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Loneliness among Elderly People: Can Food and Meals Change this Situation?

In a relationship, it is natural that one person lives longer than the other, leading to many challenges, including the possibility of loneliness. This article focuses on how food and meals can help reduce loneliness among the elderly. There are many reasons for loneliness or emptiness, including being a widow or a widower, illness, and poverty. As the number of elderly people is greatly increasing in all welfare states, meals are an important function that should be maintained throughout life. This study used CurroCus® group interviews, or fast focus groups. Nine CurroCus® groups were conducted, lasting for 37–56 min (average = 45 min). Altogether, 76 persons participated, ranging in age from 60 to 87 years; participants were predominantly female (> 80%). The collected empirical data were recorded, transcribed, and entered into NVivo 11.0. Interviews were analysed using a grounded theory approach. The main findings of this article fall into two main categories: togetherness and life action. Based on the interpretation of respondents’ answers, elderly people make both conscious and unconscious choices that help reduce loneliness. They also gather around food and meals to experience more togetherness. In future research, loneliness strategies carried out unknowingly should be investigated more closely. In addition, elderly participants should self-report on meal activities throughout the day.


Introduction
Awareness of loneliness among today's elderly has grown, and this article examines how they use food and meals as a method to reduce loneliness. Many different forms of loneliness exist among different groups, and existing literature has discussed a loneliness scale (Smoyak 1984), widows' coping strategies (Gass 1987), leisure time (Chin-Sang and Allen 1991), spousal caregivers (Bergman-Evans 1994), adolescent loneliness (Antognoli-Totland and Beard 1999), and loneliness among elderly immigrant women (Kim 1999). In recent years, research on loneliness has focused on finding predictors of loneliness in the aging population (Cohen-Mansfield et al. 2016) such as sociodemographic and health factors (Prieto-Flores et al. 2011), reducing loneliness among older people (Agren and Cedersund 2020), and prevalence among older people (Victor et al. 2005). Coyle and Dugan (2012) focused on the relationship between social isolation and loneliness among older adults, and Taylor (2020) illuminated how social isolation influences loneliness in the same age group. In summary, the boundary rises between social isolation and loneliness through a lack of connection and social interaction versus a subjective problematic feeling.
Several researchers have illustrated eating habits and meal experiences from different perspectives and focuses in recent decades (Bourdieu 1984;Hansen 2016;Meiselman 2000Meiselman , 2003Odencrants et al. 2020;Piqueras-Fiszman and Spence 2014). The research is varied and has examined older consumers from different approaches (Deierlein et al. 2014;Jonsson et al. 2020;Liu et al. 2014).
The proportion of older adults in Norway is rising, with approximately 600,000 people above 67 years old. About half a million of these older adults live at home. The largest increase among the elderly has occurred among those over 90 years old (SSB et al. 2016). In addition, the large cohorts born during World War II is now among the oldest in the community (SSB et al. 2016). The same trend with a rapidly growing number of elderly people is happening all over the world. Among this group of elderly people, malnutrition is a major challenge affecting their health and quality of life (Katsas et al. 2020). Considering the mortality rate towards 2060, life expectancy will increase by 5 to 9 years in Norway. The number of very old people who will live alone and are likely to experience loneliness will probably increase rather than decrease based on SSB (Statistics Norway) projections in Norway. Against this backdrop, the same will happen across much of the world (Katsas et al. 2020).
Loneliness is described by the lonely as an "emptiness" or "hollow feeling" according to Tannenbaum (1967). Those persons perceived to be immune to loneliness possess characteristics that permit growth and constructive behaviours when faced with a loss or change (Austin 1989). Similarly, persons with less creative potential tend to be lonelier than those with more creative potential, highlighting the concept of aloneness, which is similar to loneliness, among older women being treated for depression. Poverty can also be a reason for loneliness (Theeke 2010), and loneliness was found to be an important predictor of anorexia neurosis and the risk of malnutrition (Ramic et al. 2011). Weiss (1973 distinguished between emotional and social loneliness, but focused on special contexts where one type of loneliness is associated with special kinds of relationships and another type of loneliness is linked to the absence of an engaging social networking. Another article confirmed that loneliness has an impact on many areas that affect nutrient status, from appetite to ability to carry out purchases (Ferry et al. 2005). Based on the theoretical insights, loneliness in this article is a feeling of emptiness that reduces the intake of food, which is why individuals try to avoid using food and meals.
The aim of this paper is to focus on the elderly and their ability to cope with loneliness using food and meals as strategies to minimalize it.

Materials and Methods
Method choices depend on the area being investigated. In this article, the focus is on loneliness and food. In the various peer-reviewed articles examined, food was absent or sparsely described. This study used an inductive, qualitative approach to fulfil the aim of this paper. Qualitative methods focus on different aspects of data, such as people, relationships, and experiences (Tweksbury 2009). Therefore, qualitative methods allow even more in-depth investigations of relationships between different areas.
The criteria for participating in the current study CurroCus® (CC) group interviews were that individuals were over the age of 60, exercised at least once a week at Skipper Worse (SW) fitness centre in Stavanger, made their own meals at home, and purchased their own food. SW is owned by the National Society for Public Health. An earlier study found few connections between healthy older people and meal experiences (Hansen 2016), providing the basis for investigating this group.
CC group interviews were chosen as the data collection method for this explorative study (Hansen and Kraggerud 2011). CC differs from traditional focus groups in several areas. The CC group interviews take between 20 and 45 min, and those included in this article averaged 45 min. Traditional focus groups (TFG), which were not used in this study, can take between 1.5 and 2 h (Breen 2006;Greenbaum 1998;Morgan and Krueger 1998). CC adopts a more questioning approach, using a shorter time than TFG, while comparing several information-gathering points as well as writing down answers to fixed questions and considering moderators' notes. The CC method has been used for data collection in different contexts and projects since first being published (Hansen 2015;Hansen et al. 2018;Hansen and Kraggerud 2011;Vabø et al. 2016).

Procedure
CC group interviews were conducted in a step-by-step manner, following the earlier work of Hansen and Kraggerud (2011, pp. 485-486). CC group interviews were conducted on four different days during the spring and fall of 2016. Respondents were offered coffee to drink during the interviews. The same seating was used for all interviews, with all participants situated around an oval table. Participants were given the necessary information about the study and the research number authorized by the Norwegian Centre for Research Data (NSD): "47014 food and meals 60+". They signed written consent forms to indicate their willingness to participate in the study. The written consent forms and shared information were approved in advance by NSD to ensure that they safeguarded individuals' rights and privacy in relation to the General Data Protection Regulation (GDPR). There was no link between the participants and the information provided. Only the project manager had access to the code key that connected the various participants with different CC group interviews.

Analysis of the Interview Data
Grounded theory (GT) procedures make it possible to handle the qualitative data from focus group interviews. GT can be used in various situations (Glaser and Strauss 1999;Silverman 2005). The coding followed a GT approach used in several papers (Hansen et al. 2005;Hansen and Kraggerud 2011;Vabø et al. 2016), which included forming codes by analysing the empirical data from the raw material, which equals open coding in GT (C-level). The next level, known as axial coding in GT (B-level), occurs at a higher level of abstraction than the previous one. The number of codes at a lower level will be included in fewer higher abstraction levels (Fig. 1). The highest level, selective coding (A-level), represents the final coding in GT (Hansen 2019).

Results
The data provided by older adults who participated in the CC group interviews were analysed, and the results are presented here based on the grounded theory approach. Grounded theory operates on three different levels of abstraction. Open coding represents the C level, axial coding is the B level, and-finally-selective coding is the A level. In this article, axial coding and selective coding are presented in more detail by considering the conceptual clarification, quotes, and analysis of the concept in the article's context.

Togetherness
The A-level category togetherness consists of four B-level categories: the avoidance of loneliness, living conditions, social atmosphere, and interactions. The term togetherness is an expression for how older people try to connect with people in their lives to minimize the likelihood of loneliness. Among other ways, they use food and meals as a targeted tool to avoid loneliness.

Avoidance of Loneliness
The older adults use different strategies to avoid loneliness both before they experience loneliness and when they face situations of loneliness (e.g., when they become a widower). Men and women take different measures to avoid loneliness. Women in this survey obtained younger friends who provided them with company today who could also become "relatives" in a future situation when a caring home is the next stop. "But I still see that those who govern in the cities must think about building such small apartments and collective like Lervig Pier +, and not that they have so many meals they have made. And I have been there and looked in apartments and they have been arranged very well, so common that they should come to joint meetings and cosy lounges. They have meeting rooms, fireplaces, and libraries. People buy apartments there so that they do not have to sit in that apartment all day. Also, they can count on meals being served and having a canteen. I think they did [this intentionally]. I think this is the future, because it does not have to be older people, but single people and people who have moved and are lonely." Interview ID 30025 Meanwhile, several male respondents indicated going to the store to shop, often with a shopping list. They shop not only to acquire the necessary goods, but also to be social with other people, whether store employees or acquaintances. Women often choose to visit cafés with girlfriends to reduce their loneliness. Reducing loneliness creates a larger social framework in life that more often results in the possibility of eating meals with others who can increase their nutritional intake.

Living Conditions
Living condition factors include a lot of security and a desire to live in their own home or in a safe environment. Lust for life is important for those coping with loneliness, and the living form is important for the elderly. Daily life is simpler, and more people want to live in smaller homes with easier maintenance.
"Another thing I did, I lost my wife 12 years ago. So, then I promised myself-it was she who was responsible for the cooking-so I told myself, 'now boy just find the cookbook and start'. Then I promised myself that I would have dinner every day. I would not skip that, and I have not done so yet." Interview ID 30031 The respondents expressed that they wanted smaller apartments and housing if they were to move. It was important that there be common areas where they could make and gather for meals. They expressed that it could be tiring to take care of large properties as they grew older. This became their form of continuing to live with new friends around them, giving them more security and less loneliness.

Social Atmosphere
A social atmosphere is what creates an appetite in daily life and is often linked to a social setting where one eats with other people. This makes the meal a gathering point and something that older people can use to create a meal memory.
"In the group here, not for the time being, but it's part of the social game itself when we have gone and sat down to have a chat and a cup of coffee."

Interview ID 30032
Lust for food is essential to increase food intake. When one's appetite gets worse, socializing with family or friends is a good way to create a social meeting point around a meal.

Interaction
Interactions are different ways of communicating and meeting during both meals and ordinary human communication. More people cook together and also have the wish to move to a smaller apartment, which is closely linked to the living conditions. "Yeah, I have actually heard about two old brothers in Denmark who turned on Skype, and they can be different places, one in Jutland, Denmark, while having dinner with the brother in another place in the same country." Interview ID 30029 Human interaction of all types becomes important for reducing loneliness among the elderly. Even connecting with others via digital media reduces the sense of loneliness. Such digital media includes Snapchat, Skype, or regular mobile calls.

Life Actions
The A-level life actions consist of three B-level categories: purchase-making, appetizing activities, and food activities. It involves much of what is required in the preparation of food, the purchase of food and physical activity reflected in new shopping patterns, activities that stimulate the appetite of the elderly, and activities that provide a good meal together.

Purchase-Making
Making purchases in this article deals with individuals' ability to buy the food that they want to eat and cook. Their patterns of action can be a way to break up the loneliness because they then can have food relationships with others. Another consideration of this term is the help they get or want to get for the shopping.
"I shop a few times a week, but I wrote that I drive so I can vary a little." Interview ID 30029 Having their own cars means that the elderly can access a much greater number of shops, and they often drive farther to reach specialty shops. Those who have relatives are happy to go shopping with them to find the necessary foods. Those who shop at convenience stores prefer their purchases to be driven to their home. Food shopping and cooking allow them to invite family and friends to dinner.

Appetizing Activities
Certain factors increase respondents' appetites. Physical activity in the form of exercise at a fitness centre or walks in forests and fields are good examples of how to increase one's appetite. Such activities often occur with other people at the same training level. They reduce loneliness and improve physical health.
"We are five or six girlfriends from the first class at elementary school who go here and train." Interview ID 30028 The activity level varied widely among the respondents. They engaged in fitness centre training once or twice a week along with others and a training instructor. Those who met together at a café after exercising were making conscious choices to reduce their time spent alone.

Food Activities
Many elderly people have a background in food and meal activity, which participants used to reduce loneliness knowingly or unknowingly by getting together for a good meal and chatting about former times.
"It's so much nicer to eat together. After all, I see it when I have a visit and am out how much more enjoyable it is, and it tastes so much better when you are with others." Interview ID 30029 Another part of the conscious use of cooking is when men in their 70s become a widower and decide to learn to cook. The result is dinners with family and new friends who are invited for dinner because they find that there are more visits in the home then.

Discussion
The findings in this paper are based on the analysis of the empirical data collected during the CurroCus group interviews with participants. Two main categories surfaced from the data: togetherness and life actions.
Not all food and meals can solve loneliness among older people, but this discussion focuses on what is done both knowingly and unknowingly. Cohesion is something people are used to from the moment they are born. The expression "from cradle to grave" illuminates how humans are used to having someone around them. When one of the partners in a relationship dies, the feeling of loneliness can creep up on the surviving partner. The elderly respondents used different strategies to solve this issue. Visiting a café with girlfriends was one solution, and men learned the art of cooking from scratch. Among this demographic, female partners are often responsible for cooking.
The interviewees did not state that they feared poverty, as described in Theeke's (2010) article. They focused little on income, which may be due to the good pension conditions in Norway. An official report from the Royal Norwegian Ministry of Labour and Social Affairs (Labour and Social Affairs 2016) stated that there was "no poverty risk (for those aged 65+)" in Norway. OECD (2019, p. 186) reported that Norway, along with a few other countries, has the lowest relative poverty rate, which is below 5% for people over the age of 65. Some of the older people were concerned that fresh fish is often more expensive to buy than meat. They were keen to invite family and friends to visit and eat the food that they had made, and they did not see it as being disturbed. Men in particular stated that they had to get together and make dinner, like when their wives were alive. As a result, they had more visits from family and made new friends, often related to the dinner meal. Eating out at a restaurant occurred less frequently in this group, but café visits were more common. This is in line with findings from a survey that showed that elderly people ate at up to 25% more in restaurants than at home (de Castro 2002).
Purchasing food and necessities is something that the elderly often do daily because it provides them with opportunities to connect with other people, such as friends and store employees. Purchasing takes place not only at the convenience store, but also in specialty shops (e.g., fishmonger or butcher). Male interviewees tended to make small purchases every day so they could socialize with other people and exercise. They were not always aware that it could reduce loneliness, so purchasing food and drink at a store is a subconscious loneliness strategy. They also use convenience stores to a great extent. Ferry et al. (2005) highlighted the importance of convenience stores for elderly people's diets as well as their quality of life.
The elderly participants' food and meal knowledge acquired at an older age helped provide them with improved contact with family and friends. Meals have become a gathering point as a conscious choice to reduce loneliness and create more interactions with other people. Eating out at a restaurant was not as common, but cafés were used to meet with others, especially among women. Men tended to use cooking to find new friends, including new girlfriends after their wives passed away. A few of the women who had older husbands experienced that the man took more responsibility for cooking, especially dinner, after they came home from work. This indicates how important meal knowledge is for older people for reducing loneliness.
The elderly participants were aware that, when they moved, it would be to a smaller residence (e.g., apartment in a residential building) with larger common areas for various activities, such as an exercise room, game room, kitchen, and dining room. The purpose was to be able to come together and reduce loneliness as well as look after each other.

Conclusions
Based on the collected data and subsequent discussion, elderly individuals' ability to use food and meals to reduce loneliness seems to work. It is important to point out that they use this strategy both knowingly and unknowingly.
The interviewed seniors were aware that eating together, whether at home or outside the home, is a positive activity. They experience less loneliness and recognize that they eat more when in the company of other people. They were not as aware that shopping at a convenience store, conversations with employees, and the environment promote experiences of being together. Many areas, such as housing, meeting places, exercise centres, cafés, and various social media, were proven choices for socializing with others. In many of the cases mentioned, food was involved and provided a better meal experience than when alone. At the same time, this helped combat loneliness among the elderly. The group of elderly participants did not say that they had a poor financial situation, but that may be related to the fact that the Norwegian welfare system provides sufficient pensions to ensure that people do well financially. Although they found fish to be more expensive than meat, they still bought fish.
Future research should investigate unconscious loneliness strategies more closely, and the elderly living at home or their next of kin should be encouraged to report their food intake if they are at risk of malnutrition.
Acknowledgments Open Access funding provided by University Of Stavanger. This project would not have been possible without the close cooperation of Skipper Worse AS and their users, which is an important initiative for older people in the Stavanger municipality.

Compliance with Ethical Standards
Conflict of Interest The author declares no conflict of interest.
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