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*
Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa and
General Clinical Research Center, University of Iowa, Iowa City, IA 52242-1010
2To whom correspondence should be addressed. E-mail: teresa-marshall{at}uiowa.edu
 |
ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: • elderly • diet • dietary supplements • nutrition assessment • diet variety
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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,2)
.
Poor or marginal nutritional status is linked to increased morbidity
and mortality in community-dwelling and hospitalized elderly
(3
4
5)
. Low body mass indices and inadequate energy
intakes are associated with functional decline and elder failure to
thrive (6
,7)
. Deficiencies of energy and individual
nutrients are associated with decreased cognition with vitamin B-12
deficiency being particularly problematic in the elderly
(8
9
10)
. Inadequate dietary intakes of energy, folate,
vitamin D, vitamin B-6, calcium and zinc have been reported in
community-dwelling elderly over 60 y old
(11
12
13
14)
. Although effects of poor dietary habits have
been and continue to be investigated, nutrition-related
characteristics of those who survive to become the old (75 y and older)
(15)
have not been well defined.
Because nutrition can have a pronounced effect in the elderly, an
indicator of diet quality is highly desirable. The Healthy Eating Index
and Diet Quality Index measure diet quality based on food group
consumption, intake of nutrients associated with chronic disease or
diet variety (16
,17)
. However, the appropriateness of diet
restrictions in older people is questionable (18
19
20)
. The
elderly remain at risk for chronic disease, but dietary limitations
imposed by meeting disease-specific restrictions may compromise
total nutrient intake. Measures of diet variety are based on the
assumption that nutrient intake increases with diet variety and may be
a more appropriate indicator of diet quality in this population.
Krebs-Smith et al. (21)
reported that variety among
and within major food groups was associated with diet quality assessed
by the mean adequacy ratio of 11 nutrients. Diet variety was greater in
older adults (60–75 y) than in younger adults (20–30 y) but was not
related to diet quality in a study by Drewnowski et al.
(22)
.
The Nutrition Screening Initiative
(NSI)3
was developed by interdisciplinary aging specialists with input from
the American Dietetic Association to promote screening, education and
care of the elderly and to identify risk factors and indicators of
malnutrition in the elderly (23
,24)
. Usefulness of the NSI
Checklist has been evaluated with subjects over 60 y old; results
from these studies suggest that although individual components may
identify subjects at risk, the overall tool may be of limited value
(25
26
27
28
29)
.
We assessed the dietary habits and nutrient intakes of an elderly population participating in an oral health study designed to assess dental disease and oral soft tissue lesions. The purpose of this study was to describe the nutrient intakes, dietary variety and nutritional risk of community-dwelling, rural Iowans, 79 y of age and older and subsequently explore associations between the NSI Checklist components, diet quality and diet variety.
|
SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Subjects were surviving members of the Iowa 65 + Rural Health Study
(IRHS), which included 84% of residents of two Iowa counties 65 y
of age and older in 1982 (n = 3673)
(30)
. IRHS subjects were recruited for the Iowa Oral
Lesion Detection Study (OLDS) to investigate the prevalence of oral
soft tissue lesions in this population (31)
. We identified
745 members of the original IRHS cohort; 269 subjects declined to
participate. Interviews and oral health examinations were conducted
between 1996 and 1998 with 449 cohort members. Only
community-dwelling individuals (n = 420) were
included in the dietary component of the study. Standardized interviews
and questionnaires were completed by all 420 subjects and 261 subjects
returned diet records. This study was approved by the Institutional
Review Board at the University of Iowa.
Data collection.
Using a cross-sectional design, subjects were interviewed and
dental exams were completed by dental examiners in their homes.
Standardized interviews assessed self-perceived oral health, dental
utilization, tobacco and alcohol use, intellectual function (Short
Portable Mental Status Questionnaire) (32)
, medication use
and dietary habits. Dietary habit questions were modified from the NSI
Checklist (23)
. In an effort to minimize response burden,
NSI Checklist questions were consolidated with similar questions from
other forms (e.g., medications were counted rather than using the NSI
Checklist item "I take three or more different prescribed or
over-the-counter drugs a day"). Current disease status was not
ascertained; therefore, a proxy question for the NSI Checklist item
"I have an illness or condition that made me change the kind and/or
amount of food I eat" was not available. Summary scores reported
herein were calculated from the other nine NSI Checklist components.
Standard NSI Checklist scoring criteria were used; subjects with an
illness or condition altering food choices may have been misclassified
and their nutrition risk underestimated.
Dental examiners distributed and provided both written and oral guidelines for completing 3-d diet records. Subjects were requested to record all foods using household measures and brand names, the time of consumption and nutritional supplements as consumed, and were provided a written example. Subjects (n = 35) with extenuating circumstances (e.g., refusal to accept questionnaire, significant confusion, interview burden) were not provided 3-d diet records.
Diet analysis.
A registered dietitian reviewed diet records for completeness. Subjects returning blank, incomplete or illegible records (n = 41) were excluded from diet analysis. Thus, diet nonresponders included subjects who did not return records and subjects whose records were not useable. Diet responders are defined as subjects who returned complete legible records. Subjects were not contacted for verification because additional contact was perceived as excessive respondent burden in this population. Subject characteristics and NSI Checklist responses of diet nonresponders (n = 200) and diet responders (n = 220) were compared.
Diets were analyzed by registered dietitians using the Minnesota
Nutrient Data System, Version 2.92 (33)
through the
University of Iowa College of Medicine’s General Clinical Research
Center. Nutrient supplements were included when recorded on 3-d diet
records. The Nutrient Data System has data for over 16,000 foods and
supplements and provides values for 112 nutrients.
Nutrient intakes (protein, 11 vitamins and 7 minerals) were compared
with age- and gender-specific nutrient requirements defined by the
Food and Nutrition Board of the National Academy of Science
(34
,35)
. We used the estimated average requirement (EAR)
or, if an EAR was not available, a cutoff value at 67% of the adequate
intake (AI) for pantothenic acid, vitamin D and calcium or 67% of the
recommended dietary allowance (RDA) for protein to define adequate
intakes. Diet quality was determined by the number of nutrients
consumed at adequate levels; adequate levels of all 19 nutrients was
rated as ideal, 16–18 nutrients as marginal, 13–15 nutrients as
limited and <13 nutrients as inferior.
Diet variety was determined by counting the number of items within each
food group (e.g., beverages, breakfast foods, fruits) recorded on 3-d
diet records using the classification scheme of Block et al.
(22
,36)
as a guide. Sandwiches and hamburgers with buns
were coded as bread/bun and the appropriate meat or cheese. Unless
bread or buns were mentioned, hamburgers were coded as hamburger only.
Mixed dishes (e.g., stew, lasagna, soups, and pizza) were not separated
into food components, but were coded as individual mixed dishes. One of
the authors (T.A.M.) individually reviewed each 3-d diet record and
assigned foods to the appropriate food item and group. The total
Dietary Variety Score (DVS) was defined as the total number of food
items consumed during the 3-d period. The number of food items per
major food group was also determined.
Statistical analysis.
Data were analyzed using SAS, Version 8 (SAS, Cary, NC)
(37)
. Subject characteristics, NSI responses, diet quality
and DVS were reported as means and SD when numerical values
and percentages when categorical values. Nutrient intakes were reported
as medians (25th and 75th percentiles). Differences between means were
evaluated using t test or analysis of variance with
Tukey’s post-hoc analysis. Differences between categorical
distributions were evaluated using 
2 analysis or
Fisher’s exact test. A P value of <0.05 was considered
statistically significant.
|
RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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).
|
. Diet responders did not differ from nonresponders on individual NSI
Checklist components, but the distribution of NSI Checklist summary
scores differed between diet responders and nonresponders with a higher
proportion of nonresponders identified at risk. Twenty-two of 420
total subjects reported compliance with minimal servings from the Food
Guide Pyramid; diet responders did not differ from nonresponders.
|
Twenty percent of subjects reported consumption of nutrient supplements on 3-d diet records; 11% consumed multivitamins with minerals, 2% consumed multivitamins and 7% consumed single, multiple or combination supplements (e.g., vitamin C, calcium with vitamin D, antioxidants).
Median (25th, 75th) vitamin and mineral intakes from food and
percentage of subjects consuming adequate nutrient intakes from food
and supplements are shown in Table 3
. Median (25th, 75th) intakes from supplements were 0 (0, 0) for all
nutrients. Supplement use increased the number of subjects consuming
adequate intakes of folate, vitamin D and vitamin E (data not shown;
P < 0.05).
|
). Supplement use significantly increased the number of nutrients
consumed at adequate levels; however, 34% of subjects (n
= 76) still had inadequate intakes of 13 or more nutrients. The
number of nutrients consumed at adequate levels did not differ by
gender.
|
. The total DVS was correlated with the number of nutrients consumed at
adequate levels from food sources (r = 0.498;
P < 0.05), total energy (r = 0.522;
P < 0.05), energy per kg of body weight (r
= 0.362; P < 0.05), and dietary fiber
(r = 0.421; P < 0.05). Associations
between total DVS and both number of nutrients consumed at adequate
levels from food sources and fiber remained after adjustment for total
energy (data not shown; P < 0.05). Neither the total
DVS nor the number of nutrients consumed at adequate levels was
associated with the NSI Checklist summary score.
|
|
DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Diet responders were younger and more likely to be cognitively intact than nonresponders. Cognitive limitations may have impaired nonresponders’ ability to complete the 3-d diet records. Current weights, weight gain and weight loss did not differ between responders and nonresponders, suggesting that nonresponders had access to sufficient quantities of food.
NSI Checklist components did not differ by responder status; however,
nonresponders were more likely to be at nutritional risk based on the
NSI Checklist summary score. Higher cognitive impairments exhibited by
nonresponders may have interfered with their ability to respond
accurately to the NSI Checklist. However, these data are consistent
with the findings of Ortega et al. (38)
who reported
individuals with lower cognitive function had lower intakes of total
food, vegetables, fruits and the nutrients folate, vitamin C,
ß-carotene, iron and zinc than cognitively intact individuals.
Our results suggest that rural, community-dwelling old consume
inadequate levels of several key nutrients. Although use of EAR or
>67% AI/RDA may underestimate the number of subjects with inadequate
intakes, subjects not meeting these criteria are likely to have
inadequate intakes of clinical importance. Furthermore, the EAR, RDA
and AI are established for healthy people. The health of our subjects
is not known; however, our respondents were free of acute debilitating
illness. Medication use suggests the presence of chronic disease that
may increase nutrient requirements. Specifically, >60% of subjects
did not meet their estimated needs for folate, vitamin D, vitamin E,
calcium or magnesium and >25% of subjects did not meet their
estimated needs for vitamin B-6, vitamin C or zinc. Our data are
consistent with findings reported in other studies of
community-dwelling younger old people (11
12
13
14)
.
Supplement use allowed a small number of subjects to have adequate
nutrient intakes. However, a substantial number of subjects who might
have benefited from supplement use did not consume them. Other
investigators have reported that individuals with nutrient dense diets
consume supplements, while those with marginal diets may not consume or
choose appropriate supplements for their diets (39
,40)
.
Intakes of calcium, vitamin D and folate, which are linked to bone and
cardiovascular health, were low in this sample of elderly subjects,
despite public health messages promoting intake of these nutrients
(41
,42)
.
The positive association between adequate nutrient intakes and greater
diet variety in this study agrees with studies of younger adults
(21
,43)
. The Dietary Guidelines for Americans 2000
emphasize the need to select a diet varied in whole grains, fruits and
vegetables to improve fiber intake, limit fat intake and obtain
nutrients concentrated in different fruits and vegetables
(44)
. Of potential concern, consuming a greater variety of
energy dense foods has been associated with increased energy intake at
meals in both rats and humans and with increased body fat in humans,
which may contribute to obesity and related chronic diseases
(45
46
47)
. As expected, intake of a greater variety of
vegetables was inversely associated with body fat (47)
. An
association between dietary variety and excessive energy intake in
elderly people is unlikely, because many of them have limited energy
intakes (6
,7
,11
,13)
. Our results suggest that the current
Dietary Guidelines for Americans 2000 (44)
, the Food Guide
Pyramid (48)
and other programs that promote a varied diet
are appropriate guidance for the elderly to achieve adequate nutrient
intakes.
One objective of the NSI is to identify individuals whose nutritional
status is at risk. In this study, nutritional risk defined by the NSI
Checklist was not associated with nutrient adequacy or variety of foods
consumed. Our categorization of at risk is made without the NSI
Checklist component diet-associated disease, which may result in
misclassification of individuals from a higher risk to a lower risk
category. Also, the NSI is designed to identify risks due to a variety
of medical, psychosocial or environmental factors, which may not affect
current food intake. Previous studies support the hypothesis that the
NSI Checklist is more appropriate for education and awareness than for
identification of at-risk elderly people (25
26
27
28)
.
Limitations of this study include the cross-sectional nature of
data collection, difficulties inherent in dietary data collection and
the unique nature of the sample studied. Cross-sectional studies
allow for associations to be identified, but not for identification of
causal relationships. Furthermore, our subjects are the survivors; we
do not have dietary data on IRHS participants who did not survive or
chose not to participate. Genetic and environmental factors may have
allowed these individuals to survive in a relatively healthy condition;
diet may or may not be related to their survival. Although current diet
may be consistent with early diet, we cannot make assumptions regarding
diet and longevity from this study. Our assessment of diet simply
reflects our best measure of what rural, community-dwelling older
people are currently eating. A subset of original IRHS cohort members
who chose not to participate in the OLDS study did not differ from OLDS
participants in either age or gender distribution (49)
.
However, it is conceivable that nonparticipating original IRHS cohort
members had poorer cognitive and nutritional statuses than OLDS
participants, which would both underestimate the true risk of this
group and limit the generalizability of our data.
All data were self-reported. Diet respondents may have changed dietary habits in response to the process of recording their diet. In addition, actual intakes may differ from recorded intakes due to declines in eating, memory deficits, subtle cognitive deficits or fine motor difficulties compromising the recording process.
Although results of our study may not be directly applicable to the old living in urban, coastal or southern regions, they are consistent with results described by others in younger old people. In summary, our population of older Iowans consumed inadequate intakes of several nutrients. Recommendations to consume a variety of foods from all food groups are appropriate to improve or maintain nutrient intakes from foods. Multivitamin/mineral supplementation with additional calcium may be necessary for the old to achieve adequate nutrient intakes.
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FOOTNOTES |
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3 Abbreviations used: DVS, Diet Variety Score; EAR, estimated average requirement; IRHS, IA 65+ Rural Health Study; NSI, Nutrition Screening Initiative; OLDS, Oral Lesion Detection Study; RDA, recommended dietary allowance.
Manuscript received March 26, 2001. Initial review completed April 20, 2001. Revision accepted May 29, 2001.
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