentuate the important link between food intake, food perception and control as still very prominent in old age, e.g. how perceptions of health, slimming and body size play significant roles in eating habits and food preferences, especially among older women (Gustafsson and Sidenvall Reference Gustafsson and Sidenvall2002).
The objective of this article is to follow this line of qualitative research and to contribute to the field with an analysis of the strategies frail home-dwelling older people who receive food from a public supplier develop and utilise in eating situations, in order to make these meaningful. In a Danish context this segment of older people has so far not been the subject of much research (Mahler and Sarvemäki Reference Mahler and Sarvemäki2012). Focusing on this group thereby allows us to gain insights into the eating strategies of a population segment which is currently of great concern to the Scandinavian welfare states and to contribute to knowledge about the importance of the arrangement of the eating situation, the articulation and connection to previous skills, and how the perception of the body impacts on eating behaviours. More specifically, we use the term ‘arena’ to describe these three themes as specific clusters or junctions where meaning and practices related to appetite and eating situations meet and wherein the frail older person develops and utilises strategies. Our research questions are twofold:
• Which strategies do the arenas inspire and give rise to?
• How are the strategies used to create eating situations that are considered to be meaningful and acceptable by the frail older person?
Our focus on eating strategies is inspired by the work by nutritional researchers Elisabeth Vesnaver and colleagues on the presence and importance of eating strategies for dietary resilience among self-reliant older people (Vesnaver et al. Reference Vesnaver, Keller, Payette and Shatenstein2012). In their study, Vesnaver et al. (Reference Vesnaver, Keller, Payette and Shatenstein2012) define strategies as ‘adaptive strategies that enable an individual to maintain an adequate diet despite facing dietary challenges’ (p. 731). Adaptive strategies are thereby seen as positive features that, if successfully adopted by the older person, result in dietary resilience.
The analysis rests on the assumption that adaptive strategies as defined by Vesnaver et al. are also prominently at work in the eating situations of frail home-dwelling older people who have been identified as a vulnerable segment by municipal health authorities. We find that a focus on the strategies among this group entails an opportunity to contribute to the existing work with insights about agency and resources of frail older people. The importance of extending and developing the understandings of the eating situations of frail older people follows previously generated ethnographic insights about the agency and resources of vulnerable older people (Grøn Reference Grøn2016). According to Grøn, understanding the experiences of this group, both in the minds of care personnel and the vulnerable older people themselves, is inherently dynamic depending on the situation. Focusing on the co-existence of vulnerability and resources, and on the development of adaptive eating strategies in the practices of frail older persons, thus opens up a more nuanced understanding of their everyday life and also, perhaps, leads to a more adequate mobilisation of the hitherto unrecognised resources among this group (Grøn Reference Grøn2016).
Studying older people who have been characterised as very frail and who daily face eating challenges, we do, however, not see adaptive eating strategies as only positive. In our study the strategies are not necessarily tied to the development of dietary resilience but, as we will show, can also counteract nutritionally beneficial eating habits. This widening of the concept of eating strategies can thus be used to highlight the daily mobilisation of resources – good as well as bad – taking place in this demographic group, and to show how investigating these provides valuable insights into how the strategies interplay with and impact on health-related behaviour.
Method
Our study is based on qualitative, semi-structured interviews and observations with 25 frail, home-dwelling older people who live in Copenhagen Municipality, undertaken over a three-month period in 2015. All of them receive food from Copenhagen's municipal food supplier KMS (Københavns Mad Service à la Carte). The participating older men and women are aged between 72 and 101. All of the informants except one couple are widowed or never-married and live alone. They were recruited via telephone calls made by KMS staff. During the telephone calls, the older people were asked if they would be part of the study. On acceptance they were informed about the purpose and duration of the interviews and observations, and gave permission for the researchers to contact them. All of the participants signed a consent form and could leave the study at any time. The study was a collaborative project between researchers from the University of Copenhagen and Copenhagen Municipality, partly funded by the municipality, but based on a formal agreement, which permitted the researchers to design the project, analyse the data and disseminate the results without interference from the municipality.
This article is based on the interviews which were semi-structured conversations about topics associated with food delivery, daily eating habits, the informant's appetite throughout the day and any recent changes there may have been in relation to this. The informants were interviewed, observed and photographed in their homes around the time when the food was delivered (about 11:00 am). The visits lasted between 30 minutes and two hours, including the interviews. The researcher either ate her packed lunch or had ordered a portion of the same food that was delivered to the informant. The interviews were based on open-ended questions, with the aim of letting the informant lead the conversation and through this to point to and identify themes. The interviews have all been transcribed verbatim and coded inductively according to main analytical themes (Jespersen, Sandberg and Mellemgaard Reference Jespersen, Sandberg and Mellemgaard2017).
Food as a welfare service
Public food delivery to home-dwelling citizens was introduced in Denmark in 1968, when Copenhagen Municipality started a trial project delivering food (Jensen Reference Jensen2015). The programme was initiated as a reaction to a combination of a longer life expectancy, a political strategy to reduce the institutionalisation of older citizens and the desire of many to remain in their own homes for as long as possible (Jensen Reference Jensen2015). This resulted in more older Danes living in their own homes despite facing challenges in relation to the daily running of their household (Ældrekommisionen 1981). In the 1970s, the programme spread to other municipalities in Denmark. The Danish municipal food delivery programme can be compared, on an international level, to meals-on-wheels programmes. However, a significant difference is that all Danish citizens are eligible for food delivery services from either a public or a private provider, if they are referred to the service. The Danish state subsidises a proportion of the production cost and the citizens thus pay a very low price for the service. The delivered food is the main meal of the day and it is delivered hot. The meal service also includes the possibility to buy a range of snacks and supplementary meals such as breakfast; these are all delivered cold. The citizen is moreover offered the option to shop for groceries from an online catalogue to be delivered to their home.
In Copenhagen Municipality, where we conducted our study, home-dwelling older people can be referred to food delivery services if they ‘are not capable of cooking for themselves or transporting themselves to an eatery/restaurant’ (Copenhagen Municipality 2012b, our translation). This means that the older people who receive the food service are considered to lack the personal and network-based resources to be able to maintain a good nutritional status. Referral to food delivery services are undertaken by an assessor, i.e. a health professional who is employed by the municipality. Assessments take place upon the request of the general practitioner or care personnel, and involve an evaluation of the older person's ability to eat and drink, their mobility in the home and outside the home, the mental and psychological state of the person, and the presence of any illnesses or handicaps (Copenhagen Municipality 2012b). During the assessment, the older person is asked about weight loss, their appetite and whether they require a special diet for diabetes or heart disease, or food that is easy to chew and swallow. Thus, the assessment of whether a home-dwelling older person requires food delivery services is based on an evaluation of the nutritional status and of the social, mental and physical condition and resources of the individual – including an assessment of their ability to undertake shopping and cooking tasks. When an older person is referred to the meal service, he or she is free to choose between either a private or a public food delivery service.
In Copenhagen Municipality, 2,740 older people received food deliveries in 2015 and 1,854 of them received food from KMS (Copenhagen Municipality). Since 2004, the municipality has formulated and implemented special meal and food policies for the older people in their community (Copenhagen Municipality 2004, 2012a). The most recent policy, Appetite for Life, is based on a wish to meet individual requirements, to live up to nutritional standards and to make food that meets a high culinary standard (Copenhagen Municipality 2012a). This means that the municipal food service offers a variety of meal solutions for the older people based on the same medical and nutritional categories that are used in the assessment procedure (low fat, easy to chew, high energy content) and is determined by national recommendations and guidelines (Madkulturen 2015).
The informants in this study all have, due to their situation of having been assessed as frail, access to a range of public services including publicly produced food, which meets stringent health requirements and is delivered directly to them, a situation that is unique to the Scandinavian welfare states. This system thus enables the informants to buy quality meals with a sufficient amount of nutrition but it also means that their eating situation is characterised by a lack of freedom to choose the food they eat and to decide how and when they will eat it. These circumstances are the inevitable structure which surrounds the informants’ eating situations. As such, it also underlines why the three arenas we are analysing in this article stand out as key areas to focus on in order to understand the development of eating strategies for this particular group of older people.
Arranging the eating situation
Our study showed that the practical arrangement of the eating situation is one of the primary arenas for the formation of the informant's eating strategies. The strategies relate in particular to the dining environment and the handling of practical challenges associated with the unpacking, arrangement and eating of the delivered food.
It is apparent that many of the informants use the dining environment to help them create meaningful eating-alone situations. The specific choice of eating arrangement is dependent on individual preferences and what the given person likes to focus on while eating. Some choose their computer or television. Mille, who is 85 years old, eats at her computer every day.
Interviewer: What do you do while you are eating?
Mille: (Speaks quietly as though she is confessing something) I sit at my computer! (laughs) And I play solitaire! I actually do. Yes, because I have nobody to talk to, I sit alone and it is so much fun to play solitaire, there is always something new!
Mille uses solitaire as a way to be entertained and create variation, elements that she considers valuable in relation to her meal situations. Not all of the informants who sit by a screen while they eat, like Mille, articulate that being alone is something that influences their eating behaviour. For others, eating in front of a screen is a strategy that emphasises eating as a daily activity. For example, Ole, 82, also sits at his computer when he eats. Ole always types the menu for the week into a spreadsheet and has it open on the screen in front of him during the meal. Although Ole does not play a game while he eats like Mille, he uses the computer screen actively as a strategy that allows him to monitor his eating and position the food as an activity in his everyday life, which is created via the repeated systemisation that he routinely carries out.
Other informants prefer other types of dining arrangements. Dorthea, 84, is a former organist and concert pianist. She sits alone by the window in her living room with a view of the yard. The food is placed on the window sill on top of a tea towel in case she should spill.
Yes, it is so lovely. I like this flat so much, because you have the sky and everything, you know. And if you could only look over to the next building, it would not be fun … I sit over here because it is a bit more fun than just sitting and looking into the wall there.
For each meal, Dorthea carefully arranges her eating area by the window. She establishes it as a window to the world, from where she can follow what is happening outside. The sky and the life she can see outside add meaning to her eating situation. Through their choice of dining environment, the meticulous arrangement of the food and the activities they do or views they have, many of the informants succeed in creating meaningful eating situations. For some, this is associated with a sense of a lack of social contact, but for many it is simply what they do every day, a habit which gives meaning to the situation and is associated with a feeling of routine.
When it comes to practical challenges associated with the consumption of the delivered food, the plastic tray that contains the food particularly forces our informants to develop strategies. Many of them find it difficult to open the plastic tray and confusing to have to transfer the delivered food to a real plate. Dagmar, 95, is having mince with mashed potato. She looks at the food, which has been delivered in the usual white plastic tray.
Dagmar: Oh, yes, this is one of the best dishes!
Interviewer: It really does smell good down there.
Even though Dagmar likes the mince dish she generally thinks the food is too monotonous and boring. She continues to talk about the food and ends up with saying ‘If I put it on a plate it gets cold in no time.’
Dagmar has developed a pragmatic strategy in which the food remains in the plastic tray. In this way, she eats warm food instead of cold. For her, the practical aspect of eating out of the tray outweighs an aesthetically pleasing presentation. The same strategy can be found among several of the other informants who also choose to eat out of the tray. For those informants who in contrast make an effort with the food's presentation, the tray plays a different role. For them, the tray represents a way of eating that is not desirable, and transferring the food away from it is a strategy that helps them to retain a sense of having a normal eating situation.
The practical arranging of the eating situation is an important arena for understanding how the older people create meaningful eating situations even though it also reveals many different kinds of strategies. The strategies formed do, however, allow the older people to order and make sense of their current situation which for almost all of our informants means that they eat alone and live with ways of serving the food that in many aspects differ from those they had earlier in life.
Articulating and re-connecting to earlier skills
Another arena we encountered in our material, especially among the female informants, was an articulation of and re-connecting to their previous cooking skills. The material shows that the women, in particular, use the knowledge that they have gained as the one in their households with primary responsibility for cooking as a strategy to create meaning in relation to the delivered food.
Precisely because of their skills and previous cooking practices, they often find that the food from KMS diverges from the way in which they would have prepared it themselves. When asked, Asta, 96, said the following, after having eaten her food from KMS:
Interviewer: How did the food taste today?
Asta: It tasted good. Do you know what I thought it was lacking? Onions! I used to put onions with beef patties, in any case. Soft fried onions. But it still tastes good, nonetheless.
Throughout the interviews, it is apparent that the accompaniments and preparation of the food in particular are crucial to whether or not the food is considered to be proper. Like Asta, Dagmar, 95, also criticises how the food has been prepared and its accompaniments:
And when I say that there should be beer in it, there are some people that are very surprised. ‘But why do you think it is called øllebrød [beer bread, a kind of porridge]?’ … In the old days, I used to put some slices of lemon in it, but it is not the same anymore.
Indeed, the composition of dishes and how they are prepared used to be a key aspect of our female informants’ daily cooking practices. The articulation of a specific deviation from the composition or preparation method of a particular dish can therefore be understood as a subtle strategy that allows them to maintain a relationship to their former practices and knowledge. However, this strategy does not always mean that our informants see their current lack of cooking practices as problematic. On the contrary, our study shows that many have, to a great extent, accepted their current (lack of) capabilities with regards to cooking. This can be seen in the case of Mona, 88.
Interviewer: Did you used to cook?
Mona: Yes, and I had many guests. Yes, I was always praised for my good food. But that was then.
Interviewer: Do you miss being able to make your own food?
Mona: No, I accept that it is the way things are now.
Like Mona, many of our female informants have accepted their situation and no longer want to make food. They ‘just eat whatever is served’, as Mona puts it. Although most of the informants accept their situation, many of them, especially the most highly functioning, have the desire and energy to choose their own food. For example, Ane, 80, wishes to choose and even buy her own food but cannot be bothered to make food just for herself:
I looked in Irma [local supermarket]. They have some ready meals, so that is the kind of thing I would buy. I can't be bothered to stand and make food myself, not just for one person, I really can't, but perhaps I shouldn't say that too loudly? (laughs).
Thus, the informants want to have some influence over the food, but at the same time, they do not wish to bear the responsibility. Lone, 85, is pleased to be free of cooking. She has never really enjoyed it.
Interviewer: Can't you be bothered to cook?
Lone: No, I can't … I put up with what I get … or not put up with … it actually tastes good … I used to cook, but I was never one to say … aaaah yes, now I am going home to cook.
Interviewer: Do you know what you are getting today?
Lone: No, I don't know.
Interviewer: Is it ok that way?
Lone: Yes, it is EXCITING. You never know how it will taste, but the way that it is made, it tastes good.
Our material thereby shows how previous and life-long experience with food and cooking becomes part of a set of strategies that adds meaning to the meal. For some it is the taste of the food, for others it has more to do with either missing being in charge or enjoying not having that responsibility any more.
Perceptions of the body
It is widely acknowledged that a large proportion of frail older people have a small or varying appetite (Edfors and Westergren Reference Edfors and Westergren2012; Wikby and Fägerskiöld Reference Wikby and Fägerskiöld2004), and this is also the case among our informants. As much as this is a general and unsurprising tendency, our study also clearly shows that the informants’ perception of their body is nonetheless an arena that is highly significant in relation to their eating strategies.
A pronounced characteristic among our informants is that they find it difficult to get used to their current physical state. In the interview with Ane, 80, when asked about great-grandchildren, she answers:
Interviewer: Do you want great-grandchildren?
Ane: I am not sure, soon it will not matter. Now I am becoming old and I am also sick. It is not much good if you can't do anything with them … Yes, I actually find it quite hard that I am growing old … and that I can't do what I used to. It bothers me a great deal. It is like doing a somersault in the wrong direction.
Ane associates growing old with a way of being in the world with a body that feels wrong compared to earlier in life. Ane's perception can, with some variations, be found among the majority of our informants. Although the feeling of physical decline is registered by both male and female informants, there is a clear gendered pattern in our material with regards to the perception of the body and body image. This includes which bodily aspects that the informants consider to be most important, as well as the eating strategies they develop in order to cope with their current condition, capabilities and appearance.
Our study indicates that the female informants in particular find it hard to accept their body's current appearance. The importance of the physical appearance is manifested in the female informants’ acute awareness of their body's size and shape, despite the fact that their food consumption is small or average and that they are either underweight or normal weight. This awareness of their bodily appearance impacts their eating strategies.
Lone, 85, specifically points out that she deliberately avoids over-eating.
I eat when I am supposed to, I do not OVER-eat … I eat when I am supposed to or when I want to, or whatever you call it … I don't think I am too fat or anything … do you think I am?
This quote shows that Lone considers over-eating to be wrong, and that she deliberately avoids eating too much. Refraining from what she considers as over-eating becomes part of her eating strategy. For Lone, the strategy is also linked to how others view her body, and it is clearly important for her to be reassured by others that her perception of her body size is correct. Dora, 88, is another example of someone who has deliberately used diet to avoid becoming overweight throughout her adult life, which also affects her current eating strategies.
I have never been fat or chubby. But I have had to think about it many times during my life, that now it was time for a diet. And I think a lot of people do that. You don't want to become a big, fat balloon, and you have to be able to fit into the clothes you usually fit into.
Yet another example is Mona, 88. She emphasises during the interview that she used to receive compliments from her husband for ‘looking good for her age’. Throughout her adult life, she has associated being overweight with something visible, quantifiable and negative. She has repeatedly used diets as a way to avoid the undesirable state and she has retained an ideal of a slim body in her old age.
The informants are all categorised as frail older people for whom a high intake of energy and nutrition is important, but due to their focus on being slim and on body weight, the female informants avoid what they believe is over-eating and associate the consumption of energy-dense foods such as chocolate and sweets with something forbidden and shameful.
This can be seen in the case of Mille, 85:
I drink my afternoon coffee and I eat some cookies with it! (Mille speaks in a very low voice and smiles broadly – as though she has done something forbidden.) I always have cookies in the house. My daughter sometimes says: Mum, you shouldn't eat so many cookies! (laughs) … But my daughter is also a nurse, so she knows a bit about what is healthy and so on!
Mille associates the cookies with being unhealthy and she considers eating a few cookies to be something extraordinary that is linked with a sense of transgressing a boundary. The quote also shows that Mille's perception of doing something wrong is reinforced by her daughter, who brings her own understanding of healthy and unhealthy food into play in relation to Mille's consumption of cookies. Mille's consumption of and relationship to food is both affected by her own understanding of what constitutes healthy and unhealthy food, and by her relative's (daughter's) understandings.
This association becomes especially problematic in combination with a limited food intake, which is often unacknowledged. It is evident that this association is the result of a body perception that the women have had throughout their adult lives.
Whereas the female informants’ strategies are linked to their perceptions of body size and appearance, we find that those of the male informants are, to a greater degree, aimed at helping them to cope with a loss of physical abilities. One example is Vagn, 84. According to him, it does not make sense to be dissatisfied with the food that the municipality delivers ‘otherwise you can just make your own’, he says. The statement shows that Vagn does not recognise that cooking is beyond his current capabilities, even though he has almost lost his eyesight and cannot see the things in his kitchen. In spite of his handicap he still makes food for himself, including lunch, which consists of open sandwiches on rye bread. Precisely because he participates in its preparation, this meal is his favourite of the day. For male informants like Vagn, the strategy results in positive experiences with food and a sense of being able to cope. For others, however, the strategy ends up having a negative impact on their relationship with food. John, 92, experiences great frustration in relation to eating. He suffers from a narrow oesophagus which means that his daily meal can be a struggle if the consistency of the food is incorrect. John does not want any kind of modified food, because he finds the blended food appalling, and under no circumstances does he wish to have it:
I saw it when we went over to Queen Ingrids [care] Home, there were people there that couldn't … it was just a kind of mush … No way!
Despite his eating difficulties the blended food is not something John wants to associate with himself and his current body. He associates it with people who cannot eat unaided and are handicapped, something he does not recognise in himself. However, this means that his meals are often a frustrating experience, because he cannot swallow the food. In John's case, the strategy of distancing oneself from one's current bodily condition thereby results in reduced food intake and generally unsatisfying eating situations. It spite of this, John mobilises this strategy on a daily basis which means that he uses a lot of energy on a strategy that hinders a nutritionally sound food intake.
The strategies developed by the men can, in some cases, lead to them refusing the food solutions that, in terms of nutrition, would be best for them.
Our material clearly shows that perceptions of the body results in various strategies among both the female and male informants. These are in some cases positive, as they help some to re-connect and hold on to previous skills. We do, however, also see that for quite a few, the strategies emanating from or relating to body perceptions counteracts positive perceptions of energy-dense foods and special services aiming at tackling under-nutrition and eating disabilities. In this way, the mobilisation of strategies results in eating situations that, from a nutritional perspective, may increase the vulnerability of frail older people.
Discussion
Our analysis of the three arenas highlights how qualitative insights into the eating strategies developed by frail older people improves our understanding of the resources they activate and the efforts they put forth on a daily basis to create meaningful eating situations. The strategies we find in our material seem, however, to affect the nutritional vulnerability of our informants in both positive and negative ways.
Vesnaver et al. (Reference Vesnaver, Keller, Payette and Shatenstein2012) found that having control of the food and eating situation was central to their informants’ development of dietary resilience. Our informants, like the more resourceful, also seek to obtain some measure of control with their food. The differences between our frail informants and the self-reliant older people are mainly their degree of freedom and the amount of resources they can mobilise. These restrictions are important to the arenas in which it is possible for the frail older person to develop and deploy eating strategies.
By developing strategies for arrangement of the eating situation, our informants are able to add a personal touch to a meal situation in which the main element, the food, is controlled and standardised by the municipality. The strategies are all performed within the walls of the informant's homes, and even though they may appear of small importance to outsiders, it is evident that the strategies for arranging the food and the dining environment are closely related to the individual situation and preferences of the informants. The strategies reveal whether diversion, hot food or specific material objects are required to create a meal situation that is meaningful for the frail older person. Our material, furthermore, shows that the strategies are not necessarily focused upon a desire to sit face-to-face with other people. This is interesting, as is the fact that the practical aspect often outweighs cosiness or attractive meal presentation. In Denmark there is currently a focus on a holistic understanding of the eating situation, and especially on the positive effects of social meals, i.e. eating together, and on the importance of nicely situated and arranged meals (Madkulturen 2015; Copenhagen Municipality 2012a; Kofod Reference Kofod2000). The material clearly highlights that the framework set by the meal delivery service is of great importance to the shaping of the strategies. This finding is in line with previous research emphasising the, often negative, importance of rigid structures (Sydner and Fjellström Reference Sydner and Fjellström2005, Reference Sydner and Fjellström2007). Our material, however, also shows that even if the strategies developed to create meaningful eating situations differ from self-reliant older persons, and from those expected by experts, it is clear that even frail older persons daily mobilise resources and form strategies that allow them to create eating-alone situations that are very meaningful and which contribute to their feeling of being in control with their meal situation.
Previous studies have highlighted that especially older women's earlier roles as housewives were very important to their identity, and therefore, the loss of this ability becomes associated with privation (Gustafsson and Sidenvall Reference Gustafsson and Sidenvall2002). Our study shows that this is by no means always the case. One way to understand this difference between our informants and those of Gustafsson and Sidenvall may be due to the fact that our informants have been retired and many have been alone and dependent on help for many years. Thus, many have lived their current, more isolated and dependent, life for a longer time and have distanced themselves from their former active working lives and from living with children and spouses. In this sense, our informants’ previous household and cooking activities can be considered latent practices, which are not reproduced through concrete acts, but rather by constant referencing and re-connecting (Shove and Pantzar Reference Shove, Pantzar, Löfgren and Wilk2006).
The women are able to distance themselves from the loss of previous resources in relation to cooking, because it is not equated with the loss of their latent knowledge about food. On the contrary, by re-articulating their knowledge, they mobilise mental resources and through these maintain an aspect of the life fulfilment that cooking used to give to some of them. In spite of their often strong opinions about the way the food was prepared, presented and the (lack of) accompaniments, the majority of the female informants state that they are very happy with the delivered food. The referencing and re-connecting thereby becomes a strategy that allows them to mobilise and use their relationship to the delivered food in a positive manner and strengthens their relationship to the food they receive.
Our study of the third arena, the perceptions of the body, indicates that the female informants in particular find it hard to accept their body's current appearance. This finding is supported by other studies which have also found that physical appearance is more important to women than men (Berg and Tornstam Reference Berg and Tornstam1999). Like their cooking skills and knowledge, the ideal of a slim body is a sedimented understanding, which, consciously or unconsciously, becomes central to their eating strategies (Shove and Pantzar Reference Shove, Pantzar, Löfgren and Wilk2006). The equating of health and slim bodies with restrictive food consumption has also been found in other studies that indicate that a focus on moderate consumption and eating healthy food is a general tendency among older people in Europe (Lundkvist et al. Reference Lundkvist, Fjellström, Sidenvall, Lumbers and Raats2010), and especially so among older women (Gustafsson and Sidenvall Reference Gustafsson and Sidenvall2002). Our material contributes to this field with knowledge about how the mobilising of resources to maintain or live up to the ideal of a slim body for some results in the formation of eating strategies that are problematic and may cause frail women with these sedimented understandings to be even more nutritionally vulnerable than other frail older women. A focus on this particular kind of eating strategy may therefore open up nuanced perceptions of the nutritional vulnerability of women that can help improve care initiatives and meal solutions.
With regards to the male informants, our material supported previous findings of the ways in which men mobilise physical resources to distance themselves from the loss of the ability to make food. The somehow surprising mobilisation of powers which is used as a strategy helps Vagn and some of our other male informants to continue cooking and preparing meals in spite of their disabilities. It helps them to emphasise their independence and to maintain that, in spite of a loss of abilities, their body is still a source of activity and competences (Moss et al. Reference Moss, Moss, Kilbride and Rubinstein2007). This mobilisation, however, results in nutritionally sound eating habits only in some cases. For others, the result is more negative as the distancing and self-reliant strategy causes some to refuse receiving much needed help, thereby increasing their nutritional vulnerability.
Conclusion
This study is based on interviews and observations with frail, home-dwelling older people in order to shed light on the extent to which they mobilise resources that enable them to develop and deploy eating strategies as a way of creating meaningful eating situations. Frail older people and their diet receive a great deal of attention in the current political initiatives within the Scandinavian welfare state. In spite of this, there are only a few studies that focus on the actual eating situations and the resources invested by the older people. Our study shows that frail, home-dwelling older people who receive food despite their frailty and apparent lack of resources also form and utilise strategies in relation to eating, as do more highly functioning older people. In our study, we found that the eating situation in particular, understood as the dining environment, and practical circumstances, previous abilities and perception of the body are central arenas for our informants’ mobilisation of resources for eating strategies. The strategies are particularly formed in areas that allow the older person to add meaning and a personal touch to an otherwise structurally determined eating situation. Furthermore, our material shows that mental and physical skills and experiences, even when they are no longer put to practical use, are still strategically employed to create meaning in the eating situation.
Overall, the mobilisation and creation of strategies helps our informants to create meaningful eating situations by diverting their attention, bringing balance to the practical circumstances and creating meaning in relation to the composition and preparation of the food. However, we have also observed that some of the resources mobilised result in strategies that, especially those formed on the basis of body perceptions, negatively affect the older people's nutritional vulnerability. In these examples we see a clash between the self-perception of the older person and the established knowledge of a nutritional healthy eating practice.
Our material reveals that a whole life's worth of embedded family patterns, gender perceptions and food practices has a significant impact upon an older person's eating strategies. In particular, the development of strategies linked to body perceptions illustrate what could be called gendered patterns of eating practices, which are not only a Danish phenomenon, but are a common characteristic among the European elderly population (Irz e t al. Reference Irz, Fratiglioni, Kuosmanen, Mazzocchi, Modugno, Nocella, Shakersain, Traill, Xu and Zanello2013).
Based on this, we suggest that a deeper and more nuanced understanding of the resources mobilised in relation to eating strategies should be integral in future studies of older people's wishes and needs in relation to food. Focusing on whether these eating strategies result in nutritionally appropriate or inappropriate eating patterns will reveal how the eating situation is an arena that is a key element in their self-perception, and in the activation of their abilities, opinions and preferences. Our results also show that, for this group of older people who lack vigour and strength, social interaction during mealtimes is not necessarily a priority. Nor are stereotyped ideas of ‘cosiness’ and fine crockery necessarily important to all of them. Instead, the older people tend to mobilise resources in ways that allow them to create strategies that provides a dining environment that they perceive to be good and manageable; where they can carry out meaningful activities during the meal, engage with the provenance of the food, its history and composition and, not least, carry out acts that support the ideas and wishes they have in relation to their own body. In this sense, resources and the eating strategies the older people create based on them are central elements in the daily life of the welfare state's frail, older, home-dwelling citizens.
Acknowledgements
The authors would like to thank Marianne Iversen, Sidse Vinkler Rasmussen, Karin Bredgaard, Merete La Motte, Henriette Friis Sørensen, Mette Frøsig and all other involved persons at Copenhagen Municipality, Sundheds og Omsorgsforvaltningen, Mad og Måltidsteamet and Københavns Madservice a la carte. We would also like to thank the informants who let us into their homes and lives. Not least a warm thanks to our two student assistants, Marie Larsen and Nynne Uldal Meisner, and our intern, Cammilla Bundgård Toft. The article is based on the project Appetite for Food (Appetit på maden). The project was carried out in the spring of 2015 as a collaboration between and funded by the CALM project – a 2016 excellence programme at the University of Copenhagen and Copenhagen Municipality. The collaboration with Copenhagen Municipality was based on a formal agreement and the project adheres to the AAA Statements on Ethics.
