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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M153-M158 (2003)
© 2003 The Gerontological Society of America

Direct and Indirect Effects of Everyday Emotions on Food Intake of Elderly Patients in Institutions

Catherine Paquet1,2, Danielle St-Arnaud-McKenzie2,3, Marie-Jeanne Kergoat2,4, Guylaine Ferland2,3 and Laurette Dubé1,2

1 Faculty of Management, McGill University, Montreal, Quebec, Canada.
2 Research Center, Institut Universitaire de Gériatrie de Montréal.
3 Nutrition Department, Université de Montréal.
4 Medicine Department, Université de Montréal.


   Abstract
Top
 Abstract
Research Methods
 Results
 Discussion
 REFERENCES
 
Background. Decreased food intake is an important risk factor for malnutrition, which is highly prevalent among geriatric patients. The emotional nature of the hospitalization experience and the complex organizational setting involved in meal production and delivery services in institutions increase the risk for decreased food intake. Everyday emotions are known to have a particularly strong influence on decision-making and behavior in the elderly, and have also been shown, in younger populations, to influence food intake and its psychological antecedents, such as quality perception and satisfaction judgments. The objective of this paper is to study the direct impact of elderly patients' everyday emotions on food intake and their indirect effects mediated by quality perceptions and satisfaction judgments.

Methods. Thirty patients (20 women, 10 men, 65–92 age range) in a geriatric rehabilitation unit were observed on repeated meal episodes (average of 46 care episodes per patient) where they provided self-reports for emotions (positive emotions, anger, anxiety, and mild depressed feelings), perceived meal quality, and satisfaction. Food intake was measured in terms of energy and protein content.

Results. The impact on food intake was favorable, and both direct and indirect for positive emotions, direct and negative for anxiety, direct and positive for mild depressed feelings, and indirect and negative for anger. Indirect effects were mediated by quality perception judgments but not by satisfaction, which was not significantly related to food intake.

Conclusion. Results suggest that, given their impact on food intake, measuring and monitoring patients' everyday emotions may be an important innovative strategy to improve food intake of elderly patients in institutions.

PROTEIN energy malnutrition is highly prevalent among geriatric patients in health care facilities and nursing homes (1–3), with well-established aversive consequences on patient health and quality of life (4–6). Decreased food intake is considered the most important risk factor for malnutrition in institutions (1). This setting brings about additional factors that clinicians need to consider in their efforts to ensure nutritionally adequate food intake to elderly patients, beyond the causes of decreased food intake observed for free-living elderly (2,7,8). For instance, the intrinsic emotion-laden nature of one's experience in institutions (9,10) is likely to affect food intake. Everyday emotions—that is, emotions experienced at nonclinical levels that arise in the course of everyday life from the appraisal of events carrying some personal significance (11)—are known to guide judgments, decisions, and actions (12). Evidence collected in nonobese young adult populations (13–16) shows that everyday emotions impact food intake, with effects being variable from one emotion to another. Given the evidence that the role of everyday emotions in guiding decision-making and behavior may increase with age (11,17), it is important to investigate how elderly patients' everyday emotions may influence food intake in institutions.

Another consideration is that ensuring adequate food intake in institutions, unlike other types of clinical interventions, is contingent on a number of organizational factors lying outside the patient–professional encounter, such as menu design; production and delivery of food conforming to safety, nutritional, and sensory standards; meal service in a favorable environment; and availability of feeding assistance (18). Numerous health and consumer studies (for a review, see 19) have shown that in organizational contexts such as institutions, one's behavior is conditioned by perceptual (i.e., perceived quality) and evaluative (i.e., satisfaction) judgments of service production and delivery. There is robust evidence that affective states such as emotions influence both perceptual (20,21) and evaluative judgments (22,23). It is therefore possible that beyond direct effects, everyday emotions also have indirect effects on food intake through their influence on psychological antecedents of food intake such as perceived quality and satisfaction judgments. The present study was designed to disentangle, using a longitudinal approach, the direct and indirect effects of everyday emotions on food intake of elderly patients in institutions (Figure 1).



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  		Figure 1. Direct and indirect effects of emotions on food intake for patient i at meal j

 

   Research Methods
Top
 Abstract
 Research Methods
Results
 Discussion
 REFERENCES
 
Overview of Study
The data used in the present paper were collected as part of a larger study on the individual and organizational determinants of food intake and nutritional status of elderly patients admitted to a rehabilitation unit of a geriatric hospital. Thirty patients (mean age: 78.8 ± 12.7 years, 20 women, 10 men) were observed on repeated meal episodes (46.8 ± 26.8 episodes per patient). The sociodemographic characteristics of the participants are presented in Table 1. Patients younger than 65 years and with an established diagnostic of dementia were not considered. Patients with scores below 23 on the Mini-Mental Status Examination (24) and scores above nine on the Geriatric Depression Scale (25) were also excluded to ensure valid reports of judgments and nonclinical emotions.


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  		Table 1. Demographic Characteristics of the Participants (n = 30)

 
We used a given episode (i.e., a meal) as the unit of analysis. Episode-level measures were obtained for all three main meals, every other day of the hospital stay for a maximum of 6 weeks or until discharge. For each episode, patients, assisted by experimenters, provided premeal self-reports of momentary emotions, and postmeal retrospective reports of perceived meal quality and satisfaction with the meal. Food intake was also assessed postmeal by experimenters.

Measures
Patients were asked to indicate the degree to which each of the measures corresponded to their current state or judgment using visual analog scales anchored by "not at all" and "very much." These scales were then transformed into numerical scales ranging from 0 to 153 mm with 1 mm gradation.

Emotions.-- Participants were asked to indicate the extent to which they were feeling "at the present time," each of 10 emotion items selected from existing multi-item scales of everyday emotions that have shown good reliability in the health domain (9,10): Positive emotions (proud, confident, reassured, hopeful; {alpha} =.86); anger (angry, frustrated; {alpha} =.68); anxiety (anxious, nervous; {alpha} =.61), and mild depressed feelings (depressed, discouraged; {alpha} =.83). Individual average scores were computed for each emotion.

Perceived quality.-- Participants provided self-reports on food and service, two dimensions of perceived quality that have been found reliable in prior research conducted in institutional food services (26): food (tastefulness, appropriateness of food temperature and texture, palatability; {alpha} =.84); service (staff attitude, service timeliness, duration, feeding assistance, sitting position; {alpha} =.87). Individual average scores were computed for each perceived quality dimension. The correlation between the two scores was 0.66 (p <.001). A multivariate approach was therefore taken when the two perceived quality dimensions were used as dependent variables.

Satisfaction.-- Satisfaction was measured at the overall level (satisfaction with the meal as a whole), as well as specifically for service (satisfaction with interaction with staff), and food components (satisfaction with food). The correlations between overall and food satisfaction, overall and service satisfaction, and food and service satisfaction were 0.75, 0.47, and 0.53, respectively. All three items were significantly correlated (p =.01). For this reason, they were estimated simultaneously using a multivariate approach.

Food intake.-- Food intake was derived from the visual estimation of plate leftovers in relation to the standardized portion being served and expressed in terms of calories and protein content. Plate leftovers were estimated using the Comstock scale (27), converted to intake scores and then translated into energy and protein intakes using the NutriWatch Nutrient Analysis program (Version 6.1.5F Delphi, © Elizabeth Warwick, Cornwall, Prince Edward Island, Canada). Energy and protein intake were also estimated simultaneously due to the significant correlation between the two measures (r = 0.71, p <.001).

Estimation and Analytical Strategy
Our model was tested using the random multilevel approach, which offers a flexible method of modeling repeated measurements (28) by accounting for both within (i.e., from one meal to the other for a given patient) and between (i.e., from one patient to the other) participants' variability using a random effects approach. The two-stage least-square estimation procedure (29) was also used to overcome the problem of simultaneous equations arising from the presence of variables that are both dependent and independent. The multilevel model was estimated using the MLwiN Software Version 1.10.0006 (Multilevel Models Project Institute of Education, London, U.K.).

The direct effect of emotions on food intake was assessed once potential indirect effects mediated by perceived quality and satisfaction were accounted for (Figure 1). Such indirect influence of emotions on food intake can be said to occur if (a) emotions significantly affect the mediators (satisfaction and perceived quality), (b) emotions significantly affect food intake in the absence of the mediators, (c) the mediators have a significant and unique effect on food intake, and (d) the effect of emotions on food intake is reduced upon the addition of the mediators to the model (30). The amount of mediation is defined as the reduction of the effect of emotion on food intake, which was tested using the Sobel test (31).


   Results
Top
 Abstract
 Research Methods
 Results
Discussion
 REFERENCES
 
We first estimated the predictive power of premeal emotions on perceived food and service quality using a multivariate approach. Results are reported in Table 2. Positive emotions and anger had respectively favorable and deleterious impacts on both perceptual judgments. Anxiety was also negatively related to perceived service quality, while the relationship was not significant for food quality. Mild depressed feelings were not significantly related to perceived quality.


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  		Table 2. Parameter Coefficients (p Values) for the Multivariate Model for Perceived Quality (n = 2705)

 
Given that perceived quality is an antecedent of satisfaction and is also under the influence of emotions, we controlled for its influence in estimating the impact of emotion on satisfaction. Results are shown in Table 3. As can be concluded, once the effect of perceived quality is accounted for, only two negative emotions significantly impacted satisfaction negatively, namely, anger for satisfaction with the service and anxiety for both food and overall satisfaction.


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  		Table 3. Parameter Coefficient (p Values) of the Multivariate Model for Satisfaction (n = 4045)

 
The influence of satisfaction, perceived quality, and emotions on food intake behavior was then assessed. We first looked at the effect of emotions on food intake without controlling for the potential mediating effects of perceived quality and satisfaction. As can be concluded from the results of the restricted model reported in Table 4, the more intense the positive emotions reported by patients, the higher their energy and protein intakes. A similar effect was observed for mild depressed feelings, with more intense reports associated with higher intake, whereas reports of anger were associated with lower protein intake. We then assessed which of these effects persisted once the indirect effects were taken into account. Results from the full model (Table 4) revealed that positive emotions had the most stable effects on food intake. Both energy and protein intakes remained significantly higher with reports of more intense positive emotions. The negative impact of anger vanished, while anxiety now negatively affected protein intake.


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  		Table 4. Parameter Coefficient (p Values) of the Restricted (n = 2748) and Full (n = 2692) Multivariate Models for Food Intake

 
Turning to the mediating effects of perceived quality and satisfaction, analyses revealed that none of the satisfaction measures were significantly related to food intake, neither in terms of energy nor protein intake, ruling out any potential mediation of the relationship between patient emotions and food intake by satisfaction. Food quality, being positively related to both measures of food intake, and service quality, being negatively related to energy intake, remain two mediator candidates.

Analyses revealed that the favorable effect of positive emotions on both protein and energy intake was in part mediated by perceived quality. Sobel tests showed that the reduction of the effects of positive emotions on energy intake observed after controlling for indirect effects was due to the partial mediating effect of both sensory (p =.016) and service quality (p =.043), whereas the reduction in the effect on protein intake was only due to a partial mediation by sensory quality (p =.006). The positive impact of mild depressed feelings on food intake observed in the restricted model was diminished for both measures of food intake, remaining significant for energy intake, while disappearing for protein intake. Given that mild depressed feelings had no impact on perceived quality, the latter was not considered as a potential mediator for these types of emotions. Results also showed that the effect of anger on protein intake observed in the restricted model was completely mediated by perceived quality, since the effect fell below significance in the full model. Sobel tests revealed that this mediating effect was assumed only by meal quality (p =.042). In the full model, anxiety was negatively and significantly related to protein intake, a relationship that did not reach significance in the restricted model.


   Discussion
Top
 Abstract
 Research Methods
 Results
 Discussion
REFERENCES
 
Results of the present study show that everyday emotions experienced by elderly persons in institutions are important predictors of food intake, having both direct behavioral impact and indirect influence through their impact on quality perceptions. In particular, positive emotions directly influenced both intake indicators as well as sensory and service quality, whereas anxiety negatively influenced food intake directly and indirectly by tinting downward service quality perceptions. These results are consistent with past studies that have found a valence–congruent relationship between emotions and food intake in younger adult populations (16). However, two of our findings point to the need to consider, beyond valence, the various appraisals differentiating emotions. First, our result that the influence of anger on food intake was completely mediated by its negative impact on quality perception is tied to agency appraisals that anger experiences are associated with seeing others as being the cause of one's negative feelings (12,32). The second result of relevance is the direct and positive impact of mild depressed feelings on energy intake, without any indirect influence through quality perceptions. Given that clinical depression is generally considered a risk factor for decreased food intake in the elderly (2) and has been linked to weight loss in nursing homes (33) and nutritional condition in free-living elderly (34), one can attribute this result to methodological limitations. However, considering that only nondepressive patients were included in the present study, it could also be that food intake has a different relationship with subclinical depressed feelings than it has with clinical depression. Mild depressed feelings in this case are akin to sadness, which, according to appraisal theory of emotions (12), triggers action tendencies towards rewarding oneself (35), a potential reward being food in the present context. This would also be consistent with studies supporting a positive connection between dysphoric mood and carbohydrate consumption (see 15 for a review), which has been accounted for physiologically by some researchers (36). In addition to replicating the present results, future research should test the moderating effect of the intensity of mild depressed feelings on their relationship with food intake.

The findings that emotions influence quality perceptions and satisfaction judgments are consistent with aforementioned studies on the ability of affective states to color perceptual and evaluative judgments. However, in the present context, where patients were in contact with service providers, we cannot rule out the fact that it is not necessarily or exclusively perceptions that are changed by patient emotions, but the objective reality proper. Emotions are not only ways to express one's feelings, but they also convey cues to others on how to react (37). It may be such objective changes in the care given by providers in response to patient emotions that underlie some of their indirect effects on food intake. Therefore, future research should specify which share of the impact of emotions on quality perceptions and satisfaction is tied to objective reality versus perceptions and judgments of this reality.

Surprisingly, we found a negative relationship between service quality and energy intake. Although we cannot exclude the possibility that these results are tied to methodological limitations of the present measures, it is however unlikely, in light of the good nomological validity reflected in their relationships with all measures of emotions and satisfaction. The replicability of the present results will have to be tested in future research. Alternatively, one may speculate that such a reverse relationship could emerge due to a decrease in intake of high-energy food to the benefit of high-protein food as service quality increases. This can occur due to technical aspects of the meal, such as the fact that high-protein food is often more difficult to eat, and its ingestion might require more time, as well as more assistance. This would be consistent with a recent study that indicated a need to increase the quality of feeding assistance to improve food intake in nursing home residents (38). However, one would have to look at objective measures of service quality to test this a posteriori explanation.

Patient satisfaction, albeit being itself sensitive to patient emotions (specifically anger and anxiety), did not as such significantly account for variations in food intake. This is somewhat worrisome considering that patient satisfaction is a central indicator in formal quality programs used in most institutions (39), and its monitoring at the core of management's efforts to ensure nutritionally adequate food intake. Our results suggest that adequate food intake may be more effectively promoted by focusing less exclusively on patient satisfaction and instead finding innovative ways to (a) monitor the sensory quality of the meals, and (b) measure patient emotions and integrate their consideration into the everyday provision of care surrounding the meal, beyond the "art of care" principle or psychotherapeutic/pharmaceutical treatments.

In fact, changes in the sensory quality of food through flavor enhancement have already been shown to lead to improvements in body weight and food intake in nursing home patients (40). As for the role of emotions, food intake has already been positively associated with interpersonal responses such as staff encouragement (41,42). Moreover, the physical environment can also be designed so as to reinforce the positive impact of positive emotions or undermine the negative impact of anger and anxiety. Both positive and negative emotions are sensitive to environmental parameters such as odor, music, and temperature (43,45). Accordingly, elderly subjects, when exposed to dinner music, were found to eat more, and to be less irritable, anxious, and depressed (46). Moreover, a study by Mathey and colleagues has demonstrated that improving the meal ambiance can increase body weight and prevent a decline in health status in a sample of elderly persons in a nursing home (47). Finally, de Castro showed that, as opposed to physiological factors, there is no decline in the potency of nonphysiological factors (social, psychological, and environmental) to influence food intake in elderly persons (48).

This, in addition to our findings that all four types of emotions, in their own ways, had a significant impact on food intake, justify the need to further integrate into the everyday delivery of care to elderly patients existing knowledge on emotions. Equipped with innovative, nonobtrusive ways to recognize, measure, and monitor more closely patients' emotional experience surrounding meals, providers could more effectively react to these in a way that leads to positive outcomes.


   Acknowledgments
 
This study was supported by the Canadian Institutes of Health Research (operating grant to Laurette Dubé, and Graduate Studies Fellowship to Catherine Paquet). We are also indebted to health professionals and the staff of the dietetics and food services of the Institut Universitaire de Gériatrie de Montréal for their help and collaboration during the conduction of the study.

Correspondence should be addressed to Dr. Laurette Dubé, Faculty of Management, McGill University, 1001 Sherbrooke West, Montreal, Québec, Canada H3A 1G5. E-mail: laurette.dube{at}mcgill.ca

Dr. L. Dubé is a Career Scientist of the Canadian Institute of Health Research/Social Sciences and Humanities Research Council of Canada.

Received September 9, 2002

Accepted October 11, 2002


   REFERENCES
Top
 Abstract
 Research Methods
 Results
 Discussion
 REFERENCES
 

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