The 13 participants who took part in semi-structured interviews were aged between 60–93 years and included nine women and four men. Ten participants were White British, three were British Asian; seven lived alone, six with a spouse. SNAQ scores ranged between 8–13. The number of daily medications ranged from 1–21; six participants had lost weight unintentionally in the previous 12 months.
The thematic analysis generated three themes, the first centred on appetite loss: 1) a complex web of influences on appetite loss, that include biological, psychological and social factors; with the other two centred on the lived experience: 2) living with poor appetite - variation in perceptions of poor appetite and attitudes to appetite loss; 3) living with poor appetite - the role and importance of the eating environment and social interactions. The themes are described below and illustrated with representative participant quotes, together with details of their gender, age and SNAQ score. A summary of the themes is provided in Table 1.
Table 1
Summary of themes with representative quotations
1) A complex web of influences on appetite loss, that include biological, psychological and social factors |
- Biological | | “I don’t get up tomorrow morning and go and dig holes in the roads, I don’t need the energy, I just need to fill the gap occasionally” (Male, 79 years, SNAQ: 13) |
- Psychological | | “I’ve always had mental health issues…my mental health took a turn for the worst in 2008 …and since then my appetite has got worse, my mental health has got worse which has impinged on my food intake and my appetite” (Male, 61 years, SNAQ: 12) |
- Social | | “We were in lockdown…it was a complete change of lifestyle” (Female, 76 years, SNAQ: 10) |
2) Living with poor appetite - variation in perceptions of poor appetite and attitudes to appetite loss |
- Poor recognition or acceptance | | “I would say prove it, tell me why, tell me how, compared with what?” (Male, 79 years, SNAQ: 13) |
- Eating to survive | | “I never feel like I’m not eating enough because I’m surviving” (Female, 66 years, SNAQ: 12) |
- Practical strategies | | “I like to have small portions during the course of the day so…or like a snack rather than have one big meal in the evening” (Female, 66 years, SNAQ: 13) |
3) Living with poor appetite - the role and importance of the eating environment and social interactions. |
- Eating environment | | “I think that if I eat with somebody else, I more enjoy myself than on my own… that’s why I’ve got one or two friends and then when I’m out with them I have a proper meal, I eat with my friend or I eat in a restaurant and I feel like, you know I’m happy” (Female, 60 years, SNAQ: 11) |
- Social context | | “If I’m going out for a meal with friends then I eat what I like, I can eat three courses no problem” (Female, 76 years, SNAQ: 10) |
Theme 1: a complex web of influences on appetite loss, that include biological, psychological and social factors
Individual ‘journeys’ to poor appetite were complex, influenced by a range of biological, psychological and social factors that differed between participants in their balance and impact. Appetite loss was commonly attributed to a combination of influences from the three domains, and were often interrelated.
Biological factors
The participants described age-related changes in appetite and the effects of changes in their lifestyle and routines in older age, specifically linking lower levels of physical activity to a decreased need for energy.
“It has reduced over the years; I think I definitely eat less now than even five years ago because…part of that is that I don’t do as much” (Male, 93 years, SNAQ: 11)
Daily tasks were emphasised as taking longer to perform and causing fatigue. Eating food was no longer prioritised because of the importance of managing this around routines.
“I’ve had a busy morning… I haven’t had anything to eat, I haven’t had a lunch today…and I won’t have anything to eat until teatime…” (Male, 79 years, SNAQ: 13)
Age-related changes in appetite were also linked to experience of acute illness and long-term health conditions and to the use of medication.
“Certainly, the Loratadine is designed to affect my appetite…they use it for people with obesity to try and regulate their appetite, but mine was used as a diabetic drug, quite a few years ago …I think the diabetic drugs are the main ones that have an effect on my appetite” (Female, 66 years, SNAQ: 12)
Psychological factors
Emotional well-being was often linked to appetite, with some participants attributing the loss of motivation and desire to eat to their mental health issues.
“I put it down to my mental health issues as well sort of, not be bothered of actually doing things in general… it’s just sometimes it’s too much effort to actually get up and do something like that…it annoys me, even when I’m going through a bad patch, I should eat something really, but I can’t be bothered…when I’m going through a good patch my appetite…is good…I eat more and eat better” (Male, 61 years, SNAQ: 12)
Health problems and psychological issues frequently co-existed, such as living with long term conditions and adjusting to coping with health problems that prompted negative psychological reactions leading to appetite loss and a reduced desire to eat. For example, participants described feeling embarrassed when eating with others due to a tremor in the hand or experiencing difficulties with swallowing, making it preferable to eat alone or only with close relatives. For some participants, eating was no longer a pleasurable experience.
“I think it has changed over time… the change I think over a few years now… I think it’s a gradual change since I’ve been diagnosed with diabetes and also...depression and my mental health” (Female, 60 years, SNAQ: 11)
Social factors
Social interaction around meals and food preparation was identified by many participants as an important positive influence on appetite - with appetite loss described in relation to changes in social factors, such as the loss of routine following retirement from work, or the effects of living and eating alone.
“I think also cooking for oneself goes, that adds onto the range of what one’s eating…is the lack of cooking…I vary rarely cook or bake as I used to…I was always…with family but on my own, no, it becomes worse as one gets older…” (Female, 82 years, SNAQ: 12)
Participants highlighted the negative impact of the UK ‘lockdown’ during the COVID-19 pandemic which prevented opportunities for social interaction outside the home in the period 2020–2021. Although the official lockdown had ended several months before the participants were interviewed in this study, there was still some ongoing impact, with continuing caution around social interactions advised for higher-risk groups, that included older adults.
The complexity of the web of potential influences on appetite loss described by the participants is represented in Fig. 1, underlining the differences in individual ‘journeys’ to poor appetite. Although these influences could be grouped into biological, psychological and social factors, in reality they were overlapping and interrelated; for example, with one participant describing how her physical state impacted on her social activities which, in turn, caused her poor psychological well-being, and contributing to her appetite loss.
Theme 2: Living with poor appetite - variation in perceptions of poor appetite and attitudes to appetite loss
Although all participants in the study had poor appetite, there were notable differences in their perceptions of appetite loss and their attitudes to it.
Poor recognition or acceptance
Some participants did not recognise that they had poor appetite.
“I mean I’ve been told by other older ladies, as you get older you do lose your appetite a little bit, but I just don’t know whether I have or not…will it impact me a bit further or not? I don’t know…I don’t know why I’m changing…I have no idea…food still smells delicious, but I don’t want to eat it” (Female, 66 years, SNAQ: 9)
Others were reluctant to acknowledge their appetite loss.
“I’m satisfied I eat enough… I don’t think it would cause me to be worried if I had to do without food for a couple or three days, I don’t just think I would disappear…. How do you define without and reduced?” (Male, 93 years, SNAQ: 11)
Eating to survive
Attitudes to appetite loss also differed. with some participants describing appetite only as a physical need to ‘fuel the engine’,
“I eat to live; I don’t live to eat… I know I have to eat food to live… I know that I’ve got to, at least eat two meals a day because I feel strange, I feel light headed…but I’m eating food because I’ve got to… I suppose you could class it as being the same as putting petrol and oil in your car, you want to go from A to B so you put some petrol in, I want to do something so I eat” (Male,79 years, SNAQ: 13,)
For these participants much less thought was given to food or to eating for pleasure.
“If it’s fuel for the engine I don’t always enjoy that, I get something for dinner because I feel I really need to get something for dinner…I eat because I need to” (Female, 76 years, SNAQ: 10)
Practical strategies
The differing perceptions and attitudes to appetite loss impacted on eating patterns and practical strategies used to cope with it. Some participants described very clearly the magnitude of the challenges faced.
“It’s difficult…because [husband] might sit and he’ll put, not a big dinner out but…I think it’s big, and when I look at it, I could vomit, and I think how…am I going to get that down? And then he gets annoyed…because I’m not eating properly and so it goes on…” (Female, 87 years, SNAQ: 8)
Others had practical strategies that they found helpful, although eating could be viewed as a ‘chore’ that had to fit into daily routines, often describing cooking as requiring ‘too much effort’ and preferring to ‘graze’ food or snack.
“I wouldn’t consider I have proper times of meals; I graze… (Female, 82 years, SNAQ: 12)
Linked to changes in meal patterns, many participants opted for smaller portion sizes, describing larger portions as ‘off-putting’ or ‘nauseating’.
Theme 3: Living with poor appetite - the role and importance of the eating environment and social interactions
The eating environment and social context of mealtimes were described by the participants as important influences on the desire to eat. Social interactions appeared to be closely linked to appetite, both in impacting on appetite loss (Theme 1) and in supporting participants to cope with their poor appetite.
Eating environment
Eating with others was often seen as an opportunity to socialise which, in turn, could have a positive effect on appetite and encourage greater food consumption.
“When I go out for a meal with people, before the Covid, it is a long time you’re sat at the table, you’re waiting for it to come, you’re talking, you are comparing what you’re having ‘oh that looks nice maybe I’ll have that next time’…” (Female, 61 years, SNAQ: 13)
Social context
A lack of social interaction, particularly for participants who cooked for themselves and ate alone, was therefore seen as a factor that could contribute to poorer appetite. This was highlighted both by participants who lived alone and for participants who ‘grazed’ over the day and no longer had structured mealtimes.
“It depends on the mood and the effort…the effort part… think ‘oh I can’t be bothered to chop up the onions? can I be bothered to do this and do that? especially if you’re cooking for one person” (Female, Age 61, SNAQ: 13)
Eating alone required effort and motivation whereas eating with others contributed to food enjoyment.
“If somebody came in and put a meal in front of me, I would eat it…if I go out to dinner…if somebody else prepares the food or I’m in a restaurant my appetite’s absolutely fine…social activity I suppose, if I’m eating socially my appetite improves, I would never dream of having three courses if I’m at home but I can manage three courses in a restaurant or eating out with friends” (Female, Age, 76, SNAQ: 10)
Importantly, many participants described the positive effects of food being prepared for them, being more likely to look forward to a meal and to have improved appetite.