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Diet-related practices and BMI are associated with diet quality in older adults


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To assess the association of diet-related practices and BMI with diet quality in rural adults aged ≥74 years. Cross-sectional. Dietary quality was assessed by the twenty-five-item Dietary Screening Tool (DST). Diet-related practices were self-reported. Multivariate linear regression models were used to analyse associations of DST scores with BMI and diet-related practices after controlling for gender, age, education, smoking and self- v. proxy reporting. Geisinger Rural Aging Study (GRAS) in Pennsylvania, USA. A total of 4009 (1722 males, 2287 females; mean age 81·5 years) participants aged ≥74 years. Individuals with BMI < 18·5 kg/m2 had a significantly lower DST score (mean 55·8, 95 % CI 52·9, 58·7) than those individuals with BMI = 18·5-24·9 kg/m2 (mean 60·7, 95 % CI 60·1, 61·5; P = 0·001). Older adults with higher, more favourable DST scores were significantly more likely to be food sufficient, report eating breakfast, have no chewing difficulties and report no decline in intake in the previous 6 months. The DST may identify potential targets for improving diet quality in older adults including promotion of healthy BMI, breakfast consumption, improving dentition and identifying strategies to decrease concern about food sufficiency.
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Public Health Nutrition: page 1 of 5 doi:10.1017/S1368980013001729
Diet-related practices and BMI are associated with diet quality
in older adults
Dara W Ford
*, Terryl J Hartman
, Christopher Still
, Craig Wood
, Diane Mitchell
Pao Ying Hsiao
, Regan Bailey
, Helen Smiciklas-Wright
, Donna L Coffman
Gordon L Jensen
Department of Nutritional Sciences, The Pennsylvania State University, 110 Chandlee Laboratory, University
Park, PA 16802, USA:
Department of Epidemiology, Emory University, Atlanta, GA, USA:
Center for Health
Research & Obesity Institute, Geisinger Health System, Danville, PA, USA:
Office of Dietary Supplements,
National Institutes of Health, Rockville, MD, USA:
The Methodology Center, The Pennsylvania State University,
State College, PA, USA
Submitted 25 February 2013: Final revision received 20 May 2013: Accepted 29 May 2013
Objective: To assess the association of diet-related practices and BMI with diet
quality in rural adults aged $74 years.
Design: Cross-sectional. Dietary quality was assessed by the twenty-five-item
Dietary Screening Tool (DST). Diet-related practices were self-reported. Multi-
variate linear regression models were used to analyse associations of DST scores
with BMI and diet-related practices after controlling for gender, age, education,
smoking and self- v. proxy reporting.
Setting: Geisinger Rural Aging Study (GRAS) in Pennsylvania, USA.
Subjects: A total of 4009 (1722 males, 2287 females; mean age 81?5 years)
participants aged $74 years.
Results: Individuals with BMI , 18?5 kg/m
had a significantly lower DST score
(mean 55?8, 95 % CI 52?9, 58?7) than those individuals with BMI 5 18?5–24?9 kg/m
(mean 60?7, 95 % CI 60?1, 61?5; P 5 0?001). Older adults with higher, more
favourable DST scores were significantly more likely to be food sufficient, report
eating breakfast, have no chewing difficulties and report no decline in intake in
the previous 6 months.
Conclusions: The DST may identify potential targets for improving diet quality in
older adults including promotion of healthy BMI, breakfast consumption, improving
dentition and identifying strategies to decrease concern about food sufficiency.
Diet quality
Dietary-related practices
Diets consistent with dietary guidelines that are rich
in fruits, vegetables, whole grains, low-fat dairy and
lean meats are associated with decreased morbidity and
. Quality of diet becomes increasingly important
in old age due to declining physiological function, changes
in body composition and decreased energy require-
. Risk of undernutrition is also increased in older
adults for some potentially modifiable reasons including
financial constraints, appetite decline, poor dentition
and functional and cognitive limitations
. The Dietary
Screening Tool (DST) is a validated tool that utilizes food-
based questions developed for use in assessing diet quality
in older, rural adults
. It is a simple, self-administered
questionnaire containing food- and behaviour-related
questions that assess overall dietary quality of older
. The objective of the present study was to deter-
mine the relationship of the DST with diet-related practices
and characteristics known to contribute to nutritional risk
among a cohort of adults aged $74 years.
Materials and methods
Study participants
The Geisinger Rural Aging Study (GRAS) began in 1994
with adults aged 65 years or older enrolled in a Medicare-
managed health maintenance organization. Study details
have been published previously
. The participants have
been followed as a longitudinal cohort over time with
repeated measures of height, weight, medication use,
diet-related practices, living environment, self-rated
health and functional status. In-depth dietary assessment
to estimate usual intakes has been conducted only on
small subsets of the cohort in a cross-sectional manner
and such data are not available for the entire cohort
All surviving GRAS participants (n 5993) were mailed
demographic and health questionnaires and the DST for
the current study in the autumn of 2009. After follow-up,
4009 (67 %) participants (1722 males, 2287 females; mean
age 81?5 years) returned completed surveys, providing
Public Health Nutrition
*Corresponding author: Email r The Authors 2013
information on age, height, weight, smoking status,
diet-related practices and dietary information, among
other characteristics. Additionally, self-reporting or proxy
reporting by someone other than the participant was
noted. The study was conducted according to the
guidelines laid down in the Declaration of Helsinki and
all procedures involving human subjects/patients were
approved by the Office of Research Protections at The
Pennsylvania State University and the Human Research
Protection Program of the Geisinger Health Systems
Institutional Review Board. Consent was implied by survey
Dietary screening tool
Detailed information on the development and validation
of the DST has been described elsewhere
. The DST
consists of twenty-five questions originally derived from
extensive secondary analysis of the dietary intakes of
rural older adults in the GRAS (see online supplementary
material). The possible score range is from 0 to 100 points
with 5 ‘bonus’ points for multivitamin/mineral supple-
ment use (score could not exceed 100). Responses to
questions were then scored according to the previously
validated scoring algorithm with a score ,60 considered
‘unhealthy’, 60–75 considered ‘borderline’ and .75 con-
sidered ‘healthy’
. An example of a DST question is
‘How often do you usually eat whole grain breads?’
Participants then chose from ‘never’, ‘less than once a
week’, ‘1 or 2 times a week’ and ‘3 or more times a week’
to classify their intake. Cognitive interviewing was used to
ensure understandability of questions for the population
of interest
. Points were allotted for each question based
upon breakdown of major dietary components of the
Healthy Eating Index-2005
. Dietary quality was estab-
lished by comparison with nutrient intakes
and food
group intakes
derived from multiple 24 h recalls.
Eating behaviour measures
Nine total questions identified the presence of problems
associated with diet-related practices through yes-or-no
responses. All questions were self- or proxy reported.
These questions addressed inadequate food or concerns
about sufficient food, not eating on one or more days per
month, having a decline in intake, eating alone, skipping
breakfast, having more than one alcoholic drink per day
for women or more than two per day for men, reporting
chewing difficulty and mouth pain. Associations between
all diet-related practices and DST score were analysed.
Statistical analyses
All data were analysed using the Statistical Analysis Software
Package 9?3. Descriptive data were generated using PROC
MEANS and PROC FREQ for all adults and by gender.
Multivariate linear regression models were used to analyse
associations of continuous DST score as the dependent
variable with BMI and each of the nine diet-related practices
after controlling for age (continuous), gender, education
(,high school v. $high school), smoking (ever/never)
and self- v. proxy reporting. BMI was calculated from self-
reported height and weight collected in the demographic
and health questionnaires, and was assessed both as a
continuous variable and categorically according to
National Institutes of Health guidelines (,18?5 kg/m
,25?0–29?9 kg/m
and $30?0 kg/m
). All
dietary behaviours that were related significantly to DST
score at P , 0?05 were retained as potential candidates for
the multivariate model. Results are presented as mean DST
scores with 95 % confidence intervals adjusted for age,
gender, self- or proxy reporting, and BMI when BMI was
not the independent variable of interest. P values are for
the tests of between-group differences from the multi-
variate models. Interactions between the predictors of
interest (diet-related practices and BMI) and each covariate
(gender, BMI, age, education, smoking, self- v. proxy
reporting) were assessed by including each individual
factor (e.g. gender) and its cross-product term in separate
models. Significance was considered at P , 0?05.
Descriptive characteristics of the sample are shown
in Table 1. Compared with those who completed the
DST, non-responders were older (83?2 v. 81?4 years;
P , 0?0001) and more likely to be female (OR 5 1?3, 95 %
CI 1?2, 1?5; P , 0?0001). Less than 9 % (n 333) of partici-
pants used proxy reporters and those who did were more
likely to be male (OR 5 1?5, 95 % CI 1?2, 1?9; P 5 0?0002),
less likely to report education beyond high school
(OR 5 0?5, 95 % CI 0?3, 0?7; P 5 0?0002), older (mean 83?7
SD 5?5) years v. 81?2(SD 4?1) years; P , 0?0001) and had
lower DST scores (mean 57?6(
SD 12?3) v. 60?6(SD 12?7);
P , 0?0001). The cohort was comprised almost exclu-
sively of non-Hispanic whites (98?7 %) with at least a high
school degree. Less than half the sample was male (43 %).
BMI did not differ by gender. Although over half of the
respondents lived with a spouse (n 2095), 46 % of female
respondents lived alone compared with only 20 % of male
respondents. The mean unadjusted DST score for the
sample was 60?3(
SD 12?7), with females (mean 61?9
SD 12?6)) reporting a significantly higher score than males
(mean 58?2(
SD 12?4); P , 0?0001).
Participants who had BMI , 18?5 kg/m
had sig-
nificantly lower DST scores (OR 5 55?8, 95 % CI 52?9,
58?7) than those participants with BMI 5 18?5–24?9 kg/m
(OR 5 60?8, 95 % CI 59?5, 60?9; P 5 0 ?001) after adjust-
ment for age, sex, education, smoking status and self- v.
proxy reporting. The adjusted DST score for those parti-
cipants with BMI , 18?5 kg/m
remained significantly
lower (OR 5 55?8, 95 % CI 52?9, 58 ?7) compared with the
DST score for all other BMI classes combined (OR 5 60?5,
95 % CI 60?1, 60?9; P 5 0?002). In contrast, compared with
Public Health Nutrition
2 DW Ford et al.
participants with BMI 5 18?5–24?9 kg/m
, there were no
statistically significant differences in DST score for either
overweight or obese individuals (see Table 2). There
were also no significant associations between BMI and
any of the diet-related practices.
Four of the nine diet-related practices were significantly
associated with DST score after adjustment for BMI, age,
sex, education, smoking status and self- v. proxy reporting
(Table 2). Significantly lower DST scores were found in
participants who reported a decline in intake over the
previous 3 months, skipping breakfast, concern about
having enough food and difficulty with chewing or
swallowing. The remaining five diet-related practices were
not significantly associated with DST score. No meaningful
and significant effect modifications were observed between
any variables tested (data not presented).
It was our goal to investigate the associations between
BMI, diet-related practices and diet quality in a population
Public Health Nutrition
Table 1 Characteristics of study participants: rural adults aged $74 years, Geisinger Rural Aging Study (GRAS),
Pennsylvania, USA, autumn 2009
Men (n 1722; 43?0 %) Women (n 2287; 57?0%)
Characteristic Mean or n
SE or % Mean or n SE or %
Age (years)* 81?34?281?54?4
White 1654 98?2 2234 99?1
Non-Hispanic black 29 1?715 0?7
Other 1 0?14 0?2
,High school 1327 77?1 1942 84?9
$High school 395 22?9 345 15?1
BMI (kg/m
,18?5140?859 2?6
18?5–24?9 460 26?7 696 30?4
25?0–29?9 814 47?3 839 36?7
$30?0 434 25?2 693 30?3
Ever smoke
Yes 61 3?682 3?7
No 1629 96?4 2159 96?3
Eat breakfast
Yes 1660 96?4 2190 95?8
No 62 3?697 4?2
Eat alone
Yes 305 17?7 851 37?2
No 1417 82?3 1436 62?8
Intake decline
Yes 111 6?5 161 7?0
No 1611 93?5 2126 93?0
Excess alcohol
Yes 94 5?537 1?6
No 1628 94?5 2250 98?4
Food insufficient
Yes 8 0?59 0?4
No 1714 99?5 2278 99?6
Enough food each day
Yes 1681 97?6 2254 98?6
No 41 2?433 1?4
No food some days
Yes 4 0?27 0?3
No 1718 99?8 2280 99?7
Chewing difficulty
Yes 69 4?087 3?8
No 1653 96?0 2200 96?2
Mouth pain
Yes 41 2?453 2?3
No 1681 97?6 2234 97?7
DST score* 58?212?461?912?6
DST category-
,60 917 53?3 925 40?4
60–75 629 36?5 976 42?7
.75 176 10?2 386 16?9
DST, Dietary Screening Tool.
*These data are presented as mean and standard error; all other data are presented as number and percentage.
-Categories utilized from previously published data
Diet practices and quality in older adults 3
of adults aged $74 years. There are limited data on dietary
quality for large cohorts of older adults, particularly those
living in rural areas. Our results indicate that a low DST
score is associated with low BMI and poor diet-related
practices including chewing difficulties, skipping breakfast,
concerns of food sufficiency and decline in intake.
Older adults with low BMI had a much poorer diet
quality than all other older adults, including those who
were obese. Population studies suggest that risk of
mortality is doubled in older adults who have a BMI
,18?5 kg/m
compared with 18?5–24?9 kg/m
dent of recent weight change
. The association
between obesity and mortality in older adults is complex,
with overweight and mild obesity being associated with
reduced mortality in cohort studies of adults $65 years old
with follow-up periods ranging from 3 to 18 years
In a prior investigation within a small subset of the GRAS
cohort (n 179) we found that a low nutrient-dense diet was
associated with increased odds of obesity
and lower
waist circumference was associated with a prudent dietary
. In the current study, an association between
obesity and diet quality was not detected. Of note, no
participants in our previous study had BMI , 18?5kg/m
Chewing difficulty, skipping breakfast, food insuffi-
ciency and decline in intake were associated with poor
diet quality. Chewing difficulty is linked to many adverse
clinical outcomes, including a variety of morbidities,
hospitalization and earlier mortality, and has been shown
to affect consistency and selection of food
. Skipping
breakfast is associated with decreased nutrient intake,
which may impact development and progression of
chronic disease
. In a nationally representative sample of
adults aged 60–90 years, those who were food-insufficient
consumed significantly less energy, carbohydrate, protein,
saturated fat, Fe and Zn among other micronutrients
and were more likely to report poor self-rated health than
their food-sufficient peers
. Decline in intake may lead
to unintentional weight loss which is often indicative of
underlying disease, and undernutrition in older adults is
strongly associated with increased mortality
is able to identify these diet-related practices as targetable
areas for improvement in diet quality and potentially other
health outcomes in older adults.
A relatively high response rate (67 %) in an aged
community-dwelling cohort is a major strength of this
investigation. However, there are some notable limita-
tions to address. The external validity of the DST remains
to be determined in other races and geographic regions.
The number of remaining underweight older adults was
quite low, likely due to decreased survivorship in elderly
individuals with a low BMI
. The screening ques-
tionnaires rely on self-report, making results subject
to recall bias. Additionally, only information regarding
age and sex was available for non-responders and so
additional comparisons could not be made.
Previously the DST was administered in an out-patient
clinic setting, requiring participants to visit their local
medical clinic in order to complete the questionnaire
Rural older adults experience many barriers to health care
including but not limited to social isolation, lack of
transportation and financial constraints
. By surveying
rural adults in their own homes, we were able to find
targetable areas for improvement of nutritional quality.
Overall food consumption decreases with age and it
becomes increasingly important for older adults to consume
high-quality nutrient-dense foods to meet nutrient needs
Public Health Nutrition
Table 2 Association between adjusted mean DST score, diet-related practices and BMI: rural adults aged $74 years,
Geisinger Rural Aging Study (GRAS), Pennsylvania, USA, autumn 2009
Eating practice* Adjusted mean DST score 95 % CI P value-
Skip breakfast 51?749?8, 53?7 ,0?0001
Eat breakfast 60?860?4, 61?2–
Eat alone 60?559?8, 61?30?71
Eat with others 60?459?9, 60?8–
Intake decline 56?855?3, 58?3 ,0?0001
No decline 60?760?3, 61?1–
Excess alcohol 58?756?5, 60?90?12
No excess alcohol 60?560?1, 60?9–
Food insufficient 53?948?0, 59?80?03
Food sufficient 60?460?0, 60?8–
Not enough food each day 58?956?1, 61?80?
Enough food each day 60?460?0, 60?8–
No food some days 57?449?7, 65?10?44
Always have food 60?460?0, 60?8–
Chewing difficulty 58?256?3, 60?20?03
No difficulty 60?560?1, 60?9–
Mouth pain 59?857?2, 62?30?63
No mouth pain 60?460?0, 60?8–
Underweight (BMI , 18?5 kg/m
55?852?9, 58?70?001
Not underweight 60?560?1, 60?9–
*Controlling for sex, BMI, age, smoking status, education and self- v. proxy reporting.
-Represent differences between groups (appetite decline v. no decline, concern about food v. no concern, etc.) after adjustment for covariates.
Controlling for sex, age, smoking status, education and self- v. proxy reporting.
4 DW Ford et al.
The diet-related practices found to be associated with DST
score serve as potential targets for altering behaviour to
promote nutrient and energy intakes sufficient to meet
requirements. It should also be noted that the mean overall
DST score was below optimal (mean 5 60) with 86 % of
participants scoring #75 on the DST. According to pre-
vious studies, this indicates that 86 % of this sample has
either unhealthy or borderline diet quality, and so has
room for improvement
Older adults are at increased susceptibility for malnutri-
tion due to age-associated changes in metabolism and
, and with the number of aged persons
increasing rapidly in our population
improving nutri-
tional status is a priority. Low DST scores were associated
with low BMI, being food insecure, recent decline in food
intake, skipping breakfast and chewing difficulties. These
associations may help to identify opportunities for
anticipatory guidance and interventions for health-care
professionals to promote improvement in diet quality.
Sources of funding: This work was supported by the US
Department of Agriculture (grant #1950-51530-010-02G).
Conflicts of interest: The authors report no conflict of
interest. Authors’ contributions: T.J.H., G.L.J. and H.S.-W.
contributed to the writing and editing of this paper. C.W .
and D.L.C. assisted with statistical analysis. C.S., D.M., P.Y.H
and R.B. provided editorial assistance in writing this paper.
Supplementary material
To view supplementary material for this article, please
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Public Health Nutrition
Diet practices and quality in older adults 5
... W badaniach Forda i wsp. [8], prze-prowadzonych w USA wśród 4009 osób powyżej 74 lat, średni wynik wyniósł 60,4 pkt, natomiast w badaniach Cottella i wsp. [5] wśród 96 Brytyjczyków w wieku 55 ÷ 80 lat uzyskano średnio 66,7 pkt. ...
... Również w badaniach Forda i wsp. [8] z 2014 roku osób z ryzykiem żywieniowym było mniej niż w badaniach własnych -46 %, a bez tego ryzyka -14 %. Należy jednak podkreślić, że wyniki prac innych autorów, dotyczące korelacji między ZS a sposobem żywienia i stanem odżywienia, nie są jednoznaczne. ...
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Frailty syndrome (FS) is associated with the weakness of the physical and/or mental health of elderly peopleand it is becoming a global problem. The objective of the research study was to characterise elderly peopleattending Day Care Senior Centres, in terms of the occurrence of frailty syndrome, dietary habits and nutritional risk. The survey was conducted among 49 individuals (21 men and 28 women) aged 61 -97 (on average 77.5 ±8.8) from Warsaw (24 people) and Rzeszów (25 people), who lived on their own, but attended Day Care Senior Centres on a regular basis, where they were provided half board. A Cardio-vascular Health Study Scale (CHS) was applied to assess the frailty syndrome, while the nutritional risk was estimated on the basis of Dietary Screening Tool (DSC). The frailty syndrome was diagnosed in 39.3% of women and 9.5 % of men (26.5 % of the surveyedin total), the pre-frailty syndrome in 46.4 % of women and 52.4 % of men (49 % of the surveyed in total); 14.3 % of women and 38.1 % of men (24.5% of the surveyed in total) did not show any symptoms of FS. The differences between the men and women surveyed were significant. The nutritional risk was diagnosed in 63.3 % of the people in the group surveyed, the probable nutritional risk –in 34.7 % and only 2 % of the surveyed did not show this symp-tom. No correlation between the occurrence of FS and nutritional risk was found. Elderly peoplewith FS less often consumed wholegrain bread and yet more often sweets (tendency 0.1 > p > 0.05). Slightly less often their diet contained fatty cold cuts, vegetables,dairy products, non-fried fishand more often lean cold cuts, fruits and dietary supplements (there was no statistical significance). Further prospective cohort studies are needed to better understand the cause-effect relationships between the occurrence of frailty syndrome and malnutrition
... Among publications between 2010 and 2014, "oral health problem" and "dry mouth" were oral health related terms that kept on appearing at the bibliometric mapping, these lead to problems as chewing difficulty and xerostomia [55][56][57]. It is likely that denture wearers and/or elderly with a low number of teeth either avoid foods that would create discomfort or use food modification techniques [55,56,58]. ...
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Objectives: The objective of this scoping review was to summarize and provide a visual overview of the present-day knowledge on ecological determinants of eating behavior in community-dwelling elderly persons in relation with nutrition communication, considering the evolution of the field. The second objective was to integrate results in recommendations for the development of nutrition communication strategies. Methods: A literature review was performed on Medline, PubMed and Google Scholar, according with the PRISMA protocol for scoping reviews. An a-priori analysis was executed by categorizing determinants from the literature according with the different levels represented in the ecological framework and an a-posteriori analysis by using VosViewer for a chronological bibliometric mapping analysis. Results: Of 4029 articles retrieved, 77 were selected for analysis. Initial publications focused more on individual determinants of eating behavior. Over time, there was a shift towards a holistic view of eating behavior considering the “food environment”, including social networks, physical settings and public policy. Conclusion: Beyond the individual, all ecological levels are relevant when targeting eating behavior in the elderly. Nutrition communication strategies should be structured considering these influences.
... These conditions can compromise older adults' ability to live independently and increase the risks of hospitalization and institutionalization. [58][59][60] Maintaining nutritional status in community-dwelling older adults is important to reduce the risk of age-related disease and support maintenance of independent living. 43,56,[61][62][63] The current evidence base on nutritional behaviors and outcomes in older adults focuses heavily on those in hospital and aged-care settings; there is limited research on those living independently in the community. 59,60 There is, however, a growing body of research on the prevalence and correlates of meal skipping in preschool children, 31 children and adolescents, 64,65 and younger adults (aged 18-30 years). ...
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Context Meal skipping may contribute to nutrient deficiency across the lifespan. Multiple socioecological factors have been identified as correlates of meal skipping in adolescents and adults, but evidence in older adults is limited. Objective To determine the socioecological correlates of meal skipping in community-dwelling older adults. Data source Embase, PsycINFO, CINAHL, and MEDLINE electronic databases were systematically searched from inception to March 2021. Data extraction A total of 473 original research studies on socioecological factors and meal skipping among community-dwelling adults aged ≥65 years were identified. Title, abstract, and full-text review was performed by 2 reviewers independently, and a third reviewer resolved disagreements. A total of 23 studies met our inclusion criteria. Data were extracted by 1 reviewer from these studies and independently verified by another. The Newcastle-Ottawa Scale was used to assess methodological quality. Data analysis The frequency of meal skipping in included studies ranged between 2.1% and 61%. This review identified 5 domains of socioecological correlates associated with meal skipping in older adults: sociodemographic, behavioral, biomedical, psychological, and social. Conclusion Understanding the factors associated with meal skipping in older adults can inform the development of targeted interventions to improve nutrition and health. Systematic review registration PROSPERO registration no. CRD42021249338.
... In addition, the elderly take drugs, such as diuretics, with potential adverse effects [3][4][5]. Many studies have shown that malnutrition and the risk of malnutrition concern from 25% to even above 60% of the population of older people [6][7][8][9]. The criteria for the diagnosis of clinical malnutrition are different in the USA and Europe. ...
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Low diet quality among the elderly may be correlated with some diseases, including Frailty Syndrome (FS). This decline in function restricts the activity of older people, resulting in higher assistance costs. The aim of this study was to increase knowledge of diet quality predictors. Dietary intake was assessed among 196 individuals aged 60+ years using the three-day record method and FS by Fried’s criteria. Based on the compliance with the intake recommendation (% of EAR/AI), we distinguished three clusters that were homogeneous in terms of the nutritional quality of the diet, using Kohonen’s neural networks. The prevalence of frailty in the entire group was 3.1%, pre-frailty 38.8%, and non-frailty 58.1%. Cluster 1 (91 people with the lowest diet quality) was composed of a statistically significant higher number of the elderly attending day care centers (20.7%), frail (6.9%), pre-frail (51.7%), very low vitamin D intake (23.8% of AI), using sun cream during the summer months (always 19.8% or often 39.6%), having diabetes (20.7%), having leg pain when walking (43.1%), and deteriorating health during the last year (53.5%). The study suggests the need to take initiatives leading to the improvement of the diet of the elderly, especially in day care senior centers, where there are more frail individuals, including nutritional education for the elderly and their caregivers.
... Food insecurity is inversely associated with higher levels of diet quality [57], which encompasses adequacy, moderation, variety or diversity, as well as balanced nutrition and food consumption [58]. A study based on 4009 elderly adults aged 74 or more found that food insecurity was associated with a poor diet quality [59]. For instance, it can lead to a "substitution" effect [60] where nutrient-dense foods, such as lean sources of protein, are replaced with energy-dense, nutrient-poor foods, usually ultra-processed ones rich in refined carbohydrates and fats [61], giving inadequate intake of B12. ...
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Vitamin B12 (also known as cobalamin) is an essential water-soluble vitamin that plays a pivotal role for several physiologic functions during one’s lifespan. Only certain microorganisms are able to synthetize B12, thus humans obtain cobalamin exclusively from their diet, specifically from animal-derived foods. Specific sub-group populations are at risk of vitamin B12 subclinical deficiency due to different factors including poor intake of animal source foods and age-dependent decrease in the capacity of intestinal B12 uptake. Consumption of animal products produces some negative health issues and negatively impacts sustainability while a plant-based diet increases the risk of B12 deficiency. Taking a cue from the aforementioned considerations, this narrative review aims to summarize facts about B12 deficiency and the burden of inadequate dietary intake in elderly population, as well as to discuss sustainable approaches to vitamin B12 deficiency in aging population.
... En España, la Estrategia Nacional de Personas Mayores para un Envejecimiento Activo y para su Buen Trato 2018-2021 es un buen ejemplo (Instituto de Mayores y Servicios Sociales (IMSERSO), 2017). Durante esta etapa etaria pueden aparecer dificultades que van desde disfunciones a la hora de masticar, tragar o ingerir alimentos (Leopold & Kagel, 1997;Mann, Heuberger, & Wong, 2013), a otras relacionadas con patro-nes alimenticios que derivan en sobrepeso (Ledikwe, Smiciklas-Wright, Mitchell, Miller, & Jensen, 2004), asociado en muchas ocasiones a la calidad de las prácticas dietéticas (Ford et al., 2014). Otras problemáticas serían aquellas asociadas a la preparación de alimentos (Bostic & McClain, 2017) o con factores tales como la soledad o la falta de apoyo social (de Boer, Ter Horst, & Lorist, 2013), sobre todo a la hora de mantener una alimentación sa-Educación para la salud y alimentación en personas mayores. ...
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La transición demográfica implica un progresivo envejecimiento de la sociedad, con un importante impacto en las estrategias de Salud Pública. El aumento de la cohorte de personas mayores implica una mayor estratificación, con retos particulares. La nutrición y alimentación es uno central. Este artículo persigue describir las prácticas, creencias y representaciones de personas mayores, no institucionalizadas, que viven en núcleos rurales del oeste español. Pretendemos conocer el impacto que las recomendaciones profesionales (médicos, enfermeras, trabajadores sociales…) tienen en tales prácticas y cómo son incorporados el discurso de lo saludable. A partir de un diseño etnográfico, se realizó el trabajo de campo de enero a julio del año 2019. Los materiales empíricos se produjeron a partir de diferentes relaciones de encuesta (entrevistas semi-estructuradas y conversaciones informales) y unidades de observación en varias localidades de Extremadura (comarca de Las Hurdes) que envolvían a diversos agentes relacionados con todo el proceso alimentario. Las elecciones alimentarias en el grupo analizado distan mucho de las prescripciones dietéticas, que son vistas como “prohibiciones” que no consiguen suficiente auctoritas frente a la construcción simbólica que se otorga la tradición local
... In Spain, the "Estrategia Nacional de Personas Mayores para un Envejecimiento Activo y para su Buen Trato 2018-2021" (National Strategy for an Active Aging and Fair Treatment of the Elderly 2018-2021) is an example of these new kinds of policies [11]. From this age-stage several health risks can start to appear, ranging from dysfunctions when chewing, swallowing or ingesting food [12,13] to eating habits that can cause excess weight [14]-often as a consequence of the nutritional quality of dietary patterns [15]. Further complications are related to how meals are cooked [16], as well as to factors such as social isolation and lack of a support network [17]-all of which can, particularly among older men, become barriers to a healthy diet [18]. ...
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Background: Demographic transition is causing an increasingly aged society, which has a significant impact on public health strategies. Increases in the size of the elderly cohort create a wider stratification and pose specific challenges. Nutrition and diet are one key issue. This study aims to describe food-related practices, beliefs, and representations of non-institutionalized older adults in rural communities in Extremadura (Western Spain). Method: The ethnographic-based fieldwork was conducted from January to July 2019. Empirical material was collected through different research relationships (semi-structured interviews and informal conversations) and direct observation in various locations in Extremadura-involving a variety of agents associated with different aspects of the nutritional process. Results: Data analysis revealed four major themes: (1) Limitations on choice and quality of food available; (2) food preferences and cooking methods; (3) the role of nostalgia in the construction of taste preferences; and (4) perceptions of what "healthy" food is and how respondents relate to the advice provided by health professionals. Conclusions: Nutritional choices among the group studied presented significant differences from medical advice-which was seen as a series of "bans" that did not carry enough authority to alter the symbolic value attached to their traditions.
... 19 Eating alone was not associated with diet quality, as assessed by the Dietary Screening Tool, in older adults in the Geisinger Rural Aging Study. 20 Poor dentition or other mouth problems that inhibit the ability to adequately chew foods could lead to a lower quality diet being consumed. An afflicted person likely would avoid healthy foods that require more chewing, such as whole fruits and whole grains, in favor of more processed foods and fruit juices, requiring less or no chewing. ...
Objective: This analysis examined whether specific social, physical, and financial factors were associated with diet quality among older, community-dwelling women. Methods: This cross-sectional analysis was conducted in a subset of 6,094 community-dwelling Women's Health Initiative participants who completed a food frequency questionnaire, administered from 2012 to 2013, and a self-administered supplemental questionnaire, administered approximately 1 year later. The supplemental questionnaire included five questions assessing social, physical, and financial factors related to eating. Diet quality was assessed with the Healthy Eating Index-2010 (HEI-2010; range of 0-100; higher score indicates a higher quality diet). The total HEI-2010 score was calculated by summing individual scores representing the intake of nine adequacy components (beneficial food groups) and three moderation components (food groups to limit). Associations of responses to the five questions on the supplemental questionnaire with HEI-2010 scores were examined with multiple linear regression, adjusting for relevant covariates. Results: Mean ± standard deviation age of participants was 78.8 ± 6.7 years. Reporting eating fewer than two meals per day, having dental or other mouth problems causing problems with eating, and not always being able to shop, cook, or feed oneself were associated with statistically significantly lower HEI-2010 scores, compared with those not reporting these issues, after multivariable adjustment: 5.37, 2.98, and 2.39 lower scores, respectively (all P values <0.0001). Reporting eating alone most of the time and not always having enough money to buy food were not associated with HEI-2010 scores. Conclusions: Among older, community-dwelling women, eating fewer than two meals per day, dental and other mouth problems, and diminished ability to shop for food, prepare meals, and feed oneself were associated with lower diet quality. These are potential targets for interventions to improve diet quality in older women. : Video Summary:
Population aging, the epidemiological transition, and associated lifestyle changes are among the major drivers of the increased incidence and prevalence of non-communicable diseases. Preparing for change is essential to ensure progress towards achieving the goals outlined in the 2030 Agenda for Sustainable Development. The first step for health care providers is to build specific programs or interventions that guide healthy long-term food choices during old age. Thus, identifying and understanding the specific factors that influence the food choices of elderly adults and how these factors limit or encourage food consumption is imperative. The current review aimed to identify how personal, social, cultural, psychological, situational and intrinsic/extrinsic aspects of food guide or hinder the dietary choices of independent elderly individuals (aged 65 years and older) towards both healthy and unhealthy food choices. The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Thirty-seven papers satisfied the screening. Results are schematized through the Mojet model by framing all potential drivers that guide the independent elderly respectively to make healthy and less healthy choices in their diet. Findings revealed that food choices of independent older adults are shaped by a multitude of factors and sub-factors that may serve to promote or limit the desire and ability to consume a healthy food. Situational, socio-demographic, and psychological factors were the most investigated in the analysed literature, albeit with different aspects and dimensions. Future studies should extend the analysis including multiple factors and evaluate possible interactions between different dimensions. A research agenda provided insights for scholars and policymakers interested in further investigating the factors that influence food choices of this target group.
Background Allostatic load (AL), the concept of cumulative biological risk from chronic stressful exposures, may provide a framework with which to examine the links between diet, physiological stress, and disease. Objective This study examined the associations between diet quality and AL. Design This cross-sectional study was conducted using the 2015-2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Dietary intake was assessed using two 24-hour diet recalls. Diet quality was measured using the Healthy Eating Index-2015 (HEI-2015). AL was measured by a composite score of 9 biochemical markers, with ≥3 dysregulated values signaling elevated AL. All markers were collected during a physical examination. Participants/setting This study was conducted in a nationally representative population of 5,343 U.S. adults aged 19 years or older who had no prior diagnosis of diabetes (except gestational diabetes), cancer (except skin cancer), or cardiovascular disease; were not pregnant; and had complete dietary intake and AL biomarker data. Main outcome measures The outcome was odds of elevated AL. Statistical analyses performed Accounting for the complex survey design of NHANES, multivariable logistic regression was used to examine the associations between HEI-2015 score and elevated AL, adjusting for sociodemographic variables. Results A significant inverse association between AL and diet quality was observed among adults aged 31 years and older but not among those aged 19-30 years. Among adults aged 31 years and older, those in higher quintiles of HEI-2015 score had significantly lower odds of elevated AL compared to the lowest quintile (P-trend<.05). Conclusions These results suggest that, in adults over 30, consuming a more healthful diet is inversely associated with AL.
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Past investigation of diet in relation to disease or mortality has tended to focus on individual nutrients. However, there has been a recent shift to now focus on overall patterns of food intake. The present study aims to investigate the relationship between diet quality reflecting adherence to dietary guidelines and mortality in a sample of older Australians, and to report on the relationship between core food groups and diet quality. This was a population-based cohort study of persons aged 49 years or older at baseline, living in two postcode areas west of Sydney, Australia. Baseline dietary data were collected during 1992–4, from 2897 people using a 145-item Willett-derived FFQ. A modified version of the Healthy Eating Index for Australians was developed to determine diet quality scores. The Australian National Death Index provided 15-year mortality data using multiple data linkage steps. Hazard risk (HR) ratios and 95 % CI for mortality were assessed for diet quality. Subjects in quintile 5 (highest) of the Total Diet Score had a 21 % reduced risk of all-cause mortality (HR 0·79, 95 % CI 0·63, 0·98, P trend= 0·04) compared with those in quintile 1 (lowest) after multivariate adjustment. The present study provides longitudinal support for a reduced risk of all-cause mortality in an older population who have greater compliance with published dietary guidelines.
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No rapid methods exist for screening overall dietary intakes in older adults. The purpose of this study was to develop and evaluate a scoring system for a diet screening tool to identify nutritional risk in community-dwelling older adults. This cross-sectional study in older adults (n = 204) who reside in rural areas examined nutrition status by using an in-person interview, biochemical measures, and four 24-h recalls that included the use of dietary supplements. The dietary screening tool was able to characterize 3 levels of nutritional risk: at risk, possible risk, and not at risk. Individuals classified as at nutritional risk had significantly lower indicators of diet quality (Healthy Eating Index and Mean Adequacy Ratio) and intakes of protein, most micronutrients, dietary fiber, fruit, and vegetables. The at-risk group had higher intakes of fats and oils and refined grains. The at-risk group also had the lowest serum vitamin B-12, folate, beta-cryptoxanthin, lutein, and zeaxanthin concentrations. The not-at-nutritional-risk group had significantly higher lycopene and beta-carotene and lower homocysteine and methylmalonic acid concentrations. The dietary screening tool is a simple and practical tool that can help to detect nutritional risk in older adults.
2003;52:101-106 One figure omitted THE MEDIAN AGE OF THE WORLD'S POPU-lation is increasing because of a de-cline in fertility and a 20-year increase in the average life span during the sec-ond half of the 20th century. 1 These fac-tors, combined with elevated fertility in many countries during the 2 decades after World War II (i.e., the "Baby Boom"), will result in increased num-bers of persons aged 65 years during 2010-2030. 2 Worldwide, the average life span is expected to extend another 10 years by 2050. 1 The growing number of older adults increases demands on the public health system and on medi-cal and social services. Chronic dis-eases, which affect older adults dispro-portionately, contribute to disability, diminish quality of life, and increased health-and long-term–care costs. In-creased life expectancy reflects, in part, the success of public health interven-tions, 2 but public health programs must now respond to the challenges created by this achievement, including the growing burden of chronic illnesses, in-juries, and disabilities and increasing concerns about future caregiving and health-care costs. This report presents data from the U.S. Bureau of the Cen-sus, the World Health Organization, and the United Nations on U.S. and global trends in aging, including demo-graphic and epidemiologic transi-tions, increasing medical and social costs related to aging, and the implica-tions for public health.
To examine the association between body mass index (BMI) and mortality in older people. A longitudinal cohort study of an age-homogenous, representative sample born in 1920/21. Community-based home assessments. West Jerusalem residents born in 1920/21 examined at baseline in 1990 (n=447), with additional recruitment waves in 1998 (n=870) and 2005 (n=1,086). Comprehensive assessment of health variables including BMI (m/kg(2)) at ages 70, 78, and 85. The primary outcome of mortality was collected from age 70 to 88 (1990-2008). Adjusted Cox proportional hazards analysis was used to calculate hazard ratios (HRs) for mortality according to unit increase in BMI. A unit increase in BMI in women resulted in HRs of 0.94, (95% confidence interval (CI)=0.89-0.99) at age 70, 0.95 (95% CI=0.91-0.98) at age 78, and 0.91 (95% CI=0.86-0.98) at age 85. Similarly, in men, HRs were 0.99 (95% CI=0.95-1.05) at age 70, 0.94 (95% CI=0.91-0.98) at age 78, and 0.91 (95% CI=0.86-0.98) at age 85. A time-dependent analysis of 450 subjects followed for 18 years confirmed the above findings; a unit increase in BMI resulted in HRs of 0.93 (95% CI=0.87-0.99) in women and 0.93(95% CI=0.88-0.98) in men. Eliminating the first third of follow-up mortality to account for possibility of reverse causality did not change the results. Higher BMI was associated with lower mortality from age 70 to 88.
The Healthy Eating Index (HEI), a measure of diet quality as specified by federal dietary guidance, was revised to conform to the Dietary Guidelines for Americans 2005. The HEI has several components, the scores of which are totaled. The validity and reliability of the HEI-2005 were evaluated. Validity was assessed by answering four questions: Does the HEI-2005 1) give maximum scores to menus developed by experts; 2) distinguish between groups with known differences in diet quality-smokers and nonsmokers; 3) measure diet quality independently of energy intake, a proxy for diet quantity; and 4) have more than one underlying dimension? The relevant type of reliability, internal consistency, was also assessed. Twenty-four-hour recalls from 8,650 participants, aged 2 years and older, in the National Health and Nutrition Examination Survey, 2001-2002 were analyzed to answer questions 2 to 4. Results were weighted to consider sample design and nonresponse. T tests determined differences in scores between smokers and nonsmokers. Pearson correlation coefficients determined the relationship between energy intake and scores. Principal components analysis determined the number of factors that comprise the HEI-2005. Cronbach's coefficient alpha tested internal consistency. HEI-2005 scores are at or very near the maximum levels for all sets of exemplary menus with one exception; the Harvard menus scored low on the milk component because these menus intentionally include only small amounts of milk products. Nine of 12 component scores were lower for smokers than nonsmokers. The correlations of component scores were virtually independent of energy intake (< I.22I). Multiple factors underlie the HEI-2005. Coefficient alpha was .43. The alpha value for all tests was .01. The HEI-2005 is a valid measure of diet quality. Potential uses include population monitoring, evaluation of interventions, and research. The individual component scores provide essential information in addition to that provided by the total score.
This study was intended to characterize a rural population of older persons through nutrition screening and relate screening items to functional limitations and health care charges. There were 5373 participants (2522 males and 2851 females, mean age 71 y) screened over a 22-mo period by using a self-administered questionnaire adapted from the Nutrition Screening Initiative. Height and weight and cholesterol and albumin concentrations were measured, and health care claims data were obtained. The most frequent screening items reported were use of > or = 3 medications (41%) and food group intakes below recommended frequencies (> 50%). There were significant (P < 0.05) sex differences in affirmative responses to screening items and in likelihood of exceeding proposed threshold values for risk status assigned for body mass index (BMI; in kg/m2), albumin, or cholesterol. Overweight status was notable, with one-half of all subjects having BMIs > 27. Stepwise modeling procedures were used to identify screening items with the ability to predict self-reported functional limitation (logistic regression) and monthly average recorded health care charges (linear regression on logged charges). Age > or = 75 y, use of > or = 3 medications, and an albumin concentration < 35.0 g/L were significant predictors of both functional limitation and health care charges. Poor appetite, eating problems, income < $6000/y, eating alone, and depression were significant predictors of functional limitation but not health care charges. Being male, loss of 10 lb (4.5 kg), BMI > 27, cholesterol concentration < 4.14 or > 6.21 mmol/L, and functional limitation were significant predictors of health care charges only. These findings suggest that selected screening items may have be useful in the identification of subjects at potential risk for these outcomes.
Older people are growing in prevalence and their nutrition-related concerns adversely impact upon health, function, and life quality. Changes in body composition and organ system function alter nutrient requirements. The purpose of this review is to examine changes in nutritional requirements with aging and to highlight practical approaches to nutritional screening, assessment, and intervention. A multidisciplinary approach with individualized care is recommended. Health care providers who work with older people must be attentive to nutrition, because appreciable comorbidity and unfavorable outcomes may accompany either under- or overnutrition.
The purpose of this study was to examine the consequences associated with food insecurity for the nutritional and health status of the elderly in the United STATES: The data analyzed were from the Third National Health and Nutrition Examination Survey (1988-1994) and the Nutrition Survey of the Elderly in New York State (1994). Multiple logistic and linear regression analyses were used to assess the extent to which food-insecure elderly were likely to have lower nutrient intake, skinfold thickness, self-reported health status and higher nutritional risk. Regardless of food insecurity status, older people consumed less than the recommended dietary allowance for eight nutrients. Food-insecure elderly persons had significantly lower intakes of energy, protein, carbohydrate, saturated fat, niacin, riboflavin, vitamins B-6 and B-12, magnesium, iron and zinc, as well as lower skinfold thickness. In addition, food-insecure elderly persons were 2.33 (95% confidence interval: 1.73-3.14) times more likely to report fair/poor health status and had higher nutritional risk. These results indicate that food-insecure elderly persons have poorer dietary intake, nutritional status and health status than do food-secure elderly persons. It is necessary to ensure the nutritional well-being of all elderly persons who are at nutritional and health risk, including those who are food insecure and have even poorer nutritional and health status than those who are food secure.
Nutrition is a prime concern for the optimal health of older persons. Nutritional requirements for older persons must take into account the physiologic changes that occur with aging. The gastrointestinal tract is the site of key structural and functional changes that affect nutrient intake and assimilation. A working knowledge of nutritional screening, assessment, and interventions can assist the practitioner in providing quality care for the older patient.