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,2
* Laboratory of Clinical Epidemiology, Geriatric Department, National Institute of Research and Care on Aging (INRCA), Florence, Italy;
Molecular and Nutritional Epidemiology Unit, Cancer Study and Prevention Centre (CSPO), Scientific Institute of Tuscany, Florence, Italy;
** National Institute of Research on Food and Nutrition (INRAN), Rome, Italy;
Laboratory of Epidemiology Demography and Biometry, National Institute on Aging, Bethesda, MD; and
Longitudinal Studies Section, Gerontology Research Center, National Institute on Aging, National Institutes of Health, Baltimore, MD
2To whom correspondence should be addressed. E-mail: ferruccilu{at}grc.nia.nih.gov.
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ABSTRACT |
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 TOP ABSTRACT SUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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KEY WORDS: • InCHIANTI • aging • nutrient intake • food consumption • disability
Many epidemiologic studies suggest that inadequate nutrition may strongly influence health status in both young and older persons (1). A nutritionally adequate diet is considered a critical component of a lifestyle aimed at promoting healthful and active aging (2,3).
Several reports have focused on the nutritional needs of older persons (4,5), and it has been suggested that the Mediterranean diet has characteristics that are particularly suitable for an elderly population (6,7). Although Italy is probably one of the most typical Mediterranean countries, only a few studies have systematically examined dietary habits in that country (7–11), and even fewer have studied large and representative samples of the older population. The epidemiologic studies conducted on population-based samples have generally neglected the oldest section of the population, which includes those persons in whom nutritional problems frequently occur.
Given the above-mentioned limitations, very little information is available on the quality, quantity and composition of dietary intake in the older population, and even less is known about risk factors for inadequate intake of nutrients in older Italians. In the InCHIANTI study, we evaluated dietary intake in a population-based sample, including a large number of old and very old persons. Using data from the InCHIANTI study, we estimated the daily intake of nutrients and food. Moreover, in older persons, we evaluated whether functional problems related to eating capacity are associated with inadequate intakes of nutrients.
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SUBJECTS AND METHODS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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In brief, in August 1998, 1270 persons 
65 y old were randomly selected from the population registries. In addition, men and women were sampled randomly from the age strata 20–29, 30–39, 40–49, 50–59 and 60–64 y and sequentially invited to participate in the study until at least 30 men and 30 women for each decade between 20 and 59 y and 10 men and 10 women aged 60–64 y had been enrolled. Additional subjects (n = 29) were randomly selected among those who were 90 y old, to obtain a sample of 30 men and 30 women in this age group. Of the initial 1299 subjects, 39 were not eligible because they had died or left the area. Overall, 1453 subjects were recruited. The participation rate was 69.4% in those aged <65 y and 91.6% in those aged 65 y. Of these, 634 men (<65 y, n = 142; 65 y, n = 492) and 802 women (<65 y, n = 154; 65 y, n = 648) with an age range of 21–103 y, underwent a complete dietary interview and were included in the final analytical sample.
Clinical visits and assessments were performed in the study clinic and were preceded by an interview conducted at the participants’ homes. Trained interviewers administered two structured questionnaires. One collected data on dietary intakes and the other included many questions on household composition, social networks, economical status, education, and general information on health and functional status. Cognitive impairment was assessed by the Mini-Mental State Examination (MMSE)2 (13). In persons with hearing or aphasic problems and in those who scored 
18 on the MMSE, the interview was administered to a proxy. Overall, 77 interviews (5.2%) were conducted with proxies.
Responses to questions concerning perceived difficulty in performing selected Activities of Daily Living (14), Instrumental Activities of Daily Living (15), and the ability to chew food were used as indicators of nutrition-related difficulties. Activities investigated included the following: chewing food, self-feeding, shopping for basic necessities, carrying a shopping bag, cooking a warm meal and using fingers to grasp or handle. By combining responses to questions concerning nutrition-related difficulties, subjects were classified into three groups: no difficulties; 1–2 difficulties; 3 difficulties.
The InCHIANTI study protocol was approved by the INRCA ethical committee. All subjects received an extensive description of the purposes and known risks of the study procedures, and all gave written informed consent.
Assessment of dietary intake.
Nutritional data were collected using the food-frequency questionnaire originally developed and validated for the assessment of dietary intake in Italian volunteers participating in the European Prospective Investigation into Cancer and nutrition (EPIC) (16), a multicenter study conducted in 10 European Countries aimed at investigating the relationship between diet and cancer (17,18).
The EPIC food-frequency questionnaire was administered by trained interviewers and provides a detailed assessment of food consumption during the previous year through a large number of structured and precoded questions. The EPIC questionnaire is organized into two parts as follows: 1) questions focusing on general dietary habits such as particular dietary regimens and frequency of meals consumed away from home; and 2) 237 questions investigating the frequency of consumption of specific food items or dishes during the last year. To improve the precision of the assessment, participants are also asked to specify the size of the portion usually consumed, in comparison to a range of portions that are shown in colored photographs.
Responses to the EPIC questionnaires were automatically read by an optical scanner. Software, specifically designed for the EPIC-Italy questionnaire, transformed information about food consumption into daily intake of food items, energy, and macro- and micronutrients. Nutrient data for specific foods were obtained from the Food Composition Database for Epidemiological Studies in Italy (19). For the purpose of this analysis, food items were further grouped into broader categories to facilitate presentation.
Persons with inadequate intake of selected nutrients were identified according to the Italian Recommended Nutrients Levels (LARN) (20) for specific age and sex groups.
Statistical analysis.
Daily intake data are reported as means ± SD, according to sex and age group. Differences in energy and selected macro- and micronutrient intakes among age groups were evaluated by ANOVA, using a general linear model. The effects of age and sex on inadequate intake of nutrients were tested by a general linear model. Finally, multivariate logistic models were used to evaluate the association between difficulty in activities related to eating behavior and inadequate intake of selected nutrients. To avoid multicollinearity, each variable with "1–2 difficulties" or "3 or more difficulties" in nutrition-related activities was singularly entered in separate models that included a fixed set of covariates, i.e., age (continuous), sex, living alone (yes/no), education ( middle grade/high school or higher), cognitive impairment (MMSE score 21/>21), and self-perception of inadequate economic status (adequate/inadequate). A further logistic model, designated "model 2," was also adjusted for energy intake. All analyses were performed using the SAS statistical software, version 8.1 (21).
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RESULTS |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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DISCUSSION |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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As in this study, several studies have suggested that the effect of age on dietary habits may be attributable to functional impairments (8,22,23) and chewing problems (24,25). These factors may lead elderly persons to have a monotonous and energy-restricted diet, which easily results in an inadequate intake of nutrients. Our findings suggest that the older population may be at high risk of malnutrition, and that it is important to assess capacities related to eating behavior to prevent nutritional problems in older persons. Thus, adequate family or social supports to purchase, prepare and cook food may help to maintain a varied and balanced diet (23,26).
It is important to point out that there are substantial differences between Italian and American recommendations for adequate intake of specific nutrients. In particular, the adequate intakes for vitamin E and folate (15 mg/d and 400 µg/d, respectively) according to U.S. recommendations are twice as high as the Italian LARN (8 mg/d and 200 µg/d, respectively). By using the U.S. guidelines, most of the InCHIANTI participants would have been defined as having an inadequate intake of both vitamin E and folate (90–100%). In Italy, the recommended levels of vitamin E were estimated using a tocopherol equivalent-PUFA ratio of 0.4. Because the InCHIANTI study population reported low PUFA consumption, the tocopherol equivalent-PUFA ratio was quite high (from a mean of 1.36 in older women to 2.29 in the youngest men), leading to a lower requirement for vitamin E. Under these circumstances, we used the lower bound of the adequate intake as the reference (4 mg/d in men and 3 mg/d in women).
A critical issue that must be addressed is that in the current version of LARN, all women > 50 y old and men > 60 y old are grouped in the same "geriatric" category. In the most recent editions of the U.S. Recommended Dietary Allowances, subjects > 50 y old are further subdivided (50–70 y and >70 y) in both sexes, but the recommended intakes do not vary, except for vitamin D (27).
Despite an evident decrease in energy intakes, vitamin and mineral needs seem to remain stable, suggesting that an increase in nutrient density in the older population would be required, a result quite difficult to achieve. With the aging of the Western world populations, an extremely important question to be addressed is whether nutrient requirements remain constant with age or do indeed differ for old and very old subjects.
Because there are few epidemiologic studies of sufficient size that have assessed nutrition in the elderly population, adequate information is not available to support specific recommendations on nutrient intakes in subgroups of older persons. It seems unlikely that nutritional requirements extrapolated from younger "healthy" populations can be applied directly to the elderly.
An important limitation related to the cross-sectional nature of the present study should be taken into account in interpreting data on dietary intake across the age spectrum. Our data appear to suggest that intakes of energy and nutrients decline with aging; however, we cannot rule out the existence of a cohort effect. Thus, our results must be investigated further in longitudinal studies.
In conclusion, our investigation confirms findings of previous studies (28,29) by indicating that total energy intake as well as intakes of macro- and selected micronutrients tend to be lower in the older age groups, in both sexes. Similarly, the percentage of persons with a low intake of nutrients compared with recommended levels was higher in older age groups. Older people chose different foods, suggesting that older persons tend to adapt their diet to the functional difficulties that often occur during the aging process. In fact, we found that having three or more eating-related difficulties was a significant predictor of inadequate intake of energy and most of the selected nutrients. After adjustment for energy, the relationship with vitamin C remained significant. This result suggests that older persons who have nutrition-related difficulties tend to consume a monotonous diet, reducing the consumption of fresh food, such as fruit and vegetables. Dieticians could improve diets in the elderly by suggesting meals that satisfy their altered food attitudes, including foods that are easy to purchase, prepare and chew, thus ensuring adequate intake of all macro- and micronutrients. Finally, more attention to functional problems in the growing elderly population and provision of formal or informal help for those who have difficulty in purchasing, processing and eating food may reduce, at least in part, the percentage of older persons with poor nutrition.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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3 Abbreviations used: EPIC, European Prospective Investigation into Cancer and nutrition; LARN, Recommended Nutrients Levels; MMSE, Mini Mental State Examination.
Manuscript received 28 March 2003. Initial review completed 2 May 2003. Revision accepted 17 June 2003.
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LITERATURE CITED |
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TOPABSTRACTSUBJECTS AND METHODSRESULTSDISCUSSIONLITERATURE CITED |
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