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Prevalence and socio‐demographic predictors of dietary goal attainment in an older population

Prevalence and socio‐demographic predictors of dietary goal attainment in an older population Karen L. Webb, William N. Schofield Department of Public Health and Community Medicine, University of Sydnev; Westmead Hospital, New South Wales dietary intakes and anthropometry of a large, free-living population of middle-aged and older Australians who participated in the Australian Blue Mountains Eye Study (BMES), and to identify the sociodemographic characteristics associated with attainment or non-attainment of dietary goals. Method: Anthropometry and dietary intakes were compared with current population dietary goals and Recommended Dietary Intakes for 2,873 people (79% of eligible residents) aged 249 years who participated in the BMES. Nutrient intakes were measured by a validated food frequency questionnaire. Results: Nutrients for which mean intakes deviated most from nutrition goals included: percentages of energy from total and saturated fat, carbohydrate and alcohol (men),as well as absolute intakes of calcium, zinc and fibre. More than half the men (SOY0) and women (54%) were overweight or obese. Several micronutrient goals were more likely to be met in households where the respondents andl or their spouses were independent. Married men were more likely to meet goals for fibre and iron, but less likely to meet the goal for cholesterol. Several goals were more likely to be met by men and women who had qualifications after leaving school, those with higher job status and non-pensioners, suggesting an socio-economic status dimension. Conclusions and implications: These results indicate that over- rather than under-nutrition i more prevalent among s community-dwelling older people, although under-nutritionshould not be overlooked. Particular sub-groups that are less likely to meet some dietary goals may require targeting in community nutrition interventions. Ross Lazarus Faculty of Medicine, University of Sydney; New South Wales Wayne Smith National Centre for Epidemiology and Population Health, Australian National University; Australian Capital Territory Paul Mitchell Department of Ophthalmology; University of Sydney; Westmead Hospital, New South Wales Stephen R. Leeder Faculty of Medicine, University of Sydney; New South Wales opulation dietary guidelines’ and goals2 that are intended for people of all ages have been widely promoted in Australia since the early 1980s. They include recommendations to reduce total and saturated fat, sodium, dietary cholesterol, and to increase dietary fibre, total carbohydrate, calcium and iron. Among older people, there are additional concerns about the adequacy of intakes of energy and selected micronutrients (such as zinc, folate, vitamins B-6, B-12 and D, potassium and magnesium). Low intakes of these (substantially below recommended dietary intakes)3 occur c ~ m m o n l y . ~ Evidence is accumulating that health benefits, including decreased morbidity and overall survival, can accrue from improvements in diet, even at older age^.^-^ However, well-designed population nutrition education messages are still required to highlight these benefits for older people, while giving due consideration to their special needs and difficulties. For example, not only (Aust N Z J Pubtic Heaffh 1999;23:578-84) should many older people reduce their Correspondence to: intakes of fat, salt and cholesterol, but they are also likely to have other conditions and constraints that may limit their dietary choices further. These include existing dietrelated chronic diseases such as diabetes; use of multiple medications; reduced appetite related to reduced mobility, physical activity a n d o r depression; poor dentition; reduced smell and taste acuity; limitations in shopping, storing and preparing food; limited income; and fewer opportunities to socialise.4,26-2s Both cross-sectional and longitudinal data have shown that older people are interested in their health, and they can and do make dietary improvements for health reasons.I0-l2Thus, information about the prevalence and predictors of dietary goal attainment in older people is needed for rational planning and tailoring of nutrition promotion strategies for this heterogeneous group. Many studies of the nutritional status of older people in Australia and overseas have selected samples of the elderly living in retirement centres or nursing homes. Such Submitted: December 1998 Revision requested: June 1999 Accepted: August 1999 Dr Karen Webb, Department of Public Health and Community Medicine, Westmead Hospital, University of Sydney, Westmead, NSW 2145. Fax (02) 9689 1049; e-mail: karenwOcmed.wh.su.edu.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 6 Predictors of dietary goal attainment in an older population samples may not be representative of the majority of older people who live in the community, and thus may not provide a valid picture of the nature and prevalence of diet and nutrition problems. Thcre have been several population-based dietary surveys in Australia, hut few published studies have included a representative sample of older people."-'* The purpose of this report is to describe the measured dietary intakes and anthropometry of a large and free-living population of middle-aged and older Australians (hereafter termed 'older') who participated in the Blue Mountains Eye Study, and to identify the socio-demographic characteristics that are associated with attainmcnt or non-attainment of dietary goals. Methods Study population The Blue Mountains Eye Study (BMES) is a large, population-bawd study of older Australians undertaken to establish the prevalence and risk factors for common eye diseases in an older urban population.'""' It targeted all residents aged 49 years and older in all households of two postcode areas in the Blue Mountains region, west of Sydney, Australia. Those living in institutions were not included in the study. This geographically welldefined area has a stable and relatively homogeneous population. Of 4,433 age-eligible permanent residents, 3,654 (82.4%) were examined during 1992-93. Among 779 non-participants, 501 (1 1.3'%) refused to participate. A further 68 died ( 1.5%) and 2 10 (4.8%) moved from the area prior to arranging appointments. Thus, a total of 278 people identified in the Census could not be examined. Afier excluding this group, the response rate was 87.9%. and to locate data entry errors. These were corrected where possible, or were set to missing. FFQs with more than 12 missing values (8% of all items) were excluded from the analysis. The distribution for each nutrient was inspected and values in the upper or lower 2% were traced in the contributing FFQ and checked. The FFQ was found to have good test-retest repeatability in this population, and to have reasonable concurrent validity compared with three four-day weighed food records collected over one year.20 Nutrient intakes were compared with various current population nutrition goals and targets, and recommended dietary intakes2-j Of 3,654 participants attending the eye examination, 3,267 (89.4%) attempted and returned the dietary questionnaire. Of these, 394 ( 1 2%) were excluded from the analyses due to missing or extreme values. Thus, the final sample was 2,873 (79%) who satisfactorily completed the FFQ. Anthropometry Weights and heights were measured on subjects wearing light clothing and without shoes, using portable digital scales and a wall-mounted metal tape with moveable headpiece. These measurements were not taken for subjects whose assessments were made at home visits, or who could not stand without support (n=40). Body Mass Index (BMI) was calculated as weight (kg) divided by height2 (m). Weight status was classified by BMI using WHO standard criteria.22 Central obesity was not measured in this study. Socio-demographicinformation Socio-demographic and other characteristics of respondents were identified from interviewer-administered questionnaires at the clinic visit. Information included marital status, household composition, country of birth, main occupation during lifetime, current employment status, pensioner status, type of living accommodation. Variables indicating household and individual functional independence were indirectly derived from questions regarding who cleans and shops for the household, receiving meals on wheels, and ability to read a newspaper without assistance. Respondents' main occupatiodjob during working life was coded using both the ABS classification scale and the Daniel Job Prestige Dietary assessment Participants were sent a 145-item semi-quantitative food frequency questionnaire (FFQ) and asked to bring this with them on the day of their eye examination. They were encouraged to complete the FFQ without assistance. The FFQ was modified from an early Willett FFQ" adapted for Australian diet and vernacular. It was produced in large font for easier reading by older, potentially visually impaired subjects and the food list was expanded to include commonly consumed foods containing fats, vitamin C and beta-carotene. Respondents indicated their usual frequency of consuming food items during the past year, using a nine-category frequcncy scale, ranging from never to four or more times per day. They were asked to modify the reference serving size when their usual portions were larger or smaller than the reference. Questions were also included about foods frequently consumed but not otherwise included in the food list, as well as use of vitamin and mineral supplements. Intakes of energy, 16 nutrients and other food components were calculated using a purpose-designed computer program that incorporated the Australian Tables of Food Composition (Nuttab Nutrient values for folate, vitamins B-6, B-12, D and E, and copper, which may be of concern in the diets of older people, are not included in this nutrient database and so were not assessed in our study. Nutrient estimates were screened for extreme values Statistical analysis Statistical analyses were made using both parametric and non-parametric methods as appropriate. These included crosstabulations of prevalences with sex, age and BMI categories (using chi-squared tests on frequencies) and comparisons between mean values, using analysis of variance followed by t-tests (Newman-Kuels method). Where appropriate, trends were tested using orthogonal polynomials following analysis of variance. Multiple logistic regression was used to predict dietary goal indicators from demographic variables, controlling for age, and these were analysed separately for men and women for the main results, but were also pooled to enable testing of the sex effect. The socio-demographic predictor variables (including those in 1999 VOL. 23 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Webb et al. Table I , as well as living situation, pension, employment status, functional independence) were entered into the equations after age using a stepwise routine and were only retained if they made a significant @<0.05) independent contribution, thus accounting Table 1:Socio-demographic characteristics (%) of the BMES population compared with Australians aged 49 years and older. ~ ~ ~~ for multicollinearity. Analyses were conducted using SAS and SPSS statistical package^.^"^^^ Socio-demographiccharacteristics of the study population The BMES population are similar to the wider Australian population of comparable age in many respects (Table 1).2h Exceptions are that the BMES population has a somewhat different agc structure (a higher proportion in their 70s and a lower proportion in their 80s) and are of a higher SES, as indicated by a higher percentage of home/flat ownership, higher educational attainment and qualifications after leaving school, and lower proportions are migrants and manual workers than the older Australian populatiomZ6 Approximately three-quarters of the men and half the women were currently married and one-quarter of women were widowed. Most of the men and more than half the women lived with at least one other person, but one-third of women lived on their own (data not shown). The majority of men and women owned their own homes or flats. Half the women and two-thirds of the men were retired. Two-thirds of women and half the men received a pension. Fewer than I % ofthe respondents reported using the mealson-wheels service. Only 2-3% of men and women depended on those outside the household to do their weekly food shopping, and 5-6% required outside assistance with cleaning. BMES Women n=l,588 Age 49-<50 50-59 60-69 70-79 80+ Marital status 0.6 28.7 37.8 25.3 7.6 55.4 13.7 23.0 7.9 Men n=l,245 Australia Women Men Married now Separatedldivorced Widowed Never married Country of birth Australia & New Zealand 72.5 UK and Ireland 17.5 Europe & former USSR 7.5 Other categories -. 2.5 . .. . .. . ~~~ ~~ ~~~ Accommodation ~____ Qualification after leaving school Own home/flat Rental Inadequately describedl not stated Other as hostellboarding housekaravanlliving with. relatives . .. .. Weight status The prevalence of overweight and obesity (combined) was high for both sexes; 54% for women and 60% for men (Table 2), and the difference in BMI between the sexes was not statistically significant @=0.571). There was a significant decrease with age in BMI that was largely linear @<0.001), and there were no significant difference between men and women in this age effect n/a nla nla n/a Bachelor degree 5.1 and higher Undergraduate and 36.8 assoc diploma Vocational qualification 6.5 NO post-school 43.1 qualification Inadequately described1 8.5 Not stated Occupation 19.6 54.8 16.6 Women Table 2: Weight status classified by BMI category (%) by age: Blue Mountains Eye Study 1992-93. BMIcategory 49-64 65-74 All 1,588 2.6 4.3 39.2 34.3 19.7 1,245 1.1 1.4 38.1 45.0 14.5 Managers and administration Professionals Para-professionals Tradespersons and related workers Clerk and sales and service workers Plant and machine operators and drivers Labourers and related workers Home duties Inadequately described/ Not stated n Underweight less than 18.5 Acceptable 18.5 to less than 20 weighta 20 to less than 25 Overweight 25 to less than 30 Obese 30 and over Men n Underweight less than 18.5 Acceptable 18.5 to less than 20 weighta 20 to less than 25 Overweight 25 to less than 30 Obese 30 and over nla nla Note: (a) The ‘acceptable weight’categor)! as defined by WHO, includes those with a BMl 18.5 ~ 2 0 . 0 . have presented data separately for this subgroup to We enable comparisons with previously published survey data in which acceptable weight has been defined as a BMI of 20 4 5 . AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 6 Predictors of dietary goal attainment in an older DoDulation Table 3: Mean (se) intakes of selected nutrients in relation to dietary goals, by age, Blue Mountains Eye Study I, 1992-93. Women Age (years) ~ ~ Men >75 34.2 (0.4) 49-64 65-74 ~- All 34.6 (0.2) 12.8 (0.1) 46.0 (0.2) 2.6 (0.1) 280 (3.5) 28 (0.3) 194 (2.8) 12.4 (0.1) 49-64 65-74 >75 34.4 (0.4) 13.0 (0.2) 46.2 (0.5) 3.9 (0.5) 328 (10.1) 2,374 (60) 28 (0.8) 197 (8.6) 13.6 (0.3) 887 (27.7) 11.6 (0.3) 347 (7.2) All 34.7 (0.2) 13.1 (0.1) 44.4 (0.2) 5.4 (0.2) 333 (5.2) 2,400 (28) 28 (0.3) 186 (3.0) 13.5 (0.1) 928 (12.5) 11.9 (0.1) 362 (3.4) Diet goel . ~ _ _ _ _ _ Total fat 230% energy 35.0 (0.2) ~. Saturated fat 210% total energy~- 12.9 (0.1) . Carbohydrate 255% total energy 45.2 (0.3) . - .__ .Alcohol 25% total energy 2.9 (0.2) . Dietary cholesterol 5300mg/day 279 (5.0) Sodium 52300 mg 2,049 (29) Fibre 230 @day 28 (0.4) . Vitamin . ._ - ug A 2750 2,397 (65) __ . Vitamin . ___ mg C 230 195 (4.1) . . . Iron mg/d 27 M. 212F o r 2 5 F254 __ 12.3 (0.2) yr __ ~ ~~~ ~~ ~ ~~~~ ~~ ~ ~~ 34.3 (0.3) 12.6 (0.2) 46.4 (0.3) 2.5 (0.3) 279 (5.7) 2,041 (35) 28 (0.5) 2,364 (79) 190 (4.3) 12.2 (0.2) 34.9 (0.2) 13.2 (0.1) 43.3 (0.3) 6.3 (0.4) 343 (8.4) 28 (0.5) 183 (4.3) 13.6 (0.2) 938 (18.7) 12.2 (0.2) 366 (5.0) 34.4 (0.3) 12.9 (0.2) 45.3 (0.4) 4.5 (0.3) 319 (7.5) 28 (0.6) 187 (4.8) 13.4 (0.2) ~~ 13.1 (0.2) 47.6 (0.4) 2.8 (0.3) 288 (8.4) 30 (0.9) 197 (6.4) 12.8 (0.3) 2,099 (51) 2,055 (20) 2,387 (112) 2,385 (46) 2,434 (44) 2.358 (41) 2,342 (125) 2,116 (69) 2,012 (116) 2,216 (71) Calcium~800mg/dor1OOOF~54yr 925 (14.9) 901 (18.2) __ . - ~ . _ _ _ ~ _ _ _ _ _ _ 900 (28.1) 913 (10.7) 930 (20.5) 11.7 (0.2) 362 (5.6) Zinc 212 mg 10.9 (0.1) 10.7 (0.2) 10.7 (0.2) 10.8 (0.1) Potassium 21950 mg 4,012 (48.8)3,963 (54.2) 4,022 (89.5) 3,998 (34.0) Magnesium 2320 rng M; 2270 mg F 342 (4.2) 331 (4.5) 333 (7.2) 337 (2.8) 4,084 (58.2)4,071 (62.5) 4,032 (89.8) 4,072 (39.0) @=0.098). The prevalence of underweight was low for both men and women until age 75, when it increased for women to about 4%. Dietary goals Mean intakes of several nutrients (for which a decrease is recommended) exceeded the population goal. Total and saturated fat were cxcessive compared to population dietary goals for both women and men (Table 3). Among men, the mean intakes of sodium. alcohol and dietary cholesterol also were higher than recommended. Among the nutrients for which an increase is recommended, mean intakes were lower than the population goal for three of these including carbohydrate, fibre and zinc, whereas mean intakes of several others (vitamins A and C, iron, potassium and magnesium) were above the RDIs. Differences in mean intakes between the age categories were small for most nutrients. Notable exceptions were intakes of alcohol, vitamin A and calcium, which were lower among older men, and cholesterol, which was higher among older women (all pC0.05) The proportions of the study population that met various dietary goals is shown in Table 4 and were lowest for carbohydrate, total and saturated fat. Also, large proportions of the population failed to meet the dietary goals for dietary fibre, zinc and calcium. More women than men met dietary goals for carbohydrate, Table 4: Prevalence (%) meeting dietary goals by age, Blue Mountains Eye Study I, 1992-93. Women Aaefvears) 49-64 65-74 275 Men All 22.9 21.8 10.7 81.9 64.2 69.3 36.9 94.0 99.4 88.8 37.5 32.9 96.7 72.0 49-64 65-74 >75 All Diet goal Total fat.530% energy __ . _ _ Saturated fat 510% total Carbohydrate 255% _ ~ energy total _ _ _ -~ . _ _ Alcohol 55% total energy ___ . Dietary cholesterol 5300 mg/day . ___ Sodium . _ 22300 _ -~~ mg Fibre >30 g/day -Vitamin A 2750 ug __ Vitamin C 230 mg Iron mg/d 27 M, 212F or 25 F 254 vr Calcium 2800 mg/d or 1000 F 254vr Zinc 212 mg Potassium 21950 mg Magnesium 2320 mg M; ,270 mg F ~~~~ ~ ____.__ 1999 VOL. 23 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Webb et al. alcohol. cholesterol, sodium, and magnesium but women were less likely than men to meet the calcium goal (all p<0.05). Socio-demographic predictors of dietary goal attainment from logistic regression Age: For some nutrients and for BMI, the likelihood of meeting goals increased with age. Both older men and women were more likely to attain the goal for alcohol (pC0.03, p<0.001, respectively) and for BMI within the 'acceptable' range @<0.001 for both) than were younger respondents. Older women were also more likely to attain the goals for iron @<0.0001) and potassium ( ~ ~ 0 . 0 9 ) were younger women. For other nutrients there were than no significant age differences. Marital status: For men, marital status was significantly related to attainment of several dietary goals, including total fat, fibre, cholesterol, and iron. However, no associations were found between goal attainment and marital status for women. Men who were currently married were more likely to meet the fibre goal (38% vs. 28%) than men who were separated, divorced, widowed and never married @<0.03). Currently married men were less likely to achieve the cholesterol goal (52% vs. 62%, p<0.02). Widowed men were less likely to meet the fat goal than married men or those who had never married (19%, 22% and 25%, respectively, met the goal, p<O.OOI ). Household composition and accommodation: Men living in their own homes were more likely to meet the fat goal than those living in the homes of other relatives @<0.03). Those living with their spouse were more likely to meet the fibre goal than those who were not @<0.01). Both men and women who lived with their spouse or with a son or daughter were more likely to be overweight than those who lived alone, with other relatives, or with friends or boarders @<0.012). Country of birth: Country of birth was a significant predictor for attainment of several dietary goals. Although they were a small proportion of the sample, women from southern Europe were significantly more likely than Australian or UK-born women to achieve the saturated fat ( ~ ~ 0 . 0 5 ) total fat goals @<0.001) and and the alcohol goal @<0.03), but were also more likely to be overweight @<0.008). Men born in southern Europe or the UK were less likely to achieve the cholesterol goal @<0.03) and the 3) alcohol goal ( ~ ~ 0 . 0than those born in Australia or elsewhere. Respondents born in UK were more likely to achieve the carbohydrate goal than other groups; significant for men, but not for women ( ~ ~ 0 . 0 3 7 , p=0.09). Socio-economic status (SES): Indicators of SES were related to dietary goal attainment. Men and women who obtained qualifications after leaving school were more likely to meet goals for fibre @<0.0008,p<0.001, respectively) and magnesium @<0.004, p<O.OOl, respectively). Qualified women were also more likely to meet the calcium goal @iO.OOl). Men with higher-prestige occupations were more likely to attain the fibre goal @<0.02), Women with and less likely to meet the alcohol goal ( ~ ~ 0 . 0 0 2 ) . higher-prestige occupations were also less likely to attain the alcohol goal @<0.01). These were independent effects in the logistic regression equation, and were collinear with receipt of a pension, which did not enter the equation @<0.023 on its own). Retired men were also more likely to mcct the alcohol goal than those who were employed @<0.01).Women with higher-prestige jobs were less likely to achieve the carbohydrate goal (p<0.035) but they were more likely to meet the cholesterol goal (y<O.OOOX). Male and female non-pensioners were more likely to meet the cholesterol goal (p<0.03, p<0.003, respectively) and the magnesium goal than male and female pensioners @<0.003,p<0.004, respectively). In addition, male non-pensioners were more likely to achieve the carbohydrate goal @<0.02), and female nonpensioners were more likely to meet the calcium goal than pensioners @<0.001). 'Independence': Men who lived in households where they or their spouses did the shopping were more likely to meet dietary goals for fibre @<0.002), sodium @<0.002),iron (p<0.003),vitamin A @<0.002) and magnesium @<0.02). In households where they or their spouses did the cleaning, men were more likely to meet fibre @<O.OOI) and iron @<0.001) goals. Women who lived in households where they or their spouses did the shopping or the cleaning were more likely to meet goals for fibre @<0.02), sodium (p<0.03) and iron @<0.002) and the effect for iron was collinear with those who did their household shopping (/1<0.02 when entered first). Men who could not read a newspaper without assistance were less likely to meet the cholesterol goal @<0.004), and women who could not do so were less likely to meet the vitamin A goal @<0.03). Discussion Dietary goal attainment, assessed in terms ofthe extent to which the population means deviate from the various nutrient goals (Table 3), gave a similar picture to the results of proportions of individuals who met the goals (Table 4). In the BMES population of middle-aged and older people, aspects of diet requiring the greatest changes to meet current dietary goals are similar to those for the general population; i.e. reductions in total and saturated fat, alcohol, cholesterol and sodium, and increases in dietary fibre and calcium. Increasing zinc, and possibly magnesium, also merit consideration as priorities for nutrition intervention in older people. In addition, obesity persists as a prevalent problem into older age, reflecting an imbalance between dietary energy intake and energy expenditure in physical activity. While our study population is similar in many respects to the older Australian population, its higher level of socio-economic status may have resulted in a somewhat better picture of dietary goal attainment for some nutrients and a poorer picture for others than for the older population generally. However, the similarity of results of diet and anthropometry in our study and those of older samples previously published suggests our results are likely to be typical of older communities.".I5 The accuracy of our estimates of most nutrient intakes, particularly the population means, are likely to be reasonable. While FFQs tend to over-estimate intakes of several nutrients among individuals compared with other dietary assessment methods, t h e mean intakes in our study were comparable with those obtained AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 6 ___- Predictors of dietary goal attainment in an older population for othcr studies of oldcr populations which used FFQ1-’.lJ 24or the goal more often than those who were currently married, dihour recall method,I5 although small differences observed are vorced or widowed. However, for dietary fibre and iron, married likely to be due to differences in diet assessment methods, sammen were more likely to achieve these goals than other groups. pling, and year of the study (secular trends). These differences and inconsistencies may be partly attributable Reasonable agreement between our FFQ and weighed food to reporting biases (in which married women may have assisted records (WFR) was found for most nutrients (with the exceptions their spouses to complete the FFQs), or to real differences in food of protein, zinc and retinol) in our concurrent validity study when habits, e.g. married men may consume more high-cholesterol classifying individuals by quintiles of intake using each method.z0 meals (e.g. eggs for breakfast), snacks and/or desserts, and more Our FFQ measured slightly higher mean zinc intakes and subvaried meals, which are prepared for them, than unmarried men stantially higher beta-carotene (and therefore retinol equivalents) who have to prepare for themselves. These apparent differences than WFR. Thus, attainment of these dietary goals may be somemay have occurred by chance, as many comparisons were made what lower than reflected in our results. in this study. Further assessment of the food habits and food Thc stability we found in intakes of some nutrients (and prevasources of cholesterol, iron and fibre is needed to identify the lence ofgoal attainment) across age groups of elderly in our study habits associated with nutrient goal attainment among older marhas been noted p r e v i o ~ s l y ~ . although others have observed l~.’~ ried men compared to their unmarried, divorced, or widowed counthat intakes of some nutrients, and diet quality, tend to terparts. As noted above, conflicting results are likely to be attributable to Other socio-demographic variables which may be related to variations in sample characteristics, dietary measurement methdiet quality in older p e ~ p l esuch~ ~social isolation and loneli~ , as ods, secular trends, and definitions of diet quality. ness, and recent life events such as loss of spouse, were not measThe applicability of population dietary guidelines and RDls ured in this study and so their relative importance cannot be (including those for people aged 54 years and older) for older assessed. The SF-36 has been used in the five-year follow-up of Australians has been questioned, and the evidence in favour of BMES, and will enable a more valid assessment of the relationrevising these is currently being reviewed2’ (Professor Colin Binns, ship between diet and functional independence than was obtained personal communication). in this study. The results of our study confirm that, according to current Underweight and weight loss among those over age 75 (parguidclines, over-nutrition rather than under-nutrition is moreprevaticularly women) have been widely documented and are associlent among free-living older Australians, although the latter should ated with higher mortality and morbidity, although it is unclear not bc overlooked. With few exceptions, differences in the prevaa) whether underweight and weight loss cause illness or result lence ofdietary goal attainment and weight status by age, sex and from itZZ b) the extent to which interventions to reverse unand other socio-demographic characteristics were not large, suggestderweight may improve health. Population-based trials to increase ing that population goals (in their present or revised form) are body weight, particularly among older women, are needed to confirm the feasibility and health benefits of such a change. widely applicable to the population of free-living elderly. The results ofthe analysis ofpredictors of dietary goal attainment, howAddressing the problem of overweight in the elderly requires some consideration. While there is no doubt that excessive weight ever, do suggest the need to tailor whole-population nutrition has many health costs for the elderly, it has been noted that, at interventions to target some nutrients or food components among nutritionally vulnerable sub-groups of the older population. For older ages, the lowest mortality occurs at moderate levels of overexample, men in their 50s and 60s (particularly upper SES) tend weight.22Thus, a higher BMI cut-point (e.g. 27-30) may be more appropriate for those aged 70 and over who would benefit from to over-consume alcohol, placing them at risk of weight gain and hypertension. Women aged 55 and over are at risk of low calcium weight reduction, particularly those with co-morbidities. At lower intake because of their increased requirements (as reflected in the levels of overweight, individuals may be at risk of nutrient inadincreased RDI). equacies by a reduction in energy intake, and are therefore best As others have found, we observed that older people who are advised to increase physical activity, rather than reducing energy socio-economically disadvantaged (as indicated by job prestige, intake, to maintain or augment lean body mass.22 Because the qualifications obtained, type of accommodation, and the pension) study reported here lacks validated measures of physical activity, and those who are dependent with regard to activities of mainthe extent to which excessive energy intake or inadequate expenditure contributes to the high prevalence of overweight is untaining a household (cleaning, shopping) were somewhat less likely than others to achieve several dietary recommendation^.^,^^ clear. One exception in our study was that job prestige was inversely Two micronutrients, zinc and magnesium, often found to be relatcd to alcohol goal attainment. This may reflect both a higher marginal in the diets of the older samples: were also marginal in disposable income available for expenditure on alcohol, along our sample. Dietary zinc is important because of its role in wound healing and immunity in the elderly, while magnesium plays a with peer norms that lead to higher alcohol consumption. significant role in calcium and potassium metabolism, and may Consistent with previous studies, marital status was a predictor of dietary goal attainment for men, but not for w ~ m e n . ~ , ~have a role in heart disease risk.4 ~ The descriptive epidemiology of diet quality and goal attainHowever, the direction of the associations were not consistent; for dietary cholesterol, men who had never been married achieved ment among older Australians in this study, based on current 1999 VOL. 23 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Webb et al. population goals, suggests that the priorities for population-based interventions to improve nutrition in this age group are similar to those of the general population: reducing the prevalence of obesity, reducing intakes of total and saturated fat, cholesterol, sodium and increasing intakes of carbohydrate, fibre and calcium. In addition, zinc and magnesium intakes, and underweight among women aged 75 and over, should be considered for further attention. This study contributed no information about other nutrients which may be at risk in the diets of older people, including vitamins D, B-12, B-6 and folate. The analysis of predictors of goal attainment suggests that health gains may be achieved by targeting vulnerable sub-groups (by age, sex, socio-economic status and household independence) for particular dietary goals. Clearly, the results of this study can only contribute some of the information required to rationally plan interventions to address nutrition problems in older populations. The next step is to identify the food habit changes most likely to lead to an improvement in population goal attainment. Such information would contribute to ‘evidence-based message design’ and to the design of effective environmental interventions which aim to improve the availability of healthy food choices for middle-aged and older citizens. Acknowledgments We thank the individuals who participated in this study for their high level of co-operation and participation. We also acknowledge Doungkamol Sindhusake for assistance with Table 1 and Vicki Flood for helpful comments on the manuscript. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Prevalence and socio‐demographic predictors of dietary goal attainment in an older population

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References (29)

Publisher
Wiley
Copyright
Copyright © 1999 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1999.tb01540.x
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Abstract

Karen L. Webb, William N. Schofield Department of Public Health and Community Medicine, University of Sydnev; Westmead Hospital, New South Wales dietary intakes and anthropometry of a large, free-living population of middle-aged and older Australians who participated in the Australian Blue Mountains Eye Study (BMES), and to identify the sociodemographic characteristics associated with attainment or non-attainment of dietary goals. Method: Anthropometry and dietary intakes were compared with current population dietary goals and Recommended Dietary Intakes for 2,873 people (79% of eligible residents) aged 249 years who participated in the BMES. Nutrient intakes were measured by a validated food frequency questionnaire. Results: Nutrients for which mean intakes deviated most from nutrition goals included: percentages of energy from total and saturated fat, carbohydrate and alcohol (men),as well as absolute intakes of calcium, zinc and fibre. More than half the men (SOY0) and women (54%) were overweight or obese. Several micronutrient goals were more likely to be met in households where the respondents andl or their spouses were independent. Married men were more likely to meet goals for fibre and iron, but less likely to meet the goal for cholesterol. Several goals were more likely to be met by men and women who had qualifications after leaving school, those with higher job status and non-pensioners, suggesting an socio-economic status dimension. Conclusions and implications: These results indicate that over- rather than under-nutrition i more prevalent among s community-dwelling older people, although under-nutritionshould not be overlooked. Particular sub-groups that are less likely to meet some dietary goals may require targeting in community nutrition interventions. Ross Lazarus Faculty of Medicine, University of Sydney; New South Wales Wayne Smith National Centre for Epidemiology and Population Health, Australian National University; Australian Capital Territory Paul Mitchell Department of Ophthalmology; University of Sydney; Westmead Hospital, New South Wales Stephen R. Leeder Faculty of Medicine, University of Sydney; New South Wales opulation dietary guidelines’ and goals2 that are intended for people of all ages have been widely promoted in Australia since the early 1980s. They include recommendations to reduce total and saturated fat, sodium, dietary cholesterol, and to increase dietary fibre, total carbohydrate, calcium and iron. Among older people, there are additional concerns about the adequacy of intakes of energy and selected micronutrients (such as zinc, folate, vitamins B-6, B-12 and D, potassium and magnesium). Low intakes of these (substantially below recommended dietary intakes)3 occur c ~ m m o n l y . ~ Evidence is accumulating that health benefits, including decreased morbidity and overall survival, can accrue from improvements in diet, even at older age^.^-^ However, well-designed population nutrition education messages are still required to highlight these benefits for older people, while giving due consideration to their special needs and difficulties. For example, not only (Aust N Z J Pubtic Heaffh 1999;23:578-84) should many older people reduce their Correspondence to: intakes of fat, salt and cholesterol, but they are also likely to have other conditions and constraints that may limit their dietary choices further. These include existing dietrelated chronic diseases such as diabetes; use of multiple medications; reduced appetite related to reduced mobility, physical activity a n d o r depression; poor dentition; reduced smell and taste acuity; limitations in shopping, storing and preparing food; limited income; and fewer opportunities to socialise.4,26-2s Both cross-sectional and longitudinal data have shown that older people are interested in their health, and they can and do make dietary improvements for health reasons.I0-l2Thus, information about the prevalence and predictors of dietary goal attainment in older people is needed for rational planning and tailoring of nutrition promotion strategies for this heterogeneous group. Many studies of the nutritional status of older people in Australia and overseas have selected samples of the elderly living in retirement centres or nursing homes. Such Submitted: December 1998 Revision requested: June 1999 Accepted: August 1999 Dr Karen Webb, Department of Public Health and Community Medicine, Westmead Hospital, University of Sydney, Westmead, NSW 2145. Fax (02) 9689 1049; e-mail: karenwOcmed.wh.su.edu.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 6 Predictors of dietary goal attainment in an older population samples may not be representative of the majority of older people who live in the community, and thus may not provide a valid picture of the nature and prevalence of diet and nutrition problems. Thcre have been several population-based dietary surveys in Australia, hut few published studies have included a representative sample of older people."-'* The purpose of this report is to describe the measured dietary intakes and anthropometry of a large and free-living population of middle-aged and older Australians (hereafter termed 'older') who participated in the Blue Mountains Eye Study, and to identify the socio-demographic characteristics that are associated with attainmcnt or non-attainment of dietary goals. Methods Study population The Blue Mountains Eye Study (BMES) is a large, population-bawd study of older Australians undertaken to establish the prevalence and risk factors for common eye diseases in an older urban population.'""' It targeted all residents aged 49 years and older in all households of two postcode areas in the Blue Mountains region, west of Sydney, Australia. Those living in institutions were not included in the study. This geographically welldefined area has a stable and relatively homogeneous population. Of 4,433 age-eligible permanent residents, 3,654 (82.4%) were examined during 1992-93. Among 779 non-participants, 501 (1 1.3'%) refused to participate. A further 68 died ( 1.5%) and 2 10 (4.8%) moved from the area prior to arranging appointments. Thus, a total of 278 people identified in the Census could not be examined. Afier excluding this group, the response rate was 87.9%. and to locate data entry errors. These were corrected where possible, or were set to missing. FFQs with more than 12 missing values (8% of all items) were excluded from the analysis. The distribution for each nutrient was inspected and values in the upper or lower 2% were traced in the contributing FFQ and checked. The FFQ was found to have good test-retest repeatability in this population, and to have reasonable concurrent validity compared with three four-day weighed food records collected over one year.20 Nutrient intakes were compared with various current population nutrition goals and targets, and recommended dietary intakes2-j Of 3,654 participants attending the eye examination, 3,267 (89.4%) attempted and returned the dietary questionnaire. Of these, 394 ( 1 2%) were excluded from the analyses due to missing or extreme values. Thus, the final sample was 2,873 (79%) who satisfactorily completed the FFQ. Anthropometry Weights and heights were measured on subjects wearing light clothing and without shoes, using portable digital scales and a wall-mounted metal tape with moveable headpiece. These measurements were not taken for subjects whose assessments were made at home visits, or who could not stand without support (n=40). Body Mass Index (BMI) was calculated as weight (kg) divided by height2 (m). Weight status was classified by BMI using WHO standard criteria.22 Central obesity was not measured in this study. Socio-demographicinformation Socio-demographic and other characteristics of respondents were identified from interviewer-administered questionnaires at the clinic visit. Information included marital status, household composition, country of birth, main occupation during lifetime, current employment status, pensioner status, type of living accommodation. Variables indicating household and individual functional independence were indirectly derived from questions regarding who cleans and shops for the household, receiving meals on wheels, and ability to read a newspaper without assistance. Respondents' main occupatiodjob during working life was coded using both the ABS classification scale and the Daniel Job Prestige Dietary assessment Participants were sent a 145-item semi-quantitative food frequency questionnaire (FFQ) and asked to bring this with them on the day of their eye examination. They were encouraged to complete the FFQ without assistance. The FFQ was modified from an early Willett FFQ" adapted for Australian diet and vernacular. It was produced in large font for easier reading by older, potentially visually impaired subjects and the food list was expanded to include commonly consumed foods containing fats, vitamin C and beta-carotene. Respondents indicated their usual frequency of consuming food items during the past year, using a nine-category frequcncy scale, ranging from never to four or more times per day. They were asked to modify the reference serving size when their usual portions were larger or smaller than the reference. Questions were also included about foods frequently consumed but not otherwise included in the food list, as well as use of vitamin and mineral supplements. Intakes of energy, 16 nutrients and other food components were calculated using a purpose-designed computer program that incorporated the Australian Tables of Food Composition (Nuttab Nutrient values for folate, vitamins B-6, B-12, D and E, and copper, which may be of concern in the diets of older people, are not included in this nutrient database and so were not assessed in our study. Nutrient estimates were screened for extreme values Statistical analysis Statistical analyses were made using both parametric and non-parametric methods as appropriate. These included crosstabulations of prevalences with sex, age and BMI categories (using chi-squared tests on frequencies) and comparisons between mean values, using analysis of variance followed by t-tests (Newman-Kuels method). Where appropriate, trends were tested using orthogonal polynomials following analysis of variance. Multiple logistic regression was used to predict dietary goal indicators from demographic variables, controlling for age, and these were analysed separately for men and women for the main results, but were also pooled to enable testing of the sex effect. The socio-demographic predictor variables (including those in 1999 VOL. 23 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Webb et al. Table I , as well as living situation, pension, employment status, functional independence) were entered into the equations after age using a stepwise routine and were only retained if they made a significant @<0.05) independent contribution, thus accounting Table 1:Socio-demographic characteristics (%) of the BMES population compared with Australians aged 49 years and older. ~ ~ ~~ for multicollinearity. Analyses were conducted using SAS and SPSS statistical package^.^"^^^ Socio-demographiccharacteristics of the study population The BMES population are similar to the wider Australian population of comparable age in many respects (Table 1).2h Exceptions are that the BMES population has a somewhat different agc structure (a higher proportion in their 70s and a lower proportion in their 80s) and are of a higher SES, as indicated by a higher percentage of home/flat ownership, higher educational attainment and qualifications after leaving school, and lower proportions are migrants and manual workers than the older Australian populatiomZ6 Approximately three-quarters of the men and half the women were currently married and one-quarter of women were widowed. Most of the men and more than half the women lived with at least one other person, but one-third of women lived on their own (data not shown). The majority of men and women owned their own homes or flats. Half the women and two-thirds of the men were retired. Two-thirds of women and half the men received a pension. Fewer than I % ofthe respondents reported using the mealson-wheels service. Only 2-3% of men and women depended on those outside the household to do their weekly food shopping, and 5-6% required outside assistance with cleaning. BMES Women n=l,588 Age 49-<50 50-59 60-69 70-79 80+ Marital status 0.6 28.7 37.8 25.3 7.6 55.4 13.7 23.0 7.9 Men n=l,245 Australia Women Men Married now Separatedldivorced Widowed Never married Country of birth Australia & New Zealand 72.5 UK and Ireland 17.5 Europe & former USSR 7.5 Other categories -. 2.5 . .. . .. . ~~~ ~~ ~~~ Accommodation ~____ Qualification after leaving school Own home/flat Rental Inadequately describedl not stated Other as hostellboarding housekaravanlliving with. relatives . .. .. Weight status The prevalence of overweight and obesity (combined) was high for both sexes; 54% for women and 60% for men (Table 2), and the difference in BMI between the sexes was not statistically significant @=0.571). There was a significant decrease with age in BMI that was largely linear @<0.001), and there were no significant difference between men and women in this age effect n/a nla nla n/a Bachelor degree 5.1 and higher Undergraduate and 36.8 assoc diploma Vocational qualification 6.5 NO post-school 43.1 qualification Inadequately described1 8.5 Not stated Occupation 19.6 54.8 16.6 Women Table 2: Weight status classified by BMI category (%) by age: Blue Mountains Eye Study 1992-93. BMIcategory 49-64 65-74 All 1,588 2.6 4.3 39.2 34.3 19.7 1,245 1.1 1.4 38.1 45.0 14.5 Managers and administration Professionals Para-professionals Tradespersons and related workers Clerk and sales and service workers Plant and machine operators and drivers Labourers and related workers Home duties Inadequately described/ Not stated n Underweight less than 18.5 Acceptable 18.5 to less than 20 weighta 20 to less than 25 Overweight 25 to less than 30 Obese 30 and over Men n Underweight less than 18.5 Acceptable 18.5 to less than 20 weighta 20 to less than 25 Overweight 25 to less than 30 Obese 30 and over nla nla Note: (a) The ‘acceptable weight’categor)! as defined by WHO, includes those with a BMl 18.5 ~ 2 0 . 0 . have presented data separately for this subgroup to We enable comparisons with previously published survey data in which acceptable weight has been defined as a BMI of 20 4 5 . AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 6 Predictors of dietary goal attainment in an older DoDulation Table 3: Mean (se) intakes of selected nutrients in relation to dietary goals, by age, Blue Mountains Eye Study I, 1992-93. Women Age (years) ~ ~ Men >75 34.2 (0.4) 49-64 65-74 ~- All 34.6 (0.2) 12.8 (0.1) 46.0 (0.2) 2.6 (0.1) 280 (3.5) 28 (0.3) 194 (2.8) 12.4 (0.1) 49-64 65-74 >75 34.4 (0.4) 13.0 (0.2) 46.2 (0.5) 3.9 (0.5) 328 (10.1) 2,374 (60) 28 (0.8) 197 (8.6) 13.6 (0.3) 887 (27.7) 11.6 (0.3) 347 (7.2) All 34.7 (0.2) 13.1 (0.1) 44.4 (0.2) 5.4 (0.2) 333 (5.2) 2,400 (28) 28 (0.3) 186 (3.0) 13.5 (0.1) 928 (12.5) 11.9 (0.1) 362 (3.4) Diet goel . ~ _ _ _ _ _ Total fat 230% energy 35.0 (0.2) ~. Saturated fat 210% total energy~- 12.9 (0.1) . Carbohydrate 255% total energy 45.2 (0.3) . - .__ .Alcohol 25% total energy 2.9 (0.2) . Dietary cholesterol 5300mg/day 279 (5.0) Sodium 52300 mg 2,049 (29) Fibre 230 @day 28 (0.4) . Vitamin . ._ - ug A 2750 2,397 (65) __ . Vitamin . ___ mg C 230 195 (4.1) . . . Iron mg/d 27 M. 212F o r 2 5 F254 __ 12.3 (0.2) yr __ ~ ~~~ ~~ ~ ~~~~ ~~ ~ ~~ 34.3 (0.3) 12.6 (0.2) 46.4 (0.3) 2.5 (0.3) 279 (5.7) 2,041 (35) 28 (0.5) 2,364 (79) 190 (4.3) 12.2 (0.2) 34.9 (0.2) 13.2 (0.1) 43.3 (0.3) 6.3 (0.4) 343 (8.4) 28 (0.5) 183 (4.3) 13.6 (0.2) 938 (18.7) 12.2 (0.2) 366 (5.0) 34.4 (0.3) 12.9 (0.2) 45.3 (0.4) 4.5 (0.3) 319 (7.5) 28 (0.6) 187 (4.8) 13.4 (0.2) ~~ 13.1 (0.2) 47.6 (0.4) 2.8 (0.3) 288 (8.4) 30 (0.9) 197 (6.4) 12.8 (0.3) 2,099 (51) 2,055 (20) 2,387 (112) 2,385 (46) 2,434 (44) 2.358 (41) 2,342 (125) 2,116 (69) 2,012 (116) 2,216 (71) Calcium~800mg/dor1OOOF~54yr 925 (14.9) 901 (18.2) __ . - ~ . _ _ _ ~ _ _ _ _ _ _ 900 (28.1) 913 (10.7) 930 (20.5) 11.7 (0.2) 362 (5.6) Zinc 212 mg 10.9 (0.1) 10.7 (0.2) 10.7 (0.2) 10.8 (0.1) Potassium 21950 mg 4,012 (48.8)3,963 (54.2) 4,022 (89.5) 3,998 (34.0) Magnesium 2320 rng M; 2270 mg F 342 (4.2) 331 (4.5) 333 (7.2) 337 (2.8) 4,084 (58.2)4,071 (62.5) 4,032 (89.8) 4,072 (39.0) @=0.098). The prevalence of underweight was low for both men and women until age 75, when it increased for women to about 4%. Dietary goals Mean intakes of several nutrients (for which a decrease is recommended) exceeded the population goal. Total and saturated fat were cxcessive compared to population dietary goals for both women and men (Table 3). Among men, the mean intakes of sodium. alcohol and dietary cholesterol also were higher than recommended. Among the nutrients for which an increase is recommended, mean intakes were lower than the population goal for three of these including carbohydrate, fibre and zinc, whereas mean intakes of several others (vitamins A and C, iron, potassium and magnesium) were above the RDIs. Differences in mean intakes between the age categories were small for most nutrients. Notable exceptions were intakes of alcohol, vitamin A and calcium, which were lower among older men, and cholesterol, which was higher among older women (all pC0.05) The proportions of the study population that met various dietary goals is shown in Table 4 and were lowest for carbohydrate, total and saturated fat. Also, large proportions of the population failed to meet the dietary goals for dietary fibre, zinc and calcium. More women than men met dietary goals for carbohydrate, Table 4: Prevalence (%) meeting dietary goals by age, Blue Mountains Eye Study I, 1992-93. Women Aaefvears) 49-64 65-74 275 Men All 22.9 21.8 10.7 81.9 64.2 69.3 36.9 94.0 99.4 88.8 37.5 32.9 96.7 72.0 49-64 65-74 >75 All Diet goal Total fat.530% energy __ . _ _ Saturated fat 510% total Carbohydrate 255% _ ~ energy total _ _ _ -~ . _ _ Alcohol 55% total energy ___ . Dietary cholesterol 5300 mg/day . ___ Sodium . _ 22300 _ -~~ mg Fibre >30 g/day -Vitamin A 2750 ug __ Vitamin C 230 mg Iron mg/d 27 M, 212F or 25 F 254 vr Calcium 2800 mg/d or 1000 F 254vr Zinc 212 mg Potassium 21950 mg Magnesium 2320 mg M; ,270 mg F ~~~~ ~ ____.__ 1999 VOL. 23 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Webb et al. alcohol. cholesterol, sodium, and magnesium but women were less likely than men to meet the calcium goal (all p<0.05). Socio-demographic predictors of dietary goal attainment from logistic regression Age: For some nutrients and for BMI, the likelihood of meeting goals increased with age. Both older men and women were more likely to attain the goal for alcohol (pC0.03, p<0.001, respectively) and for BMI within the 'acceptable' range @<0.001 for both) than were younger respondents. Older women were also more likely to attain the goals for iron @<0.0001) and potassium ( ~ ~ 0 . 0 9 ) were younger women. For other nutrients there were than no significant age differences. Marital status: For men, marital status was significantly related to attainment of several dietary goals, including total fat, fibre, cholesterol, and iron. However, no associations were found between goal attainment and marital status for women. Men who were currently married were more likely to meet the fibre goal (38% vs. 28%) than men who were separated, divorced, widowed and never married @<0.03). Currently married men were less likely to achieve the cholesterol goal (52% vs. 62%, p<0.02). Widowed men were less likely to meet the fat goal than married men or those who had never married (19%, 22% and 25%, respectively, met the goal, p<O.OOI ). Household composition and accommodation: Men living in their own homes were more likely to meet the fat goal than those living in the homes of other relatives @<0.03). Those living with their spouse were more likely to meet the fibre goal than those who were not @<0.01). Both men and women who lived with their spouse or with a son or daughter were more likely to be overweight than those who lived alone, with other relatives, or with friends or boarders @<0.012). Country of birth: Country of birth was a significant predictor for attainment of several dietary goals. Although they were a small proportion of the sample, women from southern Europe were significantly more likely than Australian or UK-born women to achieve the saturated fat ( ~ ~ 0 . 0 5 ) total fat goals @<0.001) and and the alcohol goal @<0.03), but were also more likely to be overweight @<0.008). Men born in southern Europe or the UK were less likely to achieve the cholesterol goal @<0.03) and the 3) alcohol goal ( ~ ~ 0 . 0than those born in Australia or elsewhere. Respondents born in UK were more likely to achieve the carbohydrate goal than other groups; significant for men, but not for women ( ~ ~ 0 . 0 3 7 , p=0.09). Socio-economic status (SES): Indicators of SES were related to dietary goal attainment. Men and women who obtained qualifications after leaving school were more likely to meet goals for fibre @<0.0008,p<0.001, respectively) and magnesium @<0.004, p<O.OOl, respectively). Qualified women were also more likely to meet the calcium goal @iO.OOl). Men with higher-prestige occupations were more likely to attain the fibre goal @<0.02), Women with and less likely to meet the alcohol goal ( ~ ~ 0 . 0 0 2 ) . higher-prestige occupations were also less likely to attain the alcohol goal @<0.01). These were independent effects in the logistic regression equation, and were collinear with receipt of a pension, which did not enter the equation @<0.023 on its own). Retired men were also more likely to mcct the alcohol goal than those who were employed @<0.01).Women with higher-prestige jobs were less likely to achieve the carbohydrate goal (p<0.035) but they were more likely to meet the cholesterol goal (y<O.OOOX). Male and female non-pensioners were more likely to meet the cholesterol goal (p<0.03, p<0.003, respectively) and the magnesium goal than male and female pensioners @<0.003,p<0.004, respectively). In addition, male non-pensioners were more likely to achieve the carbohydrate goal @<0.02), and female nonpensioners were more likely to meet the calcium goal than pensioners @<0.001). 'Independence': Men who lived in households where they or their spouses did the shopping were more likely to meet dietary goals for fibre @<0.002), sodium @<0.002),iron (p<0.003),vitamin A @<0.002) and magnesium @<0.02). In households where they or their spouses did the cleaning, men were more likely to meet fibre @<O.OOI) and iron @<0.001) goals. Women who lived in households where they or their spouses did the shopping or the cleaning were more likely to meet goals for fibre @<0.02), sodium (p<0.03) and iron @<0.002) and the effect for iron was collinear with those who did their household shopping (/1<0.02 when entered first). Men who could not read a newspaper without assistance were less likely to meet the cholesterol goal @<0.004), and women who could not do so were less likely to meet the vitamin A goal @<0.03). Discussion Dietary goal attainment, assessed in terms ofthe extent to which the population means deviate from the various nutrient goals (Table 3), gave a similar picture to the results of proportions of individuals who met the goals (Table 4). In the BMES population of middle-aged and older people, aspects of diet requiring the greatest changes to meet current dietary goals are similar to those for the general population; i.e. reductions in total and saturated fat, alcohol, cholesterol and sodium, and increases in dietary fibre and calcium. Increasing zinc, and possibly magnesium, also merit consideration as priorities for nutrition intervention in older people. In addition, obesity persists as a prevalent problem into older age, reflecting an imbalance between dietary energy intake and energy expenditure in physical activity. While our study population is similar in many respects to the older Australian population, its higher level of socio-economic status may have resulted in a somewhat better picture of dietary goal attainment for some nutrients and a poorer picture for others than for the older population generally. However, the similarity of results of diet and anthropometry in our study and those of older samples previously published suggests our results are likely to be typical of older communities.".I5 The accuracy of our estimates of most nutrient intakes, particularly the population means, are likely to be reasonable. While FFQs tend to over-estimate intakes of several nutrients among individuals compared with other dietary assessment methods, t h e mean intakes in our study were comparable with those obtained AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 1999 VOL. 23 NO. 6 ___- Predictors of dietary goal attainment in an older population for othcr studies of oldcr populations which used FFQ1-’.lJ 24or the goal more often than those who were currently married, dihour recall method,I5 although small differences observed are vorced or widowed. However, for dietary fibre and iron, married likely to be due to differences in diet assessment methods, sammen were more likely to achieve these goals than other groups. pling, and year of the study (secular trends). These differences and inconsistencies may be partly attributable Reasonable agreement between our FFQ and weighed food to reporting biases (in which married women may have assisted records (WFR) was found for most nutrients (with the exceptions their spouses to complete the FFQs), or to real differences in food of protein, zinc and retinol) in our concurrent validity study when habits, e.g. married men may consume more high-cholesterol classifying individuals by quintiles of intake using each method.z0 meals (e.g. eggs for breakfast), snacks and/or desserts, and more Our FFQ measured slightly higher mean zinc intakes and subvaried meals, which are prepared for them, than unmarried men stantially higher beta-carotene (and therefore retinol equivalents) who have to prepare for themselves. These apparent differences than WFR. Thus, attainment of these dietary goals may be somemay have occurred by chance, as many comparisons were made what lower than reflected in our results. in this study. Further assessment of the food habits and food Thc stability we found in intakes of some nutrients (and prevasources of cholesterol, iron and fibre is needed to identify the lence ofgoal attainment) across age groups of elderly in our study habits associated with nutrient goal attainment among older marhas been noted p r e v i o ~ s l y ~ . although others have observed l~.’~ ried men compared to their unmarried, divorced, or widowed counthat intakes of some nutrients, and diet quality, tend to terparts. As noted above, conflicting results are likely to be attributable to Other socio-demographic variables which may be related to variations in sample characteristics, dietary measurement methdiet quality in older p e ~ p l esuch~ ~social isolation and loneli~ , as ods, secular trends, and definitions of diet quality. ness, and recent life events such as loss of spouse, were not measThe applicability of population dietary guidelines and RDls ured in this study and so their relative importance cannot be (including those for people aged 54 years and older) for older assessed. The SF-36 has been used in the five-year follow-up of Australians has been questioned, and the evidence in favour of BMES, and will enable a more valid assessment of the relationrevising these is currently being reviewed2’ (Professor Colin Binns, ship between diet and functional independence than was obtained personal communication). in this study. The results of our study confirm that, according to current Underweight and weight loss among those over age 75 (parguidclines, over-nutrition rather than under-nutrition is moreprevaticularly women) have been widely documented and are associlent among free-living older Australians, although the latter should ated with higher mortality and morbidity, although it is unclear not bc overlooked. With few exceptions, differences in the prevaa) whether underweight and weight loss cause illness or result lence ofdietary goal attainment and weight status by age, sex and from itZZ b) the extent to which interventions to reverse unand other socio-demographic characteristics were not large, suggestderweight may improve health. Population-based trials to increase ing that population goals (in their present or revised form) are body weight, particularly among older women, are needed to confirm the feasibility and health benefits of such a change. widely applicable to the population of free-living elderly. The results ofthe analysis ofpredictors of dietary goal attainment, howAddressing the problem of overweight in the elderly requires some consideration. While there is no doubt that excessive weight ever, do suggest the need to tailor whole-population nutrition has many health costs for the elderly, it has been noted that, at interventions to target some nutrients or food components among nutritionally vulnerable sub-groups of the older population. For older ages, the lowest mortality occurs at moderate levels of overexample, men in their 50s and 60s (particularly upper SES) tend weight.22Thus, a higher BMI cut-point (e.g. 27-30) may be more appropriate for those aged 70 and over who would benefit from to over-consume alcohol, placing them at risk of weight gain and hypertension. Women aged 55 and over are at risk of low calcium weight reduction, particularly those with co-morbidities. At lower intake because of their increased requirements (as reflected in the levels of overweight, individuals may be at risk of nutrient inadincreased RDI). equacies by a reduction in energy intake, and are therefore best As others have found, we observed that older people who are advised to increase physical activity, rather than reducing energy socio-economically disadvantaged (as indicated by job prestige, intake, to maintain or augment lean body mass.22 Because the qualifications obtained, type of accommodation, and the pension) study reported here lacks validated measures of physical activity, and those who are dependent with regard to activities of mainthe extent to which excessive energy intake or inadequate expenditure contributes to the high prevalence of overweight is untaining a household (cleaning, shopping) were somewhat less likely than others to achieve several dietary recommendation^.^,^^ clear. One exception in our study was that job prestige was inversely Two micronutrients, zinc and magnesium, often found to be relatcd to alcohol goal attainment. This may reflect both a higher marginal in the diets of the older samples: were also marginal in disposable income available for expenditure on alcohol, along our sample. Dietary zinc is important because of its role in wound healing and immunity in the elderly, while magnesium plays a with peer norms that lead to higher alcohol consumption. significant role in calcium and potassium metabolism, and may Consistent with previous studies, marital status was a predictor of dietary goal attainment for men, but not for w ~ m e n . ~ , ~have a role in heart disease risk.4 ~ The descriptive epidemiology of diet quality and goal attainHowever, the direction of the associations were not consistent; for dietary cholesterol, men who had never been married achieved ment among older Australians in this study, based on current 1999 VOL. 23 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Webb et al. population goals, suggests that the priorities for population-based interventions to improve nutrition in this age group are similar to those of the general population: reducing the prevalence of obesity, reducing intakes of total and saturated fat, cholesterol, sodium and increasing intakes of carbohydrate, fibre and calcium. In addition, zinc and magnesium intakes, and underweight among women aged 75 and over, should be considered for further attention. This study contributed no information about other nutrients which may be at risk in the diets of older people, including vitamins D, B-12, B-6 and folate. The analysis of predictors of goal attainment suggests that health gains may be achieved by targeting vulnerable sub-groups (by age, sex, socio-economic status and household independence) for particular dietary goals. Clearly, the results of this study can only contribute some of the information required to rationally plan interventions to address nutrition problems in older populations. The next step is to identify the food habit changes most likely to lead to an improvement in population goal attainment. Such information would contribute to ‘evidence-based message design’ and to the design of effective environmental interventions which aim to improve the availability of healthy food choices for middle-aged and older citizens. Acknowledgments We thank the individuals who participated in this study for their high level of co-operation and participation. We also acknowledge Doungkamol Sindhusake for assistance with Table 1 and Vicki Flood for helpful comments on the manuscript.

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Dec 1, 1999

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