nutritional status in a healthy elderly population.pdf

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The Am erican Journal o fC linical N utritio n 6: A U G U S T

1982 A m erican S ociety for C lin ica l N utrition

1982, pp. 319-331. P rin ted in U .S.A .

N utrition al s ta tu s in a hea lthy elderly popula tion :

d ie ta ry and sup plem en ta l in takesPhilip J G arry P h.D . Jam es S. G o odw in M .D . W illiam C . H un t M .A .

E lizab eth M . H o oper R.N . a nd A ndrea G . Leon ard ltD .

A B ST RA C T D ietary and supplem enta l in takes w ereassessed from 3-dayfood r ec or ds c ol le ct ed

from 270 free-liv ing, m iddle incom e and healthy m en and w om en over 60 yr of age residing in the

A lbuquerque, NM vicinity . The 1980 Recom m ended D ietary Allow ances RD A ) w ere used to

assess adequacy of intake.Energy intake, as percentage ofthe R DA , was 90 23 m ean SD ) form en n = 125) and 87 22 for w om en n = 145). M ean daily protein intake w as 83 g for m en and

67 g for w om en and only 11 of m en and 14 of wom en failed to receive at least100 of the

RD A for protein . Frequency and am ount of v itam in and m ineral supplem entationw a s s ub st an ti al .

A pproxim ately 60 ofboth m en and wom en ingested one or m ore supplem ents; vitam ins C and

E w ere the m ost popular. In general, dietary in takes in this population appear to be adequate w ith

the possible exception of vitam in D and calcium intakes in wom en.Am J Clin Nutrl 98 2; 36 : 3 1 9 3 3 1

KEY W O RD S Elderly, healthy, dietary and supplem ental intakes, energy, vitam ins, m inerals,

obesity

Introduction

In the past 25 yr, num erous national andreg ional studies have been conducted to as-sess the nu tritional status of the elderly by

exam ining their d ietary habits. The facto rsthat in fluenced fm dings in these studies w ere

reg ion of study, age, sex ,body siz e, h ab itat,and types of illnesses, as w ell as social andeconom ic conditions 1 ). The standards usedto m easure adequacy of nu trient intake alsovaried; however, m ost studies have used the

R ecom m ended D ietary A llow ances RD A )

ofthe N ational R esearch C ouncil. C onfusionin interpretation of the stud ies resu lts fromthe fact that the R D A s have been revisednine tim es since their inception in 1941. A lso,some investigators used 100 of the R D A astheir standard of adequate in take, w hile o th -ers used 90 , 67 , 50, o r 40 o f the R D A asstandards. D ifferences in dietary m ethodol-

ogy have also resu lted in som e inconsistenciesin reported in takes of sim ilar populationgroups. Th is can be attribu ted to lack ofprecis ion in collec ting data on die tary intakes

by the m ost frequently used m ethods de-signed for this purpose; i.e ., 24-h recalls,foodrecords, and dietary histories. It has beenshow n that each m ethod used to estim ate

dietary intake hasit s advantages and disad-van tages; how ever, very little w ork has beendone to determ ine the best m ethod to be usedw ith o lder sub jects 1).

B ecause of the m any variab les noted, it is

d ifficult to com pare resu lts from the variousreported studies designed to exam ine poten-

tia l d ietary prob lem s in the elderly. W e havenarrow ed the scope of our study to the fo l-

low ing in an attem pt to m ake the results m ore

interpretable.

1 W e have lim ited our population tohealthy, non institutionalized m en andw om en over 60 yr of age. En trance to thisstudy w as lim ited to those free of m ajor ill-nesses and receiving no prescrip tion m edica-

tion.2 In order to reduce som e know n errors

in dietary m ethodology, we obtained 3-day

I From the U niversity ofN ew M exico School of M cd-icine, D epartm ents of Pathology and M edicine, Albu-querque, N M .

Supported by G rants from the U nited States PublicH ealth Service, A G 02049 and RR-00997-05,06)and aGrant-In-A id from H offm ann-La Roche, Inc.

A ddress reprin t requests to: P hilip J . G arry , P h.D .,

Surge B ldg. Room 236, University of N ew M exicoSchool of M edicine, A lbuquerque, N M 87131.

Received Septem ber 11 , 1981 .A ccepted for publication January 19, 1982.

31 9


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320 GA RRY ET A L.

food records, exclusive of weekend eatinghabits. The volunteers were thoroughly in-structed on how to record food intakes andwere provided with diet scales for weighing

f ood item s.3 ) Immediately after the 3-day food record

keeping period, a dietitian made home visitsto check completeness and accuracy of re-corded amounts and obtain informationabout vitamin and mineral supplement use,income, education, and physical activity.

4) A computerized system was used forconversion of the dietary information to en-ergy and nutrient intakes. W e believe thatthis helps standardize the computations andreduces individual computational errors.

This report summarizes our fmdings basedon the criteria noted above.

Subjects and m ethods

T hree hundred four men (n= 138) and women (n=166) from the A lbuquerque, N M area were recruited fora study entitled, A Prospective Study of N utrition inthe Elderly. T his 5-yr longitudinal study was designedto investigate the relationship between nutritional status

and immune function in a large group ofhealthy elderlyindividuals, as well as to determine prospectively the

consequences of subclinical malnutrition in otherwise

healthy elderly individuals. Volunteers were solicited bynewspaper, radio, and television advertisements as well

as by talks given at various senior centers around the

city. Only volunteers 60 yr ofage or older with no knownmedical illnesses and on no prescription medication

(other than occasional hypnotic, laxative, or analgesic)were selected. A ll volunteers lived independently in theirown homes or apartments and none was paid for partic-ipating in the study. Spouse participation was encour-aged. Tabl e I gives the distribution ofthis population bysex, age, marital status, education, and income. T he totalnumber ofsubjects is 270 (125 men and 145 women) andreflects losses due to dropout, death, or inadequate di-etary information.

I t is important to point out that this population cannotbe considered a random sample of the healthy elderly inthe A lbuquerque area. For example, while enrollmentwas not restricted to any ethnic group, all of the volun-teem were Caucasian with approximately 3% being ofSpanish/H ispanic descent (1980 census definition ofSpanish/H ispanic w as used).This contrasts sharply w ithpreliminary 1980 census figures which show about 37%

ofthe total population in the A lbuquerque areareportingSpanish/H ispanic origin (3). Education level was alsonontypical with 42% of this population having college

degrees and 16% with advanced degrees. For compari-son, 1979 U S Census estimates for the W estern U nitedStates show only 12% of individuals 65 and over having4 or more yr of college (4). W hile many of the partici-

pants were involved in activities sponsored by localsenior citizen centers, only 10 subjects (3.7% ) participatedin Title I lI c or similar nutrition programs and only one

TABLE 1

D escri pti on of p ar ti ci pants

M e n W o m en

n 1 2 5 ) n 1 4 5 )

Age (yr )

60-64 3 (2.4) 7( 4.8)65-70 48 (38.4) 59(40.7)71-75 54(43.2) 55 (37.9)

76-80 15 (20.0) 17 (11.7)80 + 5 (4.0) 7( 4.8)

M arital StatusM arried 109 (87.2) 72 (49.7)Single 16 (12.8) 73 (50.3)

Educa t ion


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D IET A RY ST A T U S OF H EA L T H Y EL D ERL Y 321

include food brand names, methods offood preparation,and recipes for any mixed dish eaten during the period.I nformation wasalso obtained on whether the meal waseaten alone or with another person and if the meal waseaten at home or at a commercial establishment.

A t the end of the 3-day recording period, a dietitianvisited their homes to collect the diet records. A t thistime each record was subjectively evaluated for com-pleteness and accuracy with participants being asked toprovide additional information about any unclearfooditem. I f vitamin or mineral supplements were used bythe subject, the brand name, contents, and amounts ofeach nutrient w ere recorded for inclusion in determiningtotal intakes. A llfood records were coded byfood itemand amount and analyzed for nutrient composition usinga computerized nutrient database (1980 ed.) obtainedfrom Case W estern Reserve U niversity, Cleveland, OH .T his data base was compiled primarily from the A gri-culture H andbook no. 8 (5) and data obtained directlyfrom commercial foodcompanies.

D ata describing income, marital status, educationallevel, physical activity level, and w hether the individualcooked for himself were also collected during the homevisit. The activity score, modified from Cassel (6), had a

range from a low of 2 to a high of 40 and varied with thefrequency and strenuousness of activities. For instance,playing tennis regularly would be assigned a score of4, and walking on errands frequently would be givena score of 2. Scores for the individual activities weretotaled, yielding a composite activity score.

T he daily intake and percentage ofthe 1980 RD A(2)were determined for energy, protein, ascorbic acid, thia-min, niacin, riboflavin, vitamins A , B B,2, D , and E,folic acid, iron, calcium, zinc, and phosphorus. T hepercentage of total energy from protein, carbohydrates,fat, and alcohol were also determined. W e judged thatthe levels of nutrient intake were inadequate if one-fourth of the population receivedless than 75% of theRD A . Based on this criterion, a segment of the popula-

tion with inadequate intakes could potentially be at riskfor developing nutritional deficiencies for a particularnutrient. T his risk was judged to be substantially in-creased if one-fourth of the population had dietary in-takes ofless than 50% of the RD A .

A nthropom etri c measurem ents

A ll volunteers were measured for weight, wearing ahospital gown, using standardized clinical scales. Heightswere determined without shoes. H eight and weight mea-surements were then used to determine percent of idealor desirable w eight (7) or body mass index (BM I), theweight in kilograms divided by the square of the heightin meters (8). Subjects with a weight greater than 120%of desirable weight or a BM I greater than 27 wereconsidered obese, while p er son s w ei ghi ng less than 80%of desirable weight, or having a BM I ofless than 20 (for

men) or 18.8 (for women), were considered thin (9, 10).

Statistical anal ysis

A ll statistical analyses were accomplished with the aidof the Statistical A nalysis System version 79.5 at theU niversity of New M exico Computing Center. A ll cor-relations presented in this paper are Pearson product-

moment correlations, and group comparisons are theusual tw o sample t test or one-way A N OV A.

Results

Anthropometry

Figure 1shows the distribution of BM I bysex. There was a small but significant de-crease in BM I with age for men (r= -0.17,p = 0.05) but not for women (r= 0.02, p =0.81).

There were no significant differences be-tween mean BM I values for men and women,and the BM I values for both sexes were dis-tributed normally. The men in our populationhad a mean weight that was 106.0% of thedesirable weight versus 107.7% for women(Table 2). In this population 15.8% of the

men and 19.5% of the women had a weightgreater than 120% of their desirable bodyweight and were considered obese. In con-trast, 2.4% of the men and 0.7% of the womenwere less than 80% of the desirable weightand thus were considered thin. U sing a BM I

cutoffpoint ofgreater than 27.0 as a measureof obesity for both sexes, 18.6% of the menand 15. 1% of the women would be classifiedas obese, while 10.8% ofthe men and 3.9% ofthe women would be considered thin, usinga BM I value less than 20.0 for men and 18.8

for women as a measure of thinness. Energyintake as measured by total k.ilocalories did

not correlate with BM I (r= 0.03). This may,in part, be explained by the negative corre-

lation between BM I and activity level (r=-0.16, p< 0.008).

D ietary in take

Table 3 gives the mean intakes of energy,protein, fat, carbohydrates, and alcohol formen and women. A lso shown are mean val-ues for percentage of RD A for energy andthe four major food items. Table 4 gives thepercentage of men and women receiving less

than 100, 75, and 50% ofthe RD A s from dietalone. Figure 2 describes the distributions of

nutrient and energy intake from diet aloneexpressed as a percentage of the RD A . Foreach nutrient the 5th, 25th, 50th (median),75th, and 95th percentiles are shown. Theseare the levels of intake at which5, 25, 50, 75,and 95% of the sample fall at or below. A lsoindicated are the mean values. D istributionsare given separately for men and women.


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M oles (N : 25)

Females ( Na 47 )

3

32

322 GAR RY ET AL.

0

0

0

8)a 0

Ca,U

Body M oss Index, kg/rn2

FIG. 1. D istributions of BM I values for older males and females.

TA BLE 2

R esults from anthropometric measurements

M e n W o m e n

H t (cm)W t (kg) ofideal weightBM I

1 74.0 ( 6.9)7 3.4 ( 11 .1 )

1 06 .0 ( 14 .5 )2 4.2 ( 3.3)

1 59 .4 ( 6. 4)60.5 (9.7)

1 07 .7 ( 15 .8 )2 3.7 ( 3.4)

* Mean (SD) .

The mean energy intake was below theRD A for both men and women. The averageage of our population, for both men andwomen, was 72 yr, and the percentage ofRD A for energy was 90 and 87 for men andwomen, respectively. Our calculated energyintakes, based on percentage of the RD A ,were determined on actual weight rather thanideal or desirable weight. This was done be-cause there is some confusion as to whetherthe elderly should be compared with desira-ble weights for height determined for menand women in their twenties (7). Because our

population, both men and women, had meanweights per unit height greater than the so-called ideal or desirable value, our reportedvalues, as percentage of the RD A s for en-ergy, are less than if calculations were basedon desirable weights. Table 4 shows that only1% of men and women failed to get at least

50% of the RD A for energy while approxi-mately one-third received less than 75% ofthe RD A.

The 1980 edition (9th) of the RD A forenergy used different energy intake standardsfor men and women greater than 75 yr of agethan did previous editions of the RD A. Thenew allowances for men and women between

5 1 and 75 yr of age and those more than 75yr takes into account the decrease in basal(resting) metabolic rate and activity with in-creasing age.

W hen we examined the relationship be-tween age and energy intake in our popula-tion, we found a significant negative correla-tion for men (r= -0.24, p = 0.007) but notfor women (r= -0.07, p = 0.397) . H ow ever,when we examined energy intakes indepen-dently for men and women less than 76 yr ofage compared to those 76 yr of age and older,a significant difference was noted for bothsexes (p < 0.02). For men less than 76 yr of

age, the mean energy intake was 2214 kcal/day (n = 105), or 88% of the RD A . For men76 yr of age and older, the mean intake was1970 kcal/day (n= 20), or 100% ofthe RDA .W omen less than 76 yr of age had a meanenergy intake of 1685 kcal/day (n= 121), or86% of the RD A. W omen 76 yr of age and


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TABLE 4

Percentage of men and women receivingless than 100,75, and 50% of RD A s from diet alone

TAB LE 3

Intake of energy ( cal ories) , protei n, f at, carbohydrates,and al coho l

Energy (cal) total% of RD A

Protein (g)% of RD A% of total energy protein froman imal s t

protein fromp lan ts ( veg et a-

bles)

W o m e n

165 3 ( 369)

87 (22)

67 (17)140 (36)

16(4)73

M en

2171 (491)

90 (23)

83 (20)1 42 ( 37)

15(3)

71

29

91 (28)37 (7)58

42

33 4 ( 168)

24 4 (63)45 (8)

16

84

1 2 ( 18 )

D I ETA RY ST A T U S OF H EA L T H Y EL D ERL Y 323

older had a mean intake of 1506 kcal/day (n= 24), or 91% of the RD A . U sing the 1980RD A standards for energy resulted in highermean energy intakes as percent of the RD A

than if we had used older standards for en-ergy intake, e.g., 8th ed. ofthe RD A (1974).

Forty-six percent of our men and 41% ofour women consumed alcohol during their 3-day food recording period. The mean dailyalcohol intake was 12. 1 g for men and 6.5 gfor women per day (p= 0.002). A lcoholintake decreased with age for both sexes (r= -0. 18, p = 0.002).

Figure 2 shows that protein intake wassubstantial in this population. Only 11% ofmen and 14% of women failed to receive100% of the RD A for protein (Table 4). I t isevident from Figure 2 that dietary intake,

Fat (g) of total energy fat from ani-

mals fat from plants(vegetables)

cho les t e ro l

Carbohydrate (g) of total energy% carbohydrate

f rom ref medcarbohydrates

carbohydratef ro m natural

sources

A lcohol (g)

S Mean (SD) .

Source of protein and fat (plant or animal) andcarbohydrate (refmed or natural) is not known for allfood items. T hese proporti ons are theref ore based on atotal protein, fat, or carbohydrate which isless than thatgiven in T able 3.

. .D ietary in-

take

< 100%

M a l e

R DA

F e m a l e

< 75%

Male

RD A

Female

< S

M a l e

RD A

F e m a l e

Energy 71 76 29 33 1 1(cal)

Pro te in 11 14 1 3 0 0

Ascor b ic 7 10 3 7 0 2acid

Thiamin 27 47 3 13 0 1Ribo- 16 29 2 6 0 0

flavinN iacin 0 0 0 0 0 0Vi tam in 9 4 97 83 86 54 61

B6

Vitamin 42 65 24 39 10 15B, 2

Fol i cac i d 86 91 70 84 37 43

Vi tam in 22 15 13 10 5 4

AVi tam in 7 9 87 70 74 50 61

D

Vi tam in 6 4 59 4 6 42 28 26

E

I ron 6 33 1 5 0 0Calcium 55 75 30 43 9 12

Phospho- 3 16 0 5 0 0rus

Zinc 91 98 65 88 21 47

expressed as percentage of the RD A , differs

27 among nutrients as well as among individ-uals. D ietary intake of some vitamins-as-corbic acid, niacin, and vitamin A -was wellabove the RD A for most individuals in the

69 (23) population, while for others-vitamins B(6) B12, D , and E, folic acid, calcium, and zinc-

a substantial percentage of the population43 was receiving less than the RDA through diet

alone. M edian dietary intake ranged from a283 (144) high of 261% of the RD A for niacinintake

1 88 ( 46) among men to a low of 40% of the RDA for46 (7) vitamin D intake among women. W hile, in13 general, there are no great differences be-

tween the men and women with respect to

87 distribution of dietary intake, women usuallyhad median intakes that were below that ofthe men in our population. For some nutri-ents, there was a great deal of variability

6 (12) between subjects in the level ofdietary intake.A scorbic acid and vitamin A demonstratedthe most variability as can be seen by notingthe large difference between the 25th and75th percentiles. For comparison, vitamin B6,zinc, and folic acid exhibited much less van-


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P ercent of R D A from D iet A lone

0 50 00 50 200 250 300 350 400

E nergy(colories) I I I I

Protein p I

468%. . I I I-

AscorbacAcid i 466%.

Thiomin l-1 1 _ x___jI I

. . I Ix I INiacin I I

Rbfl I I I X I -IOOVlf l - I : s x x : I

Vitamin 4- I

B6

Vitamin , I 7I3

FolicAcid

416%Vitam in A , ; L 63

I-

V itam in 1 zJ I

I I $ x j IVin

I Ix i -II ron

. I- I JX :i ICalcium

I I X 1 1

Phosphorus I I

med i an

Z in c:4x::j----- --- 5t h 25 th 7 5t h 9 5 th Percen t i l eI- ----4 I -I m ean

FIG. 2. D ietary intakes ofenergy, protein, vitamins, and minerals as percentage of the RD A for older males andfemales. T he 5th, 25th, 50th (median), 75th, and 95th percentiles are shown for each distribution. T hese are levels ofintake for which 5, 25, 50, 75, and 95% of the sample fall at or below. T heb ox includes the middle 50% of thedistribution and 90% of all subjects lie between the two extremeve rtic a l b a rs . The median is indicated by aver t ica l

ba r drawn through thebo x and means are marked by an X .

324


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ability in level of dietary intake. M ost distri-butions were positively skewed andthis wasparticularly pronounced for vitamins B 12 andA . This skewness results in means that are

much higher than the corresponding me-dians. The skewness in the distributions ofvitamins B12 and A was undoubtedly theresult of some individuals consuming liverover the 3-day record keeping period.

V ita m in an d m inera l su pp lem ent usa ge

Fifty-seven percent of the men and 61% ofthe women in this study were routinely in-gesting one or more vitamin or mineral sup-plements. Thirty-one percent were ingestinga daily multivitamin preparation, and 95% ofthese individuals were also taking one ormore additional vitamin and/or mineral sup-plements.

Figure 3 describes the distribution of sup-plementation level for those subjects receiv-ing additional vitamin or mineral supple-ments. Total amount of supplemental intakefor a given vitamin or mineral is computedby summing the amount contained in multi-vitamin and mineral tablets with that takenas an individual supplement. Figure 3 showsthe 5th, 25th, 50th (median), 75th, and 95thpercentiles along with geometric means andpercentage of individuals taking supplementsof the particular vitamin or mineral. Theextreme skewness of the distributions, whichis masked by the logarithmic scale, makes thegeometric mean a more appropriate measure

of central location than the simple arithmeticmean.

Ascorbic acid was the vitamin consumedmost, even though more than 90% of ourpopulation received at least 100% ofthe RD Afrom diet alone. M edian supplemental intakeof ascorbic acid was 830% of the RDA formen and 570% of the RD A for women. Fig-ure 3 also shows that vitamin supplementa-tion varies considerably from one nutrient toanother as well as among subjects taking aspecific supplement. M edian supplementalintake ranged from a high of more than1800% of the RD A for vitamin E to less than20% of the RDA for phosphorus. Of all thewater soluble vitamins, folic acid was thesupplement consumed in lowest absoluteamounts relative to the RD A.

A nalysis showed little statistical differencein mean dietary intake for those individuals

taking a specific supplement when comparedto those who did not take that supplement.In most cases, however, those taking supple-ments had, on the average, slightly higher

dietary intakes of that nutrient.For those nutrients where a large propor-

tion of the population was receiving less thanthe RD A from diet alone, supplementationlevels were, in general, sufficient. Figure 4 to

7 give the distributions of total intake (dietplus supplement) for individuals on supple-mentation and those not taking supplementsfor vitamins B6 and D, folic acid, and calcium.M edians and first quartiles (25th percentile)are also given. Because of the relatively highintakes ofsupplemental vitamin B6, folic acid,and vitamin D , there was a considerable shiftin the median intakes of these vitamins with

the first quartile values at, or well above,100% of the RD A. For example, men andwomen not taking supplemental vitamin B6had a median intake of less than 50% of theRD A , while men and women taking supple-mental vitamin B6 had a median intake thatwas approximately 275% of the RD A (Fig.4). Because supplemental intakes of calciumwere relatively low compared to the RDA ,the median intakes for those men and womentaking supplemental calcium did not changeas substantially as noted for those takingvitamin supplements. Of the women in thesupplemental group 50% were still receivingless than 100% of the RDA for calcium (Fig.7) .

G enera l ob servation s

W e next looked at whether there were di-etary differences between those individualswho ate alone most of the time versus thosewho ate with someone most of the time. Tenpercent of the men and 45% of the womenate alone most ofthe time, probably reflectingtheir marital status (Table 1). W hen we con-trolled for the effect of sex, there was noevidence of differences in eating patterns forenergy intake or nutrients, whether they atealone or not. For example, women who atealone (n = 63) had a mean energy intake of1641 kcal compared to 1657 kcal for thosewho did not eat alone (n= 77).

Eighty-nine percent ofthe women and 19%of the men cooked for themselves. After con-trolling for sex we did not fmd any dietarydifferences between those individuals who


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Percent of R D A from Supplem ents Alone

I 0 00 000 0000

I- I . I I . I {149} .1 1 .- {149}__,_,_j

Ascorbc f emale X .

taking supplement mole

Thiomin __________46% _______

N iacin46% 1- .

R iboflavin 45 %

Vitamin Ba ____________4 _ _ _ _ _ _ _ _ _ _ _

42% I- -4 K I-\ t i tormn Bie : -

Folic Acid I

Vitamin A 42%41 I f -rz4 ---

Vitam in E 50% - ----I- S }---- -49 ________

40 I -IV itam in D _ __ __ __ _ _ __ _ ______9% I 4-.. . IIron 31 1 X I i

34%

t 26 %Calcium

-4 26 %

5%0% Phohorus

- r : = - - : - - - -- - - - - - r j . - - - - . - . - - - -- - _ - . i 31%ZincI V77777777777Z 7Z Z - - - - i 24 %

5th h m edian 75th 95th percentile

, I f 1 -II igeometr icmean

FIG. 3. Supplemental intakesofvitamins and minerals as percent ofthe RD A for older males and females. Onlyindividuals taking supplements are included. For each distribution, the 5th, 25th, 50th (median), 75th, and 95thpercentiles are shown on a logarithmic scale. A lso shownare the percentage of subjects with supplemental intake.T he x includes the middle 50% ofthe distribution falling between the 25th and 75th percentiles. N inety percent ofthe distribution falls between the two extreme vertical bars. M edians are indicated by ave rtic a l b a r through the b oxand geometric means by an X .

326


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Moles

F e m a l e s

Moles

Females

Me(61n Q 12 7 3 40 % S ubjects ta kin g

287% 135% supplement48% 36% Subjects no t taking

42% 30% supplement

72

66

60

54U)

U4, 48

.0

(I) 42

36a,

.0 {1 4 9 }E 3 0

; 24

8

2

6

0

Median QM oles l55% I26% S ub je cts ta kin g

F em ales l50% 9 0% supplementM oles 62% 4305ubject5 n ot t ak in g

Fem ales 52% 39% supplement

/ /

1

< 10 2 0 6 0 KO 40 80 220 26 0 >300

T ota l F olic A cid Intake E xpressedas a P ercentage of the RD A

FIG. 5. D istribution of total folic acid intake forsubjects taking and not taking supplemental folic acid.

M edian and 25th percentile (Q values are given forboth males and females.


U)

U 6)

.0

U )

0

a,.0

Ez

T ota l P yridoxine Intake E xpressed as a

Percentage of the R D AFIG. 4. D istribution of total pyridoxine intake for subjects taking and not taking supplemental pyridoxine.

M edian and 25th percentile (Qi) values are given forboth males and females.

cooked for themselves versus those who didnot.

Discussion

The primary purpose of this report is todescribe the dietary profile of a healthy el-derly population. Because participation inthis 5-yr study was entirely voluntary, and weaccepted only individuals ingood health andnot on prescription medication, the popula-tion studied is clearly not representative of allelderly people in this locality. In addition, themean educational level and income of ourvolunteers most likely exceed the nationalaverages for elderly Americans (Table 1). I tis also probably safe to assume that our sub-

jects are more health conscious than the av-erage elderly American because they volun-teered for a study which included annualphysical exams and laboratory testing for 5

yr.Relative body weights, expressed in terms

of BM I, are considerably lower in our popu-lation than reported in two regional (1 1, 12)and one nationwide study (13). The two re-


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44

40

36

32

. 28U )

. 24

.0 20E

2 6

2

8

4

Moles

F e m a l e s

M o l e s

Females

-/

M edian Q 1 % 2O4% S ub je cts ta kin g

247% 206% supplement % 29% S ubjects not taking

41% 22% supplement

7.//

I////500

T ota l V itam in D Intake E xpressed as aPercentage of the RD A

FIG. 6. D istribution of total vitamin D intake for subjects taking and not taking supplemental vitamin D .M edian and 25th percentile (Q values are given for both m al es and f em ales.

56

52

48

44

40

36U,

32.0

( 28

24

. 20

2 16

2

8

4

hledian Q1Moles 149% 98 Subjects taking

Fsm*s 1 13 % 7 8% supplementMales 92 7 l ) S ub je cts n ottaking

Females 82% 63% I supplement

J10 40 80 120 160 200 240 280 320 360 400

T otal C alcium Intake E xpressed as a

P ercentage of the R D A

FIG. 7. D istribution of total calcium intake for sub-jects taking and not taking supplemental calcium. M e-dian and 25th percentile (Q values are given for bothmales and females.

328 GARRY ET AL.

gional studies show mean relative bodyweights that were approximately 1 SD aboveour mean BM I values for both men andwomen. The lower mean BM I values in ourstudy might reflect changes due to age, be-

cause our population had a higher mean age(72 yr) than the two regional or nationwidestudies. W e were able to fmd only a weakrelationship between age and BM I in ourmale population and none in the female pop-ulation. H owever, the K entucky study (12)found a significant negative correlation be-tween age and the BM I in their female, butnone in their male population.

W e found that 16% of our men and 20% ofour women were obese, based on havingweights greater than 120% ofdesirable weightfor height. These percentages for obesity areconsiderably lower than recent reports forfree-living elderly in M issouri (11) and Utah(14). U sing the same criteria ofobesity, K ohrset al. (1 1) examined 55 men and 81 womenin five geographic regions of M issouri (meanage approximately 70 yr) and found that 22%of their men and 59% of the women wereobese. Fisher et al. (14) reported that of 58men and 129 women living in rural U tah


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D IET A RY ST A T U S OF H EA L T H Y ELD ERL Y 329

(mean age of 69 yr), 30% of the men and 50%of the women were obese.

Of some interest was the fmding that en-ergy intake did not correlate with BM I. One

would expect that men and women on theextreme ends of the BM I scale would havedifferent energy intakes. One factor thatcould explain this fmding is the negativecorrelation of BM I with activity.

The mean energy intakes of men andwomen in our population were below the1980 RD A values. Of some interest was thefmding that the mean energy intake of men76 yr ofage and older was 100% compared to88% of the RD A for men less than 76 yr.U sing the lower standard for energy intakefor individuals 76 yr of age and older resultedin raising mean intakes for the entire male

and female populations compared to stan-dards used in previous editions of the RD A .Our fmdings of decreased energy consump-tion with age in this healthy population sup-port the lower energy standards for men andwomen 76 yr of age and older noted in the9th ed. ofthe RD A (2).

It is difficult to make exact comparisonswith recent reports designed to examine di-etary habits in the elderly for a number ofreasons. The most important factor relates todietary methodology. W e used 3-dayfoodrecords rather than 24-h recall (15-17) or diethistories (1 1). W hile there is continuing de-

bate about the best method to be used toobtain accurate data about dietary intakes(18-20), especially in the elderly, we believe

that our 3-day food records probably under-estimated intakes. This is partially based onthe fact that we did not collect weekend foodrecords. There is some indication that week-end food intakes are higher than during theweek (19). Regardless of the fmding that themajority of our men and women failed tomeet the RD A for energy, we believe thatwith the possible exception ofa few nutrients,the overall diet intakes were quite adequate.

The dietary nutrient we judged to be gen-

erally inadequate in our male and femalepopulations, on the basis that one-fourth ofthe population failed to receive at least 75%of the RD A, were vitamins B B12, D , and E,folic acid, calcium, and zinc. This may be anunnecessarily narrow defmition of made-quacy because the RD A s for most nutrients

represent upper limits of variability for ageand sex. For this reason it has been arguedthat dietary intakes that fail to meet 75, 67,or even 50% of the RD A for a particular

nutrient do not necessarily mean that individ-uals are at risk for developing a nutritionaldeficiency, especially when this informationis gathered from 3-day food records andtherefore may not give an accurate accountof habitual intake. H owever, we believe thatthe risk increases substantially if one-fourthof a population is found to have dietaryintakes that are less than 50% of the RD A fora particular nutrient. Those nutrients foundto meet this criterion were vitamins B6, D , E,and folic acid. Zinc intakes for women, butnot for men, were also in this category.

W hile it was judged that dietary intakes of

vitamin B12 were inadequate, we believe thatthere was little risk associated with the re-ported levels of intake in this population. W ebase this fmding on three factors. First, fewerthan one-fourth of the men and women werereceiving less than 50% of the RD A for vi-tamin B12. Second, because the reservepoolof vitamin B12 can be maintained for sometime on intakes less than the RD A , a seriouslimitation of intake over a prolonged periodof time would be necessary before a healthproblem would develop. Also, there is noevidence that a dietary deficiency of vitaminB12 can occur at the levels of animal food

consumed by this population. Last, we havefailed to detect anyone in this populationwith megaloblastic anemia, realizing that thiscould result from a folate as well as a vitaminB 12 deficiency state.

A lthough vitamin E intakes werejudged tobe inadequate, we do not believe that thistranslates into a substantial risk factor for thefollowing reason. Increased vitamin E intakesare probably only needed when largeamounts of polyunsaturated fatty acids(PUFA) are included in the diet. In the ab-sence of the powerful antioxidant effects ofvitamin E, increased intakes of PU FA can

contribute to free radical formation whichcan have serious damaging effects on mem-branes. H owever, we found a significant pos-itive correlation (r= 0.484, p = 0.0001) be-tween vegetable fat and dietary vitamin Eintake. Therefore, the risk associated withincreased intakes of PU FA from vegetable


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33 0 GARRY ET AL.

fat is negated by corresponding increasedintakes of vitamin E in this population.

The reason for the low vitamin B6 intakesin this healthy population is hard to explain,considering that intakes of other B-vitaminsappear to be adequate. However, one reasonthat might explain this is that data on thevitamin B6 content of many foods are lacking

(2). Therefore, our data should be viewedwith some reservations until more informa-tion about vitamin B6 levels in various foodsbecom es av ai labl e.

W hile the intake of folate, as percentage ofthe current RD A , in both men and women inthis population appears to be inadequate, thisinformation, as noted for vitamin B has tobe viewed with some reservation until moreinformation becomes available on the content

of folate in various foods. A lso, until it canbe shown that these low intakes result inmeasurable low levels of folate in plasma anderythrocytes, or clinical problems associatedwith inadequate folate intake can be dem-onstrated, these results should not be consid-ered al arming.

Considering the fmding that the proteinintakes from animal sources represents over70% ofthe total protein intake, it is somewhatsurprising that the zinc intakes are inade-quate, because animal protein is a goodsource of dietary zinc. Because of the rolethat zinc plays in wound healing and tasteacuity, the information presented hereinpoints to the need for further studies as towhether current zinc intakes in the elderlyare adequate.

The relationship of vitamin D and calciumintake and the high incidence of osteoporosisin elderly women continues to be debated byepidemiologists and clinicians as to whetherincreased intakes of these nutrients can betherapeutic. W e found intakes of vitamin Dand calcium to be inadequate in our femalepopulation. One ofthe reasons for inadequateintakes of vitamin D and calcium in womenin our population was thepoor consumptionof dairy products, especially milk. I t shouldbe noted that, while calcium intakes inwomen were inadequate in ourjudgment, themedian intake of calcium, 656 mg/day, wasconsiderably higher than the reported medianintake of approximately 500 mg/day foundin postmenopausal women in a large U nited

States survey (21). The high intakes of protein

in our population might potentiate problemsassociated with low intakes of calcium. Re-cent reports show that increased protein in-take may have a profound and sustained

effect on increasing urinary calcium excretionand, therefore, decrease calcium retention(22). H owever, it has alsobeen shown thathigh phosphorus intake reduces calcium cx-cretion by increasing renal tubular reabsorp-tion ofcalcium (22). W hile phosphorus intakein our women appears to be adequate, it isnot exactly clear how adequate levels of in-take aid retention of calcium in the elderly.

Table 3 shows that the mean protein in-take, as percentage of total energy, was ap-proximately 15%, which was higher than the12% value reported for the U nited Statespopulation as a whole (23). A nimal proteinaccounted for 72% of the total protein intakefor our population and is in agreement withthe recent report by Page and Friend (23)that animal protein accounted for more thantwo-thirds of the total protein supply in thegeneral population. Of some interest was thefmding that the percentage of energy fromfat was 37% compared to 42% for the generalpopulation (24). This probably reflects ourfmding that many of our elderly were admit-tedly restricting their cholesterol intake. Veg-etable fat comprised 42% of the total fatintake and reflects the continued increase invegetable fat relative to animal fat consump-tion noted in recent years (23). Carbohydrateintake was similar to that noted in the generalpopulation, i.e., 45% of total calories (2). Ofinterest also was the low intake of refmedcarbohydrate in this population (15% of totalcarbohydrate intake) compared to over 50%noted in the general population (25).

The use of vitamin and mineral supple-ments in this population was substantial (Fig.3). Of considerable interest was thefmdingthat approximately 60% of this populationwas taking supplemental vitamin C despitethe fact that dietary intake of this nutrientwas adequate. V itamin E supplementationwas also noted to be extremely highin thispopulation. The median intakes of vitamin Efor men and women taking this supplementwas 18 and 21 times the RD A for men andwomen, respectively.

In summary, this study, unlike many pre-vious reports dealing with dietary habits ofthe elderly, is unique in several respects. First,


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D IET A RY ST A T U S OF H EA L T H Y EL D ERL Y 33 1

we were dealing with a healthy, physicallyactive, middle-income and highly mobilepopulation. As a group there were fewerobese individuals than would be found in a

cross-sectional sampling of the U nited Statespopulation. Considering the finding that thispopulation was consuming adequate intakesof most nutrients, with a few notable excep-tions, it is surprising that energy intakes aspercentage of the current RD A are on theborderline ofbeing inadequate. However, theoverall energy intake would be higher if cal-culations were based on desirable weightsinstead of actual weights, and if we had in-cluded weekend intakes in our study. There-fore, we believe that energy intakes in ourpopulation would generally meet the RD Aguidelines established for elderly individuals.

Considering the paucity ofdata for the actualcontent of vitamin B folate, andzinc inmany food products, it is questionable howour fmdings translate into potential risks forthese nutrients in the elderly. Of real concern,we believe, are the low intakes of vitamin Dand calcium, especially in women.

W e have not been able to identify anyindividuals with overt signs of malnutritionin this population from clinical exams anddietary evaluations. Future efforts will bedirected toward possibly identifying subdlin-ical forms of malnutrition by combining di-etary and biochemical evaluations. Cl

T he authors thank Cindy Scott for her help in thisstudy and in the preparation ofthis report. The assistance

of Jill Fleig isal so g reat ly ap pr eci at ed .

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