Effect of Eating Attitudes on Body Weight Trends of African American Nursing Home Residents

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: wilsonmg@slu.edu

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


Unintentional weight loss (UWL) in older adults is associated with adverse clinical outcomes and increased mortality. This syndrome is highly prevalent in nursing homes occurring in 23 - 85% of all nursing home residents 1. Reduced energy intake, resulting from medical illness, iatrogenesis or adverse socio-economic events, is frequently implicated as the major cause of UWL in nursing homes. However, in a notable number of cases, the reduction in food intake can not be explained. The term "anorexia of aging" has been proposed to describe this phenomenon 2,3.

Within the long-term care setting, "anorexia of aging" and involuntary weight loss in older adults pose major diagnostic and management challenges. Abnormal eating attitudes and behavior have been proffered as possible explanations for some of these cases 4. 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 4,5. 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 6,7.
Distinct patterns of abnormal eating behavior with characteristics of anorexia nervosa have been described in older undernourished adults. Nevertheless, there is still limited data regarding the role of eating behavior and attitudes in the maintenance of geriatric nutritional health 8,9. Furthermore, despite available evidence indicating that culturally determined attitudes influence eating attitudes and behavior , little is known about the health effects of such differences within disparate cultures10.
Available studies of eating attitudes among older adults focus on populations that are predominantly Caucasian 5, 11. This study was designed to evaluate the eating attitudes of a cohort of African-American nursing home residents. The effect of eating attitudes on the body weight trends of these residents was also assessed.


The study site is a long term care facility (LTCF) located in the inner city of St Louis, Missouri and surrounded by predominantly African-American communities that serve as the main source of referrals. The facility has 84 residents all of whom are African American. All residents were approached for participation in the study. Residents with a Geriatric Depression Score (GDS) > 14 or a Mini-Mental Status Examination (MMSE) < 18 were excluded from the study 12, 13. Additional exclusion criteria included malabsorption, cigarette smoking, a history of cancer in the past 5 years, uncontrolled diabetes mellitus or thyroid disease, chronic obstructive pulmonary disease and recurrent diarrhea, nausea or vomiting. Patients with active congestive cardiac failure, renal failure, nephrotic syndrome or liver cirrhosis were excluded from the study. The 3- factor eating questionnaire (3-FEQ), a 51 item questionnaire, which has been validated for the measurement of eating behavior was administered to all residents. This questionnaire comprises 36 questions requiring a true/ false response and 15 multiple choice questions. Questionnaires were scored according to published guidelines, yielding three constructs scores each of which reflects one of three dimensions of eating behavior, namely; cognitive dietary restraint, dis-inhibition and hunger 14.
Monthly height, weight and Body Mass index of all participants was obtained over the preceding twelve months.
Statistical analyses were performed using Statistica.
Questionnaire scores were analyzed using 3-factor repeated measures analysis of variance (ANOVA). The three factors used were gender, educational level( <8years and > 8 years) and weight change ( loss or gain). Any statistically significant effects were further analyzed using Tukey's honestly significant difference test for post hoc comparisons of means. Data are presented as means +/- SEM. A p value <0.05 was considered significant in all analyses.


Fifty-three (22M, 31F) residents were included in the study. The demographic data for the study population are shown in Table 1. The three-way interaction between educational level, gender and weight trends were not significant. Two way interactions between educational level and gender; gender and weight trend; and educational level and weight trend were also not significant (p=0.7, 0.1 and 0.3 respectively).
The main effects of gender, educational level and weight trend on eating attitudes scores are shown in Table 2. For the purpose of data analysis, a negative weight trend was defined as > 10% decrease in the baseline body weight over a 12 month period, with no documentation of return to baseline body weight within the 12 month period. Similarly, a positive weight trend was defined as a progressive increase in weight or weight unchanged over a 12 month period ,with no documentation of decrease in body weight below admission weight.


The The 3- 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, namely dietary restraint, dis-inhibition and hunger. 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. Dis-inhibition describes the tendency to increase food intake, 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.

In this study we found that residents who exhibited progressive weight loss , in the absence of any clearly identifiable medical cause, scored significantly higher in the dis-inhibition and hunger domains of the 3-FEQ, compared with residents who maintained their weight or exhibited weight gain. The difference in dietary restraint scores between both groups was not significant. Our results also showed that neither gender nor educational level had a significant influence on eating attitudes in the study cohort.

Overall, the main psychiatric disorder associated with weight loss and undernutrition is anorexia nervosa. This syndrome involves deliberate weight loss driven by a disturbed concept of body image, whereby the affected person thinks of herself as obese, although in reality she is underweight. This theory has led to the misleading tendency to assume that high dietary restraint is the major factor responsible for weight loss associated with abnormal eating attitudes. Studies establishing the presence of anorexia nervosa like syndromes in older adults with unexplained weight loss tend to validate such assumptions 15,16.

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. Additionally, the results of several descriptive studies have led to the assumption that non-Caucasians and men may be relatively resistant to eating disorders. Data indicating that these sub-groups of the population may have less restrictive body weight standards lends credence to this assumption17,18. However, studies indicating similar degrees of body dissatisfaction among Caucasians and non-Caucasians challenge the theory of cultural specificity of eating disorders 19. This controversy remains unresolved due to the paucity of literature that objectively explores the relationship between ethnicity, cultural variation and eating behavior 20.

The results of our study, which indicate an association between eating behavior in African-American nursing home residents and significant weight loss, highlight the need for further systematic research in this area.
Several hypotheses may be advanced to explain the tendency for subjects in our study with higher dis-inhibition and hunger scores to lose weight. Residents with high hunger scores often complain of "feeling hungry all the time", indicating shorter periods of satiety. Non-institutionalized persons with a dominant hunger trait will often be observed to seek out food and eat at frequent intervals during the day. Notably, frequency of meals is more important than energy consumption in the definition of a dominant hunger trait. Thus, the older adult with disproportionate representation of the hunger trait may eat relatively more meals, while not necessarily consuming relatively greater amounts of energy. Conceivably, in nursing home residents, limited access to meals on demand in the LTC environment may result in fewer meals, thereby decreasing daily energy intake. The inability of older adults to compensate for energy deprivation by increasing subsequent food intake may further compromise daily energy intake in such residents, thereby placing the resident at even greater risk of significant weight loss 21.

Miller et al in a previous study, examined the eating attitudes of older veterans, the majority of whom were Caucasian. They identified inappropriate self-restraint around food in 60% of the cohort, suggesting that dietary restraint may be the more prevalent attitude in older adults 5. However, Waller et al in a recent study demonstrated a cross-cultural difference in eating attitudes between Japanese and British subjects. They found a strong linkage between emotional stress and food consumption, loosely termed "emotional eating", in British women. Japanese women resident in Japan showed no association, while Japanese women resident in Britain exhibited moderate traits of emotional eating 22. The findings of our study indicating increased dis-inhibition among African American Nursing home residents with significant weight loss, further emphasize the need to explore cross-cultural influences on eating behavior and nutritional health.

Although systematic cross-cultural prospective studies will be needed to adequately address a causal relationship, it is conceivable that persons with increased dis-inhibition may lack the stimulus to eat within the relatively regimented ambience of the NH. The lack of sufficient social stimulation and the paucity of situations that induce abrupt changes in emotion, as occurs within the free-living community environment, may detract from the stimulus to consume food. Additionally, 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. Hays et al identified an increased risk of hypercholesterolemia and diastolic hypertension in community-dwelling older women with high dis-inhibition and hunger traits. They hypothesized that highly dis-inhibited eaters may have a greater intake of highly refined foods which may promote the development of disease. Notably, in their study there was no association between dietary restraint and increased morbidity 23.

Review of most LTC nutritional intervention strategies identifies reduction of high dietary restraint as the primary goal. Thus, NH residents with anorexia and unexplained weight loss, regardless of ethnic origin or cultural make-up, are subjected to intervention that is directed mainly toward encouraging increased energy consumption and cognitive-behavioral techniques aimed at reducing meal related anxiety. 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.

Residents with increased hunger traits may benefit from more frequent meals and should be evaluated for satiety after each meal and offered second helpings, if desired. Easy access and availability of food between meals is critical for this group of residents. Handicapped accessible Vending machines that dispense pre-packaged "ready to eat " food snacks conveniently located within the facility would be helpful in this regard. 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. This serves the additional purpose of recreational intervention, as it increases the opportunity for interpersonal contact for such residents. Interdisciplinary involvement in nutritional intervention programs is critical to ensuring adequate nutrition in the NH. Thus, residents should be encouraged to partake of snacks during routine recreational and rehabilitative activities. This approach is particularly helpful to residents with elevated dis-inhibition traits, as the increased social interaction that occurs during such activities may enhance energy intake. An innovative recreational dining program is critical to enhance energy intake in residents who are dis-inhibited eaters.

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). Outside meal-times, it is important that the resident is encouraged to participate in interactive programs. Inter-generational, pet and music therapy are helpful adjuncts in this regard. Additionally, the institution of peer-directed recreational activities, 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. In disinhibited eaters, these interventions may stimulate energy intake.
Due consideration needs to be given to limitations of our study. Objective analysis of the association between eating attitudes and body weight trends may be confounded by the retrospective analysis of body weight. Although our study suggests the potential for cross cultural variance in eating attitudes among nursing home residents, the lack of a Caucasian control group precludes firm comment as to cross-cultural variance, allowing only for historical comparison based on previous literature. Nevertheless, this study is unique in that it is the first to examine eating attitudes among a cohort of exclusively African-American nursing home residents. 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. Awareness of these issues warrant the development of nutritional intervention programs in LTC facilities that take into account differences in eating attitudes and behavior. Health professionals in LTC settings should be cognizant of the possibility that cultural differences may influence food intake and eating behavior. 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.

Table 1: Demographics of study population; N = 53 ( 22M, 31F)
  Mean±SEM Range
Age (yrs) 84±2.3 72 - 101
Weight (lbs) 158±5.9 106 - 354
Body mass index 26.2 ± 0.9 17 - 55
Weight change (lbs) 6.3±3. 3 -61 - 83.7

Table 2: Main effects of educational level, gender and weight trends on eating attitude scores


    Education (yr)   Weight trend  
  Male N=22 Female N=31 p < 8 N=29 > 8 N=24 p negative N=13 positive N=21 p
Restraint 6.5±0.7 7.0±0.7 0.3 6.7±0.8 6.9±0.6 0.4 7.3±0.8 6.4±0.6 0.2
Dis-inhibition 3.2±0.6 4.2±0.6 0.2 3.7±0.7 4.0±0.5 0.4 4.8±0.7 3.0±0.4 0.01
Hunger 3.7±0.8 3.4±0.7 0.4 2.8±0.7 4.3±0.7 0.1 5.1±0.8 2.4±0.6 0.003

a Negative weight trend : > 10% decrease in the baseline body weight over a 12 month period, with no documentation of return to baseline body weight within the 12 month period.
b Positive: Progressive increase in weight or weight unchanged over a 12 month period ,with no documentation of decrease in body weight below admission weight.


Table 3: Practical Recommendations to combat weight loss in nursing home residents with dominant hunger or dis-inhibition traits.


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, cheerful decor and well lit.
  • Positive ambience (music, attentive staff, 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, recreational activities and resident committees
  • Accessible snack vending machines




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Published September 2003

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