Appetite and falls: Old age and lived experiences.

Falling among older adults is a well-known public health problem but the association between falling and appetite is seldom studied although poor nutritional status is accepted as a risk factor for falls. On this background the aim of this study was to understand how older adults, who have fallen several times within a year, related their experiences of appetite as a phenomenon in everyday life. In narrative in-depth interviews, eight women and four men contributed with their stories. Using interpretative phenomenology the thematic analysis resulted in three main themes: appetite for food; appetite for social relations and appetite for influence. Eating was not trivial everyday routine and required self-regimentation. Meals were not an object of desire, but of discipline out of the wish to survive. Feelings, reflections and ambivalence were bound to the lack of appetite on food. The participants were oriented towards the forbidden, the delicious and to everyday food as a strengthener and as medicine. In their dependency on help, home was the framework for establishing social relations as means of social support. As well as family and neighbours, the significant others were persons on whom the participants were dependent. Personal relationships and mutual dependencies may ensure social security in lives characterised by contingency and maintain influence in daily life. Falling is both a dramatic and a trivial incident where life and death could be at stake. From this perspective, connectedness was prominent in all fall stories. The quest for influence and a sense of social connectedness was the incentive to re-enter local community arenas and to express solidarity. In health-care practice multi-factorial fall-prevention should be complemented with a multi-dimensional approach in order to balance the medical approach with humanistic and societal approaches towards fall-prevention.

Due to the multi-factorial nature of falls among older adults (Tinetti & Kumar, 2010), it is difficult to determine casual relationships between risk factors for falls (Robertson et al., 2010; WHO, 2007). Nevertheless, Lumbers, New, Gibson, and Murphy (2001) showed that hip-fracture patients were likely to have suffered from under-nutrition prior to the accident. The association between poor nutritional status and falls is frequently mentioned but seldom studied extensively and appetite has not been a topic of interest (Vellas et al., 1992). Attention has been paid to eating habits and low body mass index (BMI) in the aging process.

In scientific literature there is a sliding passage between what is considered normal and what is considered problematic; and eating problems often seem to be treated as analytical concepts and diagnoses rather than empirical categories (Benelam, 2009; Visvanathan & Chapman, 2009). Hepworth, Mogg, Brignell, and Bradley (2009) suggested a link between negative mood, trait-eating style and the motivation to eat. They pointed out that negative moods increased subjective appetite as well as perceived stress. In contrast to this, Engel et al. (2011) suggested that poor emotional well-being was most significantly associated with poor appetite and low commitment. In 1996, Falk, Bisogni, and Sobal focused on the professional understanding of cognitive food-choice processes among older persons. They suggested a multi-perspective model for food choice including life-course influences such as personal values, ideals, social framework, personal factors, sensory perceptions, monetary considerations, convenience and physical well-being. Wikby and Fagerskiöld (2004) concluded that mood, personal values, wholesomeness, food, eating environment and meal fellowship affected appetite. They saw a connection between participants’ desire or willingness to eat and their will to live.

Older adults often make positive dietary changes following the onset of certain chronic health conditions. However, most chronic diseases appear to lead to dietary restrictions that compromise nutritional status (Shatenstein, 2008) and the older adults were frustrated not being offered sufficient counselling by their health care providers. In daily language, appetite is associated with the desire to eat. But appetite is not for all kind of food, it is particularly for food based on smell, flavour, appearance and appeal. Appetite can also be considered as a metaphor for the desire or liking for something valuable in life. Appetite has an inner and outer perception and loss of appetite can be related to feelings of anxiety, fear, grief and even of joy and excitement (Lupton, 1996; Tange Khristensen, 2003).

Aim and research questions

The aim of this investigation was to describe and understand the meaning of appetite among older adults who have fallen several times, in order to gain knowledge to future fall-preventive efforts. The research questions were:

What is the meaning of appetite in an everyday life context?

What is the meaning of appetite embedded in and mediated by subjective experiences and social interaction?

What is the meaning of falling and appetite in the practical world?

Method

The researchers’ pre-understandings were that growing old is a manifold notion with different meanings dependent on various life experiences. People's backgrounds, their life experiences and living conditions vary considerably, as do their coping strategies. Vulnerability in relationships due to temporary loss of resilience and autonomy can be part of the circumstances (Sarvimäki & Stenbock-Hult, 2004). Coping in a meaningful way and being able to manage everyday life (Gubrium & Holstein, 2000) can be a challenge, and thus support is needed to balance life. In order to describe, understand and interpret the meaning of appetite and falls in older persons the methodological source of inspirations was brought from Benner's interpretive phenomenology (Benner, 1994; Benner & Wrubel, 1989). The approach is based on the philosophy of Heidegger (2007) and Merleau-Ponty (2002). This version of phenomenology does not separate description from interpretation; instead, it draws on insights from the hermeneutic tradition and argues that all description constitutes a form of interpretation. The aim of interpretive phenomenology is to understand the participant's practical world in the framework of phenomena and their contexts. In order to uncover naturally occurring concerns and everyday taken-for-granted meanings, the primary source of knowledge is narrative accounts of everyday concerns and practical activity.

Participants

Eight women and four men have contributed to this study. They have been interviewed in-depth in narrative interviews and have told about falls and their appetite. Participants were chosen partly from fall-registration forms by the researcher/first author, partly from a senior course on fall-prevention and partly from the district nurses’ recommendations. In the municipality of interest, falling accidents are recorded. In addition staffs fill in registration forms and hand them in to the Public Health Department in order to monitor falling accidents. The researcher (MM) went through the fall-registration forms to select participants based on variations in gender, socio-economic background, more than two falling accidents in the last year and of 75 or older. The researcher first contacted the district nurses to verify if the proposed persons would be able to go through an interview considering their cognitive functions and life situations. Afterwards there was a debriefing with the participants and the district nurses. Terminally ill and persons with dementia were left out.

Data collection

The participants’ ages ranged from 75 to 94. In their working lives they had been social workers, shop employees, unskilled mechanic, children's nurse, civil servants, artist, cook and housewives. One woman had never married, four were divorced long ago and the others had been widowed within the previous 10 years. They all suffered from more than one chronic condition and they all lived alone at the time of the interview. They received some home help. One of the participants received help four times each day, five of them had help in the morning and afternoon. Four received help only in the morning, and one woman got help with cleaning, shopping and bathing twice a week. Six women and three men received one meal-on-wheels every day while the others were connected to a local community grocery-purchase arrangement. One man was interviewed in the rehabilitation ward, where he received food, care and training. The other participants were also visited regularly by district nurses. The first impression of the participants was that they were small and slim except for two women whose BMI was 24. The others’ BMI ranged from 16 to 20, which is assessed as low and a risk factor for future falls (Tinetti & Kumar, 2010). Participants’ body mass index scores were registered in the district nurses journals. The participants lived in two different local areas in a big town. Both were areas with a diverse social structure with working-class, middle-class and immigrant population.

Eleven participants were visited in their homes. One participant who was temporarily staying at a rehabilitation ward was visited on the ward. The interviews were carried out narratively (Riessman, 2008). The researcher asked the participants to tell about their falls, and how they had experienced them and what they meant for their daily lives, their meals and their appetites. The first question was: “Would you please tell about…” And then” would you please tell more about what it meant to you?” After some reluctance from the participants, as to assess the interviewer's interest, they described their fall situations and weaved in their life stories. The interviews lasted as long as the participants wished and had strength to speak, usually 1–2 h. The researcher only asked focusing questions when clarification was needed. The interviews were held in an open and comfortable atmosphere. They were audio taped and transcribed verbatim by the researcher. The entire text of each interview was analysed.

Analytical foci

The analytical process incorporated three interrelated stages: The thematic analysis and the analysis of specific episodes followed by cross analysis in order to integrate themes across the interviews. A synthesis of the results was done in order to find commonalities and differences.

The thematic analysis: The interview texts were read several times in order to include reflections, questions, comments on language use, descriptive labels and to give an overview. This led to an interpretive plan with focus on the narrator's situation, concerns, actions and everyday practices. From this process themes emerged, showing meaningful patterns and concerns in the perception of appetite in everyday life. This process involved moving back and forth between parts and the whole of the text, and the point of reference shifted from understanding to distancing and asking questions about the participant's world. Analysis of specific episodes and incidents was based on emerging themes and discourse. Table 1 shows an example of the analytical process. In accordance with aspects of commonalities and differences in the particular situation, the participant's responses were analysed together to capture the meaning in such a way that it could be recognised in other situations. Theoretically, the collection of exemplars is open-ended because it is not possible to completely explicate or freeze particular cultural meaning, concern or habitus (Benner, 1994). The last stage of the analysis was integration of themes across the interviews which was also carried out in a cyclical manner. The presentation of this study will involve distilling data to their essential terms, while still providing the reader enough textual evidence to challenge the researcher's practical reasoning and to participate in the validation of the findings (Benner, 1994).

Table I

An example of the analytical process.

Theme	Meaning unit/ the narrative account	Common meanings	Interpretation
Appetite for food/ the social coffee	“I call it the social coffee—and with dark and healthy chocolates. The sugar gives me a little kick, and then I stabilise my body with a little brandy.” (Esther).	Sugar and alcohol was a pleasure to take	Using the adjective social the participant expressed an atmosphere of well-being. Creating this moment of pleasure eating the forbidden compensated eating the healthy and nutritional correct meals on wheels.

Ethical considerations

The older persons involved were first contacted by telephone, to hear if they were willing to participate in the study. It was emphasised that participation was voluntary. In the conversation they were told about the study and the researcher. If they were interested in taking part, they received a letter describing the interview, the study and their rights. At the beginning of the interview visit, they received a form of consent to sign. Because interpretive phenomenology studies everyday practical knowledge, it was important that participants felt at ease in a comfortable atmosphere. This study has been approved by the internal security system of the municipal administration and follows the Ethical Guidelines for Nursing Research in the Nordic Countries (SNN, 2003). Participants were promised confidentiality and anonymity.

Findings

With focus on the meaning of appetite in relation to falls in everyday life, participants associated freely when asked the opening question. They told about their falling episodes and told their illness stories as a kind of autobiography. Telling about their lives, they told about their desires, wishes and wants in life and not only about appetite for food. The thematic analysis and the main themes will be presented, followed by specific episodes bound to the theme: Appetite for food, with the sub-themes; disciplined lives; “the social coffee”; food as medicine; and aesthetic dimensions of food. Appetite for social relations, with the sub-themes: social relations as “security systems”; family ties; neighbourhood and friends. Appetite for influence with the sub-themes: interpersonal influence, influence on the local community and influence on society. The statements quoted are the textual evidence chosen to illustrate the analysis of the specific episodes.

Appetite for food

Participants associated the word appetite with the desire and liking for food. They had experienced several falling incidents and they combined their appetite for food with their bodily strength and their capacity to stay upright and alive. With two exceptions, they had experienced considerable weight loss the last few years. They explained this differently according to their life situations. Besides the falling accidents, the participants suffered from several chronic conditions.

Disciplined lives; or the ambivalence towards food and eating

Helene had small stomach capacity due to her osteoporosis. Eating and food had been a pleasure all her life, but now she was experiencing difficulties, she had weakened and fallen. She had to discipline her eating and divide eating into small energy-enriched meals. She received a special menu from meals-on-wheels. Eating this diet, she could keep her weight. In between she prepared some small dishes. Alice again watched her weight, because she saw it as an instrument of strength, she ate small frequent meals, which were recommended to her. She had been offered a special menu, but it was expensive. For Eva it was a great challenge to discipline her body, to train her muscle strength and to eat what was recommended to her. She felt reproached for her weight, which was a burden to her sore knees. But she worked hard at it, and tried to eat as little as possible. Esther liked inviting guests:

But it is seldom now, but when I do [invite guests] … I write down the ingredients, the recipe and a timetable. If I am going to make Italian salad, I first have to prepare carrots and peas. I also write down if the bread is to be warmed in the oven. It is my way not to become stressed. It is stressful to have guests for all human beings! You had better lie down and rest a while and then go on.

Karen refused her family's offer to prepare her favourite dishes at her 95th birthday because she did not want to go back to meals-on-wheels after such an experience. Delicious food was in the past. When asked about her appetite for food, Mary answered, “Unfortunately, I have lost weight. Last year uterus cancer took my kilos.” In the same breath Mary told about the edges of her body and contextualised her appetite in relation to her illnesses and food-intake recommendations. Asked again, she answered, “Now I eat because I have to. I must say that. I eat because I want to stay alive. I don't feel hunger or a desire for food.” Eating food caused reflection and was not a trivial everyday routine. Many feelings were bound to appetite for food, to the lack of appetite for food and to eating itself. Appetite for food mirrored the participants’ life-situation and health condition.

“The social coffee”

The participants were well informed about healthy living. Their interpretation was that everything delicious was forbidden. Because of their exposed situations, they kept their longings and actions secret. But during the interviews, some secrets came out. “I call it the social coffee—and with dark and healthy chocolates. The sugar gives me a little kick, and then I stabilise my body with a little brandy.” (Esther).

Alice liked most a cup of coffee and some sweets or small cakes. Eva received meals on wheels and to her eating was something to get over with. The delicious part of the meal was the dessert with a cup of coffee. Eva had a cupboard with chocolates. She introduced her liking for chocolate as a sin. It was not only coffee, sweets and brandy that were forbidden fruits. Karen unveiled, “Now I get a little kick after lunch. I drink half a Guinness. I could drink a whole bottle, but then I think I would fall. I save half a bottle for the next day.” Ivar was not after food. When food was delivered, he ate it out of the wrappings as quickly as possible, to get it over with. He then would enjoy drinking a beer while watching a sports channel, because as he said, “I am an old athlete.”

The participants complemented the nutritional correct meals-on-wheels with moments of pleasure and well-being created by eating the forbidden. In this way the participants showed their inner strength in positioning their wishes. They were not able fully to decide which food to eat but they could supplement the ordinary with their extraordinary after their own taste.

Food as medicine

Esther went to the discount shop in the neighbourhood with her wheeled walker. Some days it was difficult for her to manage, but she had some reserve food in a kitchen cupboard. Her food was well planned according to her strength and her health,

“You know what I do? I boil the food. I have heard it is supposed to be good. Afterwards, I drink the water from the boiled vegetables. It is supposed to ease my rheumatism.”

The district nurse was very keen on Elna's weight. But Elna managed in her own way:

I do not have an appetite for food. Yes, perhaps some warm soup … It is good, when you have a sore throat. Camomile tea is also good. Yes, I have lost weight. Perhaps my appetite has returned? I look forward to mealtime today. It is not as my own cooking, but you can't expect that. I will not complain. I had to take the meals-on-wheels, because I ruined the cooking pots and casseroles. I could not see what I was doing (Elna laughed excusingly) the worst thing is, you cannot choose what to eat. I would have liked some soup today.

Food as medicine referred to the participants’ layman's knowledge. This knowledge represented a continuity of managing everyday life in accordance with what was supposed to be good to your health and what the participants could launch without any outside interference.

The aesthetic dimensions of food

Helene had spent her life as an artist travelling around the world. She could tell about food in Morocco, in Norway and in France,

“When I got married I went to Normandy with my husband—I still dream about it. Their mouton was called presalé, because the sheep had eaten the grass watered by the sea”

… mm … Helene coughs … “In France I learnt the culture of food.” Gunnar had been ill in his stomach all his life just like his father. He had been through several operations and had eaten special diets all his life. For the first time in his life, he enjoyed food:

Yes, I get the food from meals-on-wheels … more or less. I have been allowed to take a walk with my helper, so that we can go to the store and buy food. First we look at the goods, they are beautiful. Then I buy really delicious food. I only buy delicious and beautiful things … Yes, we visit the fruit shop and ask if he thinks there is anything really special. And then he proposes something really good we should try. I enjoy it very much.

To do something extraordinary was essential to these participants, to be attracted by beauty and luxury was appreciated.

Appetite for eating consisted of various approaches to food, nutrition, eating and meals. Most of the participants experienced ambivalence. They knew the official advice given in order to maintain their health. Even though they followed the advice to a certain degree, their personal values in combination with their life situations sometimes drew the line and gave way to other views on practical life.

Appetite for social relations

Participants showed an interest in other persons, in interdependency and in establishing relationships. Their conditions and approaches toward social relations differed. They shared the tendency to fall, their interest to tell about it, and their dependency upon others. Just as their appetite for food focused on strength their appetite for social relations focused on social security. Except for Jens, they all had their homes, which were conducive to companionship and cosy talks. Jens had tried to redecorate his institutional room at the rehabilitation ward with candlesticks, some pictures and photos.

Social relations as “security systems”

Tying individual strings to helpers was pervasive. Eva felt she had close connections to the health staff and told how she memorised their names in order to give them her personal touch. Alice, just as Gunnar, told about how attentive they were towards the staff. If they were tired or had problems of their own, Alice offered them coffee and said they did not have to clean. She presented this relationship as a kind of security system, where it was important to be well-liked to get the best help and the best helpers. Dorothea was sorry that the helpers she liked best had stopped coming. Nevertheless, she spoke about her helpers as “my helpers” and, in another connection, she said, “The little one” in an affectionate tone. To Elna, it was not only the helpers who represented a security system. She established a strong relationship to librarians, because she was dependent on the audios, and to the doctors for health reasons. Especially the physiotherapist was valuable to her because she represented Elna's way out to the street again and individual agency. With the physiotherapist, Elna trained twice a week on the staircase with the explicit goal of taking the stairs down and up again to the third floor. Her dependence of the physiotherapist's professional skills was evident and she did her best for the physiotherapist. Jens had a close relationship to one helper, who came regularly to his home. The helper had also known his wife, so she represented continuity in his life. Ivar was also interested in good relationships with his helpers, the district nurse and the physiotherapist. The last mentioned he had an ambivalent relationship to, because he did not want to train his mobility. He felt sorry for her. Mary established relationships to every person she met at the hospital as well as in her neighbourhood. At the hospital, she praised the staff for their skills. She took it as a challenge to learn the medical language to respond to the medical staff.

It was essential for the participants to establish close ties to those whom they were dependent on, it could be home-care staff, therapists or others. The participants facilitated a social security system based on relationships in order not to be left alone in an awkward situation. As persons who had experienced falling they knew the contingency of life. They built up their own social security systems.

Family ties

Dorothea lived her silent life in her living room. She had had a row with one of her sons many years before and had not seen him since. She did not think the other son's wife liked her, so she spent her days alone except for frequent home-helper visits. Elna with the impaired sight had close relations with her family, to her sons, great-grandchildren and grandchildren. She also had an arrangement with her late sister's son. He worked nearby and came Wednesdays for a cup of coffee. Shortly before he arrived, he would phone her, “Do you have the coffee ready?” She integrated her family into herself and felt a bodily sense of imbalance in their absence. When her son and daughter-in-law went travelling, she knew she had an increased risk of falling. Unfortunately, she did have a severe falling accident the last time they were away. Neither Karen nor Leif mentioned their helpers as significant others. Leif told briefly about his close connections to his sons, who supplied him with groceries and company.

Neighbourhood and friends

Although most participants had not been outside their doors for years, their sense of neighbourhood was strong. Eva maintained old friends via her mobile phone. She was the only one who was able to go outside and she planned her visits actively. Alice too used the phone to communicate. She followed family and friends through smooth and hard times. She appreciated the contacts, and she valued her skills in talking to people. She created close connections and gave advice. Esther showed her ability to establish relationships; she told how she systematically found common points of interests with her neighbours and shopkeepers. With these relationships she created her social network, social support and sense of social connectedness. For Jens, living alone after his wife's death, it was important to create new acquaintances. “Yes, relationships and getting together; you don't do that today. Why can't people help each other? Why can't they be something for each other?” In spite of this bitterness, Jens had met an Iranian couple in his neighbourhood. They had a grocery and they brought him flowers and vegetables. He felt at ease with them, and they showed great concern for his well-being.

The framework for establishing social relations was mainly a home furnished to receive and entertain guests. Their significant others were persons on whom participants were dependent. Participants sought to establish an equal relationship from which they could expect decent support if necessary. Their appetite for family and for neighbourhood relations differed according to their backgrounds and life courses.

Appetite for influence

Participants showed their appetite for influence at personal, local community and societal levels. According to the narratives, social relations were ties to people necessary for participants because of the imminence of falling and other unexpected accidents. Their appetite for influence was guided by the desire to actively shape their lives in accordance with their fundamental values and to maintain self esteem.

Interpersonal influence

A number of the participants had thoroughly prepared for the interview. They were keen on taking an advantageous position and on influencing the situation from the beginning. They had been up early, they had dressed up and they had prepared some topics, they wanted to present. Alice wore a blue and white dress—old but beautiful. She had laid the table with cups and fresh coffee. Alice positioned herself as an attractive woman, well dressed and mentally present. Helene had chosen to present herself as an interesting person and told about her interest in the aesthetic approach to sensory experiences. Elna initiated the interview by excusing herself for not having her hair done. She was well dressed and was ready to receive guests in her small apartment.

In contrast, Dorothea had no intention of gaining influence via a positive impression. From the beginning of the interview, Dorothea had gathered all her healthcare papers on her lap, and she sighed, “What shall I do with all this?” Throughout her learned helplessness, Dorothea had the strength to influence the help she received. Gunnar had had influence throughout his life, and his story circled about this topic. He came from poor living conditions, from which he had broken out. He had had a societal position with influence, he had married although divorced later on, and he found work, unlike his father. Ivar too saw himself in the same way. He had started his working career as an errand boy and had ended it as a civil servant. Now he presented himself as an old man, but still with influence over his helpers, his family and his life. He did just as he liked in spite much good and well-intentioned advice. Jens's ability to remember was failing just like his health. He was afflicted with coronary occlusion, brain haemorrhage and hernia, which made him bitter. He wanted influence but it eluded him.

“Everything is wrong, you see. At the hospital, the physiotherapist took away my wheeled walker. She said it was better I used a high walker. I fell in the middle of the other patients. I thought they were educated!”

Jens became angry, when he told about his loss of influence, but when he talked about his working life as a civil servant, he sparkled. Karen did not describe herself as someone who had broken out. Her mother had been a good cook too. In her life Karen had been an influential cook, a cook specializing in “ordinary food” rather than middle-class food. She had a strong class consciousness, and she enjoyed talking about her life values. Her leeway had been reduced, but now she had home-help instead of her past kitchen help:

They know what I expect. I expect very strong tea in the mornings. Boiling water in the cup, then the cup gets warm and they must not switch off the water. Then they have to put the tea-bag in the boiling water. The tea-bag has to stay in the cup with a saucer on the top. Some of the helpers are not really good at it (Karen laughed) But I teach them to do it properly… you have to learn how to walk before you can do it.

By telling stories of their lives the participants constructed narratives of their lives lived with dignity, autonomy and control. In their present state with falling as a life condition, they restored frailty with interpersonal influence.

Influence on the local community and on society

In spite of her daughters’ warnings, Alice wanted to extend her territory and to be again in touch with the local community. She succeeded in going to the bakery with her wheeled walker and in saying hello to the bakery girls and their customers. She did not want to be forgotten by her neighbours but wanted to maintain her influence in spite of her new position as a widow. Helene worked with her neighbours to create a good and healthy atmosphere. She also took active part in choosing staircase colour. Influence on resisting existing discourse about how older adults are slow, dull, not able to learn and requiring personal and physical growth was important to Eva. In spite of her limited mobility, Esther participated in old friends’ and secretary-college gatherings in her trade union. She was interested in new relationship and took active part in political discussions.

“I think I am the best COPD patient at the hospital. I participate in every research project they offer me, try to help other people; and I learn their language to communicate” (Eva).

“I think the Lord Mayor was a bit naive when he proposed that … hm … older persons should knock on their neighbours’ door and ask them to buy the groceries.”

During the interview, she stressed the importance of having influence as a woman and as an old woman, “As a woman I have always earned my own money.” Esther was a great fan of a social democratic female politician. If Esther was able, she attended all the meetings where the politician talked. Esther wanted to get public attention to the closing of both the local post-office and pharmacy:

I think it is really bad to do this in a quarter with many older adults. I propose that they reach an agreement with a little shop, for instance, where you could deliver your prescription one day and fetch the medicine the next.

Eva was also engaged in solidarity actions for other older adults:

I can be really mad when I see people get a wheeled walker without getting any education on how to handle it and walk with it. If you knew how often I stop people in the street and say, ‘Pardon me, but you are walking inappropriately with your walker. You should keep your arms next to your body and not hang over it. You have to carry yourself and have a straight back’. Nobody has ever told them how to manage their wheeled walkers.

She brought her mobile phone everywhere, to be able to call for help if needed. In her opinion, all older adults should be trained in handling mobile phones. She had sent a letter to a newspaper about it. Elna possessed the feeling of influence and maintained her self-esteem by her all-round knowledge. She compensated her reduced sight through listening to the radio and to audios. Listening to the newspaper, hearing the news on the radio and on television, made her part of the world. For Mary too, reading newspapers and taking part in the societal discourse was important. She was well-informed, but she had ended up a difficult economic situation. In her strong commitment to human rights and against political suppression in the world, she had donated a large sum of money, “I got a shock; I was supposed to pay a huge amount of money. I had to ask my caseworker to help me out of the situation.”

In a life marked by the threat of falls and chronic diseases, participants managed to establish feelings of social connectedness by gaining influence and position based on their views and values.

Interpretation and discussion

This article focuses on the meaning of appetite among persons who had often experienced accidental falls. The persons in this sample were characterised by their frailty and lack of appetite for food but appetite for relationships and societal influence. They were in an exposed life situation because falling stigmatises (Kingston, 2000). Falling is down, also metaphorically. The person's fell to the ground, often in humiliating positions and situations. Falling as a public health issue is considered a killer (WHO, 2007), which was well-known to the participants. They reflected on the risk and coped according to their perception of everyday health (Roberto & McCann, 2011). Fall prevention is complex, and due to the multi-factorial nature of falls, it is difficult to determine casual relationships for risk factors (Gillespie et al., 2010). In this study, most participants were thin and did not have an appetite for food. The association between appetite and falls has not been studied extensively (Vellas et al., 1992), but eating and nutritional status for a long time been part of multi-factorial fall-prevention programs (Tinetti et al., 2003). Food is both substance and symbol, and to some participants, appetite for food was more of duty than of desire. To live, they knew they had to eat, so they managed food according to their life situations, socioeconomic conditions and values. They fought to maintain their weight, most of them in order not to lose kilos or muscle-strength (Beck, 2001). Food as medicine (Helman, 2000; Nettleton, 2001) was a part of participants’ lay-man-coping strategies. They actualised knowledge gathered through life and used it to establish mental and physical homeostasis. However, their dependence upon the pre-ordered-food limited their use of this knowledge. Food as medicine and an appetite for the forbidden could be seen as the participants’ counterweight to the dominating risk-orientated discourse, where people are expected to take personal responsibility for their choices (Lupton, 1999). Lupton stresses that lay-factors often resist or directly challenge experts’ judgements on risk. At the same time, when it comes to disputes about risk the participants was well aware of their dependency on expert knowledge. Participants listened, sorted the health advice and furthermore had their own secrets. The narratives showed self-regimentation not to lose dignity and control. Their lack of inclination for food, gave rise to an appetite for social relations and for influence, bringing balance to their bodies. Because of the contingency of their bodily conditions and other uncontrollable forces, they tried to communicate their bodily self-esteem to the world through this influence (Frank, 1997).

In various ways, participants created their framework for social relationships. Their setting was homey; their homes were furnished and had the social dimensions to treat guests (Simonsen, 2001). There had been transitions in the participants’ lives, their social roles and their dependency on others had increased and their social positions needed some adjustment to appear as distinctly as they wanted them (Spalter, 2010). They valued family ties, but important to them were their individual relationships with helping staff and with other persons on whom they were dependent in their present life situation. The participants, who all had experienced falling accidents, not only increased their reliance on formal services, as Roe et al. pointed out (2009). They also had their own strategies on how to learn home-helpers’ names and how to create comfortable and comforting situations for the helpers. In this way they supported them in their hard-working lives. Through this interdependency, participants’ autonomy was facilitated through other people (Mars, Kempen, Widdershoven, Janssen & van Eijk, 2008). They managed relations with home-helpers and created their own personal support-security system.

The third and fourth ages are social categories (Higgs, Leontowitsch, Stevenson & Joes, 2009; Twigg, 2004, 2006) related to status and roles assigned on the basis of various biological, personal and social criteria. In societal discourse, ageing is viewed as a process of decline based on stereotypes (McIntosh & Kubena, 2008). The participants in this study had their own ways of positioning themselves, as: interesting, significant, valuable and with an overview of situations. One participant did it by showing her lack of power in managing situations.

Levasseur, Richard, Gauvin and Raymond (2010) have proposed a taxonomy of social activities. Characteristic for this group of study participants was that they were involved; this is the first step in the taxonomy. The next step on the taxonomy ladder is active social engagement and participation in local communities. Some participants were involved and participated in public affairs. Esther and Eva were distinct in their solidarity towards other persons their own age and fought for older adults’ societal rights. They had also made appeals to the outside world, loudly expressed their opinions and participated in debates, in order to encourage change. In gerontology (Levasseur et al., 2010), focus has mainly been on social involvement, but only seldom on social participation and social connectedness.

Methodological considerations

Interpretive phenomenology created a framework for de-contextualisation and re-contextualisation of the transcribed text with situations, concerns, activities and everyday practices as points of reference. The interpretation of the interview text went to and fro from the full text to the meaning units, sub-themes and themes in order to strengthen the interpretation's trustworthiness. To establish credibility and critical authenticity, the steps in the research process were made transparent and participants’ statements were quoted (Whittmore, Chase & Mandle, 2001). The interpretation reflected meanings and experiences that were lived and perceived by the participants. Because of interview multi-vocality, commonalities and differences had to be balanced in order to be true to the phenomena studied. It was the authors’ intention that quotations attached to the themes in the findings should give the reader the opportunity to follow the process of analysis and interpretation as well as the trustworthiness of the study (Rolfe, 2006).

Conclusion

Life with the inclination to fall, with chronic diseases and with ambivalence towards food, accentuated the participants’ need to establish their position and worth. Stories of older adults about falling and appetite created a sense of coherence between interior and exterior perceptions of life and coherence with daily life in society. Eating was not a trivial everyday routine, and it required self-regimentation. Meals were not an object of desire, but of strict planning and discipline out of the wish to survive.

Feelings, reflections and ambivalence were bound to the lack of appetite for food. But they were oriented towards the forbidden, the delicious and to everyday food as a strengthener and as medicine. Stories about falling are not often heard or listened to. When heard, they are usually used as tools for fall-prevention. These stories of falls and appetite contained both the vulnerability of life situations and of personal strategies for social relations and influence. They opened a window to lived experiences of falling in old age, not only bound to homes, but also to connectedness within neighbourhoods, local communities and societies. In their dependency on help, home was the framework for establishing social relations as means of social support. In addition to family and neighbours, the significant others were other persons on whom the participants were dependent.

Personal relationships and mutual dependencies may ensure social security in lives characterised by contingency and maintain influence in daily life. Falling is both a dramatic and a trivial incident where life and death could be at stake: falling can disrupt lives. From this perspective, connectedness was prominent in all fall stories. Appetites for influence at personal, local and societal levels were focused on. This formed a basis for mastering decisions and enabled the participants to establish interdependent relations with the municipal help system. The quest for influence and a sense of connectedness was the incentive for re-entering the local community arena and to express solidarity with other older adults at a political level. In health-care practice a multi-dimensional approach, including medical, humanistic and societal approaches, should complement the traditional multi-factorial fall-prevention in order to build fall-prevention strategies based on understanding of the life situation and the meaning of appetite and falls for the older person.