Journal of Gerontology: MEDICAL SCIENCES 1992. Vol. 47, No. 5, MI45-MI50
Copyright 1992 by The Gerontological Society of America
Nutrient Intakes and Dietary Patterns of Older Americans: A National Study Alan S. Ryan,12 Lisa D. Craig,1 and Susan C. Finn 1 'Ross Laboratories, Columbus, Ohio, department of Anthropology, Ohio State University.
A MERICANS over age 65 years constitute one of the •**• fastest growing segments of the population. It is projected that by the year 2000 the elderly will number some 35 million and will constitute 13.1% of the population (1). By the year 2010, people 65 and over will number 39 million and make up 14% of the population (1). This shift in the population places significant demands on the health care delivery system. As a result, more emphasis is being placed on all aspects of geriatric health care, including nutrition. The U.S. government has set goals and objectives for public health action pertaining to the elderly (2-3). One stated compelling goal is to "improve the health and quality of life for older adults" (1). Underlying this goal is the objective to provide dietary guidance to older Americans to prevent dietrelated chronic diseases and minimize unwanted food-drug interactions (2-3). The food consumption practices and nutritional status of older Americans have been assessed in large-scale national surveys including the first and second National Health and Nutrition Examination Surveys [NHANES I, 1970-1974; NHANES II, 1976-1980 (4-5)] and the Nationwide Food Consumption Survey [NFCS, 1977-1978 (6)]. In addition, the nutritional status of both the institutionalized and freeliving elderly has been the subject of numerous smaller-scale investigations (7-9). Information is still needed, however, regarding the nutritional and dietary status of persons 75 years of age and older. The NFCS data are now over 10 years old and may not reflect the current dietary patterns of older persons. NHANES I and NHANES II only included information from individuals through 74 years of age. NHANES III, now in progress, has no upper age limit and has been designed to elucidate more clearly the nutritional and dietary status of older Americans. However, the data collection phase will not be completed until 1994, and data analysis will further delay availability of results.
In general, food intake data from these national surveys suggested that the elderly surveyed consumed less food than required to meet energy and nutrient recommendations. They also demonstrated that a substantial percentage of the elderly population had vitamin and mineral intakes below two-thirds the RDA. Dietary data from NHANES I and NHANES II indicate that intakes of vitamins A and D, thiamin, riboflavin, folic acid, calcium, and zinc were particularly low (10). In order to more clearly define the current food consumption practices of older Americans, the Ross Laboratories Elderly Dietary Survey (RLEDS) was conducted nationwide in 1990. An important component of this survey was a nutrient analysis of foods included in the diets of elderly persons as determined from a 24-hour dietary recall. The RLEDS, national in scope, was carefully designed to be representative of the U.S. civilian, free-living elderly population. The present study describes current nutrient intake and dietary patterns of older individuals. Several indicators of dietary quality are analyzed: energy and nutrient intake, food frequency, food group intake, and the number of meals that were skipped.
METHODS
Sampling and data collection. — The RLEDS was conducted between May and August 1990. Dietary information was collected for 474 individuals aged 65 to 98 years. The sampling frame and protocol for collecting food intake and sociodemographic information were modeled after those of the U.S. Department of Agriculture's (USDA) Continuing Survey of Food Intake by Individuals [CSFII (11)]. National Analysts (a division of Booz, Allen and Hamilton, Inc.), a private firm in Philadelphia, conducted the CSFII under M145
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To assess the dietary status of older Americans, a national household survey of food consumption practices of individuals 65 years of age and older was conducted in May-August, 1990. The design and methodology of the survey were modeled after those of the USDA's Continuing Survey of Food Intakes by Individuals (CSFII). Dietary information for 474 individuals (65 to 98 years of age) in 355 households was collected by interview (24-hour dietary recall). Analyzed indicators of dietary quality were energy (calorie) and nutrient intake, food group intake and frequency, and number of meals skipped. Results indicated that substantial percentages of those surveyed had inadequate intakes of energy and nutrients. Over 40% of men had intakes of vitamins A and E, calcium, and zinc below two-thirds the RDA. For women, over 40% had intakes of vitamin E, calcium, and zinc that were below twothirds the RDA. Additionally, over 20% of older men and women skipped lunch. These data indicate that a large proportion of noninstitutionalized elderly Americans consume diets that fail to meet dietary standards.
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Sample weights. — The sample was designed to be selfweighting, i.e., every housing unit and person in the sample had a known and equal chance of being sampled. To adjust for nonresponse and to make the results projectable to the entire population of older Americans, the collected survey information was weighted. The weights provided estimates of intake that are projectable to the entire U.S. civilian population aged 65 years and older (Table 1). A detailed description of the survey design and weighting procedure is available from the senior author. Food intake. — Each food and beverage reported as ingested was assigned a code number, and amounts of foods ingested were converted by weight into grams. The amount of each nutrient in each food eaten was calculated using the weight of that food. The nutrient data base used to calculate nutrient intakes was developed by HNIS. The sources of the nutrient values were the USDA Nutrient Data Base for Standard Reference (12) and the USDA Nutrient Data Bank (13). To identify by age group (65-74 years and > 74 years) and sex the subgroups that were potentially at risk for poor nutrient intake, nutrient intakes estimated as less than twothirds the published RDAs (National Research Council of
the National Academy of Sciences) were determined (14). Following the procedure developed by Davis et al. (15) and Ryan et al. (16) to assess dietary intake adequacy, a composite measure was computed by calculating the percentage of individuals who consumed less than two-thirds the RDA for 5 or more of the 16 nutrients considered. Thus, persons consuming less than two-thirds the RDA for five or more nutrients were considered to have potentially inadequate nutrient intake. A measure of dietary patterns was developed by calculating the relative contribution that each major food group made to total mean energy intake. The diet was divided into the following seven food groups: milk products; eggs, meat, fish, and poultry; fats and oils; breads and cereals; fruits and vegetables; sweets; and "other foods." The "other" food category included alcohol, soups, snacks, sauces, gravies, and low-calorie beverages. Dietary pattern analysis provided information on the relative proportion certain foods contributed to the diets of men and women. A measure of relative intake was constructed by calculating the number of foods consumed from major food groups. The number of persons who consumed less than one food per day from each of four major food groups (milk products; meat, poultry, and fish; fruits and vegetables; breads and cereals) was then calculated. Additionally, the percentages of older adults who skipped breakfast, lunch, dinner, or snacks were computed across each sex and age group. Vitamins and/or mineral supplements consumed were recorded and analyzed as well. Methods of analyses. — Because the data collected in RLEDS were obtained through a complex sample design, specific computer programs were used that incorporated the sample weights and provided the ability to estimate the complex sample design variances [SESUDAAN for means and RTIFREQS for proportions (17-18)]. From standard errors computed using SESUDAAN and RTIFREQS, multiple contrast analysis was performed by using a z-statistic to determine significant differences between mean intakes or percentages. Differences in mean intakes or percentages between men and women and between age groups within each sex were considered statistically different at the .05 alpha level. RESULTS
Description of sample. — The unweighted and weighted counts of individuals according to selected sociodemographic characteristics are shown in Table 1. The unweighted sample of 180 men and 294 women aged 65 years and older represented national population estimates for 12,696,640 men and 18,349,900 women. Approximately one-third of the individuals reside in the southern portion of the United States. Over 90% of elderly Americans are White; approximately 63% are 65 to 74 years of age. The unweighted and weighted percentages of individuals within each sociodemographic subgroup were similar. Energy intake. — Across each age group, elderly men had significantly higher mean energy intakes than did women
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contract with the Human Nutrition Information Service (HNIS), USD A, and conducted the RLEDS. National Analysts designed the sample of RLEDS; trained the interviewers; collected the information using CSFII questionnaires as guidelines; edited and checked the data; coded and keyed the data; and prepared the final data tape. A dietary recall questionnaire was used to report all food, beverages, and dietary supplements ingested during the 24hour period of the day before the interview. Questions were directed to the respondent (or the main planner/preparer if the person was not able to speak for him/herself) concerning what was eaten, in what quantity, with whom, where, and when. Interviewers used a USDA-type instruction guide and measuring cups/spoons to aid respondents in reporting the kinds and quantities of foods consumed. A nationally representative sample of households consisted of 120 Primary Sampling Units (PSUs). The sample was stratified by nine Census Regions and three levels of urbanization. In these 120 PSUs, a total of 130 smaller geographical areas representing groups of blocks or Census Enumeration Districts were selected with a probability proportional to size for surveying. In these areas, all housing units were listed in sequence and formed the sample frame from which the households were chosen. The design was a quote-in-segment approach. Interviewers were given a starting point from which to contact each household unit in turn, and to attempt an interview in eligible households (i.e., those with at least one household member aged 65 years or older). National Analysts identified 482 households that were eligible for interview. Interviews were completed in 355 households. In the households where interviews were not taken, eligible respondents were not available or unable (e.g., too ill) to be interviewed. In the 355 eligible households, 493 persons qualified for food intake reporting and 474 provided food consumption information.
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(Table 2). Comparisons with the RDA for recommended energy intake revealed that 37% to 40% of men and women reported energy intakes less than two-thirds the RDA (Table 3). Across each age group, a higher proportion of elderly women than men had energy intakes below two-thirds the RDA.
Table 1. Characteristics of Sample Unweighted Characteristics
%
n
%
180 294
38.0 62.0
12,696,640 18,349,900
40.9 59.1
115 93 160 106
24.3 19.6 33.8 22.4
6,634,770 5,123,920 10,763,900 8,523,950
21.4 16.5 34.7 27.5
435 32 15
93.2 6.8 3.2
27,878,000 2,792,070 1,055,190
90.9 9.1 3.4
293 181 474
61.8 38.2 100.0
19,447,160 11,599,380 31,046,540
62.6 37.4 100.0
Table 2. Mean Nutrient Intakes and Their Standard Errors for Elderly Americans, 1990 Females
Males >74 Years n == 65
65-74 Years n -= 115
>74 Years n -= 116
65-74 Years n == 178
Nutrient
Mean
SE
Mean
SE
Mean
SE
Mean
SE
Energy (kcal/day) Protein (g/day) Vitamin A (RE/day) Vitamin E (Al-TE/day) Vitamin C (mg/day) Thiamin (mg/day) Riboflavin (mg/day) Niacin (mg/day) Vitamin B6 (mg/day) Folate ((jig/day) Vitamin B,2 ((xg/day) Calcium (mg/day) Phosphorus (mg/day) Magnesium (mg/day) Iron (mg/day) Zinc (mg/day) Total fat (g/day) Saturated fat (g/day) Monounsaturated fat (g/day) Polyunsaturated fat (g/day) Carbohydrate (g/day) Total fiber (g/day) Carotenes (RE/day) Copper (mg/day) Sodium (mg/day) Potassium (mg/day) Cholesterol (mg/day)
1954.5 76.7 1135.8 9.4 105.5 1.6
(113.2)t (3.9)t (82.2) (0.8) (8.4) (0.1)
(95.4)t (4.2)t
1.9
(O.l)t
1812.4 73.8 1073.0 9.2 100.3 1.5 1.8 20.5 1.8 247.5 4.2 716.8 1153.0 272.0 13.5 11.0 75.7 24.6 28.3 15.2 215.6 16.6 469.9 1.3 3279.6 2769.6 273.5
1425.7 61.5 1251.7 8.8 111.9 1.4 1.6 19.8 1.7 268.2 7.1 626.8 991.2 262.2 14.1 9.5 51.8 17.5 19.6 10.6 182.9 14.4 583.8 1.2 2546.7 2486.2 200.4
(34.8) (1.9) * (124.7) (1.5) (6.4) (0.1) (0.1) (1.5) * (0.1) (17.8) (2.2) (25.3) (27.9) (19.3) (1.4) (0.8) (2.2) (0.7) (1.0) (0.7) (4.9) (0.7) (67.9) (0.1) (88.9) (95.7) (16.2)
1395.4 54.3 1242.5 7.1 100.6 1.2 1.4 15.4 1.5 228.2 3.8 564.3 892.6 220.4 11.8 7.7 53.2 18.3 20.0 11.1 180.8 12.9 679.1 1.0 2533.8 2237.0 177.8
(64.8) (2.6) (168.2) (0.8) (8.8) (0.1) (0.1) (1.1) (0.1) (18.6) (0.9) (36.2) (46.3) (12.6) (1.4) (0.5) (3.2) (1.4) (1.2) (0.7) (9.9) (0.9) (125.6) (0.1) (167.6) (104.9) (10.7)
22.4 1.9 277.4 7.1 713.7 1201.9 289.2 14.9 11.3 76.4 25.7 29.7 15.0 239.0 16.3 484.0 1.4 3199.5 2882.4 282.1
(1.3) (0.1) (22.0) (1.7) (51.9)
(56.8)t (15.0) (0.9) (0.6)
(5.7)t d-9)t (2.3)t (1.4)t (14.0) (0.9) (57.5) (0.1) (115.7)t (142.3)t (28.7)t
•Significantly different {p < .05) between age groups within sex. tSignificantly different (p < .05) between sexes within age group.
(123.4) (1.6) (13.6)
(0.1)t (0.2) (1.6)t (0.2) (31.7) (0.5)
(68.7)t (67.3)t (18.9)t (1.2) (0.7)
(5.3)t (1.6)t (2.0)t
d-9)t
(13.8)t (2.4) (76.7)
(O.l)t (263.4)t (165.4)t (35.1)t
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Sex Male Female Region Northeast Midwest South West Ethnic background White Black Hispanic Age 65-74 years 75-98 years Total
Weighted
n
Nutrient intake. — As shown in Table 2, 65- to 74-yearold men consumed significantly higher mean intakes of protein, riboflavin, phosphorus, total fat (including saturated, monounsaturated, and polyunsaturated), sodium, potassium, and cholesterol than did women in the same age group. Men in the > 74 year age group reported significantly higher intakes of protein, thiamin, niacin, calcium, phosphorus, magnesium, total fat (including saturated, monounsaturated, and polyunsaturated), carbohydrate, copper, sodium, potassium, and cholesterol than did women in the > 74 year age group. Among women, those in the 65 to 74 year age group had significantly higher mean intakes of protein and niacin than did women in the > 74 year age group. As Table 3 shows, substantial percentages of those surveyed reported vitamin and mineral intakes less than twothirds the RDA. Over 40% of men in both age groups had intakes of vitamins A and E, calcium, and zinc below twothirds the RDA. For women, over 40% had intakes of vitamin E, calcium, and zinc that were below two-thirds the RDA. A significantly higher proportion of men in the 65 to 74 year age group than in the > 74 year age group had intakes of protein and niacin below two-thirds the RDA. For women, a significantly higher proportion of those in the > 74 year age group than in the 65 to 74 year age group had intakes of phosphorus below two-thirds the RDA. Table 3 also indicates that a significantly higher propor-
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Table 3. Percentage of Elderly Population With Nutrient Intakes Below Two-Thirds the RDA Males 65-74 Years Nutrient
> 74 Years
65-74 Years
> 74 Years
%
SE
%
SE
%
SE
%
37.8 14.6 46.6 44.8 23.2 16.2 17.9 13.1 38.1 21.6 8.7 42.6 7.3 37.3 12.5 47.0
(6.4) (3.4)* (3.9)t (6.4) (4.5) (4.4) (4.0) (3.8)* (5.7) (4.5) (4.6)t (5.3) (1.8) (6.3) (3.5) (5.0)
37.5 6.2 41.8 48.0 22.2 12.0 12.4 3.8 30.9 21.3 15.4 44.1 3.6 46.6 7.1 49.9
(4.8) (2.1)t (8.3) (9.2) (7.5) (5.1) (4.5) (2.8)t (7.2) (7.4) (4.9) (6.7) (2.5)t (7.5) (4.1)t (6.3)
40.1 10.4 28.7 42.8 19.9 13.0 10.0 10.8 28.2 15.3 19.7 47.3 8.4 28.6 17.1 56.0
(3.9) (2.0) (3.1) (4.1) (4.0) (3.2) (2.5) (2.3) (3.8) (3.6) (2.8) (4.5) (2.1)* (4.9) (3.0) (3.2)
37.7 19.0 33.5 43.4 28.1 15.7 13.3 17.9 38.3 27.2 17.3 54.0 18.5 38.3 23.1 60.3
SE (4.6) (5.4) (6.1) (6.5) (6.1) (4.5) (3.5) (4.7) (5.3) (5.9) (2.9) (6.2) (4.0) (6.3) (4.2) (5.1)
•Significantly different (p < .05) between age groups within sex. tSignificantly different (p < .05) between sexes within age group.
tion of men aged 65 to 74 years than women of the same age group had intakes of vitamin A below two-thirds the RDA. The reverse was true for vitamin B12. A significantly higher proportion of 65- to 74-year-old women than men had intakes of vitamin B12 below two-thirds the RDA. Notably, in the > 74 year age group, a higher proportion of women than men consumed less than two-thirds the RDA for protein, niacin, phosphorus, and iron. No statistically significant differences were observed in the proportions of persons who consumed less than twothirds the RDA for at least 5 of 16 nutrients by age group and sex (Table 4). Nevertheless, approximately 40% of men and 36% of women consumed less than two-thirds the RDA for at least 5 of the 16 nutrients considered in this study. Men in the > 74 year age group had the least favorable nutrient pattern. Dietary pattern. — In general, the dietary patterns of men and women were similar; no statistically significant differences were observed. Men received a slightly greater percentage of their energy intake from eggs, meat, fish, and poultry than did women. Women, on the other hand, received a relatively greater percentage of their energy intake from fats and oils, and fruits and vegetables. Food group intake. — Across each age and sex group, fruits and vegetables, and breads and cereals were the food groups least likely to be consumed less than once a day (Table 5). All the men surveyed indicated that they consumed at least one serving of a vegetable or fruit. Proportionally more men and women in the 65 to 74 year age group than those in the > 74 year age group reported consuming less than one serving of milk products. Skipped meals. — Across each age group, fewer persons skipped breakfast or dinner (Table 6). A higher proportion of men than women skipped breakfast or lunch. Across each age group, proportionally more women than men skipped a
Table 4. Percentage of Elderly Population Consuming Less Than Two-Thirds the RDA for at Least 5 of 16 Nutrients 65-74 Years % Males Females
> 74 Years
SE
%
38.4 (5.3) 33.8 (4.1)
SE
40.9 (7.1) 37.5 (7.1)
Table 5. Percentage of Elderly Population Consuming Less Than One Food Per Day From Different Food Groups 65-74 Years % Males Milk products Meat, poultry, fish Fruits and vegetables Breads and cereals Females Milk products Meat, poultry, fish Fruits and vegetables Breads and cereals
SE
> 74 Years %
SE
16.9 (6.1) 6.0 (2.2) 0.0 2.9 (1.1)
10.1 (5.2) 4.1 (1.6) 0.0 2.3 (0.8)
16.4 (4.0) 8.8 (2.6) 0.0 1.8 (1.0)
11.9 (2.3) 11.8 (5.2) 4.0 (1.6) 0.0
snack. Approximately 30% of men and 21% of women reported that they skipped lunch. Vitamin and/or mineral supplement use. — Considering both age groups combined, 36% of the men and 44% of the women surveyed indicated that they consumed vitamin and/ or mineral supplements daily. Compared with supplement nonusers, supplement users had a relatively higher proportion of persons who consumed amounts of nutrients less than two-thirds the RDA (Table 7). For supplement users, over 40% received less than two-thirds the RDA for vitamin E, calcium, and zinc from food intake. These inadequacies also were evident among the diets of supplement nonusers.
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Energy Protein Vitamin A Vitamin E Vitamin C Thiamin Riboflavin Niacin Vitamin B6 Folate Vitamin B,2 Calcium Phosphorus Magnesium Iron Zinc
Females
DIETARY PATTERNS OF OLDER AMERICANS
DISCUSSION
Table 6. Percentage of Elderly Population Who Skipped Meals, 1990 65-74 Years Meal Breakfast Males Females Lunch Males Females Dinner Males Females Snack Males Females
%
> 74 Years
SE
%
SE
7.9 4.2
(3.2) (1.6)
11.2 1.9
(5.2) (1-0)
28.9 21.0
(5.0) (4.0)
30.7 20.6
(5.5) (4.6)
7.8
(2.6) (2.2)
7.0
5.3
8.9
(3.8) (2.3)
32.6 40.7
(6.5) (3.9)
34.8 40.5
(7.7) (6.8)
As shown here, calcium, zinc, and vitamins A and E were the nutrients most often consumed in amounts below twothirds the RDA. Other surveys also have reported marginal mineral and vitamin intakes among older persons (5,6,19,21). The marginal and/or low dietary intakes of minerals in this population are of concern because the elderly are at risk for mineral deficiencies from other factors besides inadequate food intake, including drug-nutrient interactions and effects of chronic disease. The relationship between vitamin and/or mineral supplementation and the proportions of persons with intakes below two-thirds RDA indicates no real pattern of supplementation. In other words, some who consumed diets higher in nutrient intakes also supplemented their diets, whereas some individuals with inadequate intakes did not supplement their diets. While it is clear from intake data that some elderly individuals require supplementation to bring nutrient levels closer to recommended intakes, random supplementation may result in relatively excessive intakes of certain nutrients while not ensuring adequate intakes of other nutrients. There is a need for nutrition educators to focus their attention on increasing food awareness among elderly persons and on emphasizing methods of making appropriate food choices. Certain methodologic issues need to be considered in interpreting the dietary data presented here. Although the 24-hour dietary recall is a simple and rapid method of obtaining dietary information, it relies on the ability of the subjects to recall accurately, does not account for day-to-day variation, and tends to underestimate energy intakes (2224). Recently, Brown et al. (25) described a videotape assessment of the validity of the 24-hour dietary recall from elderly women in a retirement home. These authors indicated that the 24-hour dietary recall underestimated food quantities by an average of 6%. However, many researchers tend to agree that the 24-hour dietary recall is adequate for
Table 7. Percentage of Elderly Population (With Nutrient Intakes Below Two-Thirds the RDA) Taking and Not Taking Vitamin and/or Mineral Supplements Males Taking Vitamins n = 64 Nutrient
%
Energy Protein Vitamin A Vitamin E Vitamin C Thiamin Riboflavin Niacin Vitamin B6 Folate Vitamin B12 Calcium Phosphorus Magnesium Iron Zinc
42.9 16.3 44.6 50.5 22.6 20.1 23.5 15.1 39.3 22.4
SE (5.4) (2.8)* (3.9)t (7.1) (4.1) (5.4) (5.0) (3.9)* (5.6) (4.1)
7.1 (3.7)t 47.4 5.2 38.9 15.3 45.7
(5.2) (1.2) (6.3) (3.4) (5.1)
Females Not Taking Vitamins n - 116 % 34.6 8.8 45.0 43.3 24.8 11.6 11.5 6.7 33.4 21.0 13.4 40.6 11.6 29.8 19.7 59.9
*Significantly different (/; < .05) between age groups within sex. tSignificantly different (p < .05) between sexes within age group.
SE (5.1) (l.l)t (7.1) (8.2) (7.4) (6.1) (4.4) (4.1) (7.1) (7.4) (5.1) (6.7) (2.5) (7.1) (7.1) (6.3)
Taking Vitamins n = 128 % 34.8 15.5 25.7 44.5 27.5 16.8 9.0 14.7 35.6 21.4 18.4 48.0 34.8 28.5 25.7 44.5
SE (2.9) (1.4) (3.1) (4.1) (3.1) (3.2) (2.5) (3.4) (4.4) (2.8) (3.6) (4.6) (4.9) (4.8) (3.2) (4.3)
Not Taking Vitamins n = 166 % 42.2 13.4 34.7 42.0 20.7 12.3 13.3 13.4 32.5 20.1 18.7 52.0 14.0 35.3 19.9 56.5
SE (5.1) (5.6) (6.1) (6.5) (5.1) (3.5) (3.5) (4.7) (5.3) (4.9) (2.9) (6.3) (4.0) (6.2) (4.1) (5.4)
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This study provides a dietary profile of a representative sample of free-living Americans aged 65 years and older. The data considered here reflect the dietary patterns of elderly persons who are residing in the community rather than in long-term care facilities or hospitals. The data clearly document that a high proportion of these older Americans consume an inadequate diet. Previously, national nutrition and food consumption surveys have reported low energy intakes among the elderly (5,6,19). The results of this current survey indicate that energy intakes of free-living elderly Americans remain below recommended intakes. Approximately 40% of persons 65 years of age and older had mean energy intakes below two-thirds the RDA. Lower than recommended energy intakes also have been reported for the institutionalized elderly (20).
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6.
7. 8.
9.
10. 11.
12.
13. 14.
15.
16.
17.
18.
19.
20. ACKNOWLEDGMENTS
We thank Booker Smith and Jeffrey Wysong for their statistical and programming advice. A detailed description of the survey design and weighting procedure is available. Address requests and correspondence to Dr. Alan S. Ryan, Ross Laboratories, 625 Cleveland Avenue, Columbus, OH 43215. REFERENCES
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24. 25.
26. 27. 28.
231. DHHS Publ. No. (PHS) 83-1681. National Center for Health Statistics. Public Health Service. Washington, DC: U.S. Government Printing Office, 1983. U.S. Department of Agriculture. Nutrient intakes: individuals in 48 states, year 1977-78, Nationwide Food Consumption Survey 197778, Report 1-2. Hyattsville, MD: USDA, 1984. Reid DL, Miles JE. Food habits and nutrient intakes of noninstitutionalized senior citizens. Can J Pub Health 1977;68:154-8. Slesinger DP, McDivitt M, O'Donnell FM. Food patterns in an urban population: age and sociodemographic correlates. J Gerontol 1980;35:432-41. Walker D, Beauchene RE. The relationship of loneliness, social isolation, and physical health to dietary adequacy of independently living elderly. J Am Diet Assoc 1991 ;91:300-6. Zheng JJ, Rosenberg IH. What is the nutritional status of the elderly? Geriatrics 1989;44:57-64. U.S. Department of Agriculture, Human Nutrition Information Service. Nationwide food consumption survey, continuing survey of food intakes by individuals: women 19-50 years and their children 1-5 years, 4 days, 1985. CSFII Report No. 85-4. Hyattsville, MD: USDA, 1985. U.S. Department of Agriculture, Human Nutrition Information Services. USDA nutrient data base for standard reference, release 5. Springfield, VA: U.S. Department of Commerce, National Technical Information Service, 1985. Hepburn, FN. The USDA national nutrient data bank. Am J Clin Nutr 1982;35:1297-301. National Research Council, Subcommittee on the Tenth Edition of the RDAs. Recommended dietary allowances, 10th ed. Washington, DC: National Academy Press, 1989. Davis MA, Randall E, Forthofer RN, Lee ES, Margen S. Living arrangements and dietary patterns of older Americans in the United States. J Gerontol 1985;40:434-42. Ryan AS, Martinez GA, Wysong JL, Davis MA. Dietary patterns of older adults in the United States, NHANES II 1976-1980. Am J Hum Biol 1989:1:321-30. Shah BV. SESUDAAN: standard errors program for computing of standardized rates from sample survey data. Research Triangle Park, NC: Research Triangle Institute, 1981. Shah BV. RTIFREQS: program to compute weighted frequencies, percentages, and their standard errors. Research Triangle Park, NC: Research Triangle Institute, 1982. U.S. Department of Health, Education and Welfare. V-dietary. Tenstate nutrition survey 1968-1970. DHEW Publ. No. (HSM) 72-8133. Atlanta, GA: Centers for Disease Control, 1972. Stiedemann M, Jansen C, Han-ill I. Nutritional status of elderly men and women. J Am Diet Assoc 1978;73:132-9. Yearick ES, Wang M-SL, Pisias SJ. Nutritional status of the elderly: dietary and biochemical findings. J Gerontol 1980;35:663—71. Campbell VA, Dodds ML. Collecting dietary information from older persons. J Am Diet Assoc 1967;51:29-34. McCleod CC. Methods of dietary assessment. In: Carlson LA, ed. Nutrition in old age. Uppsala, Sweden: Almquist and Wilksell, 1972:118-23. Madden JP, Goodman SJ, Guthrie HA. Validity of the 24-hour dietary recall. J Am Diet Assoc 1976;68:143-7. Brown JE, Tharp EM, Dahlberg-Luby EM, et al. Videotape dietary assessment: validity, reliability, and comparison of results with 24hour dietary recalls from elderly women in a retirement home. J Am Diet Assoc 1990;90:1675-9. Suter PM, Russell, RM. Vitamin requirements for the elderly. Am J Clin Nutr 1987;45:501-12. Davis MA, Murphy SP, Lein D. Living arrangements and dietary quality of older U.S. adults. J Am Diet Assoc 1990;90:1667-72. Murphy SP, Davis MA, Neuhaus JM, Lein D. Factors influencing the dietary adequacy and energy intake of older Americans. J Nutr Educ 1990;22:284-91.
Received October 24, 1991 Accepted January 31, 1992
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obtaining the mean for a group with a large sample size (2324). Another concern is the potential for seasonality bias because the RLEDS was conducted during the spring and summer months (May-August). In the CSFII (11), six days of dietary information was collected at two-month intervals over a one-year period. The nutrient intake levels did not substantially vary over time and between the two-month intervals of data collection. Finally, there is concern that the RDAs for adults over 50 years of age are similar to those for persons 25 to 50 years. Because so few of the data used to develop these recommendations were obtained from older persons, the appropriateness of this information as a comparison standard for older Americans is questionable (26). The potential impact that socioeconomic and psychologic factors have on the dietary patterns of older Americans has been explored (8,9,16,27,28). Social isolation may adversely affect dietary quality (9). Type of living arrangements also influences the quality of nutrient intakes (15,16). As shown by Davis et al. (15) and Ryan et al. (16), more men living alone consumed a poor quality diet than did men living with a spouse. For women, income was more strongly associated with dietary patterns than living arrangement. More poor women than poor men had poor-quality diets. The impact that these sociologic variables have on the dietary patterns of the elderly persons considered in the present study needs further evaluation. Elderly persons' risk for inadequate dietary intake is well established. The results presented here bear witness to the fact that the dietary quality of older U.S. adults has not recently improved. The dietary problems are related to a multitude of physiologic, economic, and social factors; some of these factors are inevitable, but others may be ameliorated through intervention. Appropriate strategies must be designed and applied so that elderly men and women can be helped to maximize their quality of life.
Copyright 1992 by The Gerontological Society of America
Nutrient Intakes and Dietary Patterns of Older Americans: A National Study Alan S. Ryan,12 Lisa D. Craig,1 and Susan C. Finn 1 'Ross Laboratories, Columbus, Ohio, department of Anthropology, Ohio State University.
A MERICANS over age 65 years constitute one of the •**• fastest growing segments of the population. It is projected that by the year 2000 the elderly will number some 35 million and will constitute 13.1% of the population (1). By the year 2010, people 65 and over will number 39 million and make up 14% of the population (1). This shift in the population places significant demands on the health care delivery system. As a result, more emphasis is being placed on all aspects of geriatric health care, including nutrition. The U.S. government has set goals and objectives for public health action pertaining to the elderly (2-3). One stated compelling goal is to "improve the health and quality of life for older adults" (1). Underlying this goal is the objective to provide dietary guidance to older Americans to prevent dietrelated chronic diseases and minimize unwanted food-drug interactions (2-3). The food consumption practices and nutritional status of older Americans have been assessed in large-scale national surveys including the first and second National Health and Nutrition Examination Surveys [NHANES I, 1970-1974; NHANES II, 1976-1980 (4-5)] and the Nationwide Food Consumption Survey [NFCS, 1977-1978 (6)]. In addition, the nutritional status of both the institutionalized and freeliving elderly has been the subject of numerous smaller-scale investigations (7-9). Information is still needed, however, regarding the nutritional and dietary status of persons 75 years of age and older. The NFCS data are now over 10 years old and may not reflect the current dietary patterns of older persons. NHANES I and NHANES II only included information from individuals through 74 years of age. NHANES III, now in progress, has no upper age limit and has been designed to elucidate more clearly the nutritional and dietary status of older Americans. However, the data collection phase will not be completed until 1994, and data analysis will further delay availability of results.
In general, food intake data from these national surveys suggested that the elderly surveyed consumed less food than required to meet energy and nutrient recommendations. They also demonstrated that a substantial percentage of the elderly population had vitamin and mineral intakes below two-thirds the RDA. Dietary data from NHANES I and NHANES II indicate that intakes of vitamins A and D, thiamin, riboflavin, folic acid, calcium, and zinc were particularly low (10). In order to more clearly define the current food consumption practices of older Americans, the Ross Laboratories Elderly Dietary Survey (RLEDS) was conducted nationwide in 1990. An important component of this survey was a nutrient analysis of foods included in the diets of elderly persons as determined from a 24-hour dietary recall. The RLEDS, national in scope, was carefully designed to be representative of the U.S. civilian, free-living elderly population. The present study describes current nutrient intake and dietary patterns of older individuals. Several indicators of dietary quality are analyzed: energy and nutrient intake, food frequency, food group intake, and the number of meals that were skipped.
METHODS
Sampling and data collection. — The RLEDS was conducted between May and August 1990. Dietary information was collected for 474 individuals aged 65 to 98 years. The sampling frame and protocol for collecting food intake and sociodemographic information were modeled after those of the U.S. Department of Agriculture's (USDA) Continuing Survey of Food Intake by Individuals [CSFII (11)]. National Analysts (a division of Booz, Allen and Hamilton, Inc.), a private firm in Philadelphia, conducted the CSFII under M145
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To assess the dietary status of older Americans, a national household survey of food consumption practices of individuals 65 years of age and older was conducted in May-August, 1990. The design and methodology of the survey were modeled after those of the USDA's Continuing Survey of Food Intakes by Individuals (CSFII). Dietary information for 474 individuals (65 to 98 years of age) in 355 households was collected by interview (24-hour dietary recall). Analyzed indicators of dietary quality were energy (calorie) and nutrient intake, food group intake and frequency, and number of meals skipped. Results indicated that substantial percentages of those surveyed had inadequate intakes of energy and nutrients. Over 40% of men had intakes of vitamins A and E, calcium, and zinc below two-thirds the RDA. For women, over 40% had intakes of vitamin E, calcium, and zinc that were below twothirds the RDA. Additionally, over 20% of older men and women skipped lunch. These data indicate that a large proportion of noninstitutionalized elderly Americans consume diets that fail to meet dietary standards.
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Sample weights. — The sample was designed to be selfweighting, i.e., every housing unit and person in the sample had a known and equal chance of being sampled. To adjust for nonresponse and to make the results projectable to the entire population of older Americans, the collected survey information was weighted. The weights provided estimates of intake that are projectable to the entire U.S. civilian population aged 65 years and older (Table 1). A detailed description of the survey design and weighting procedure is available from the senior author. Food intake. — Each food and beverage reported as ingested was assigned a code number, and amounts of foods ingested were converted by weight into grams. The amount of each nutrient in each food eaten was calculated using the weight of that food. The nutrient data base used to calculate nutrient intakes was developed by HNIS. The sources of the nutrient values were the USDA Nutrient Data Base for Standard Reference (12) and the USDA Nutrient Data Bank (13). To identify by age group (65-74 years and > 74 years) and sex the subgroups that were potentially at risk for poor nutrient intake, nutrient intakes estimated as less than twothirds the published RDAs (National Research Council of
the National Academy of Sciences) were determined (14). Following the procedure developed by Davis et al. (15) and Ryan et al. (16) to assess dietary intake adequacy, a composite measure was computed by calculating the percentage of individuals who consumed less than two-thirds the RDA for 5 or more of the 16 nutrients considered. Thus, persons consuming less than two-thirds the RDA for five or more nutrients were considered to have potentially inadequate nutrient intake. A measure of dietary patterns was developed by calculating the relative contribution that each major food group made to total mean energy intake. The diet was divided into the following seven food groups: milk products; eggs, meat, fish, and poultry; fats and oils; breads and cereals; fruits and vegetables; sweets; and "other foods." The "other" food category included alcohol, soups, snacks, sauces, gravies, and low-calorie beverages. Dietary pattern analysis provided information on the relative proportion certain foods contributed to the diets of men and women. A measure of relative intake was constructed by calculating the number of foods consumed from major food groups. The number of persons who consumed less than one food per day from each of four major food groups (milk products; meat, poultry, and fish; fruits and vegetables; breads and cereals) was then calculated. Additionally, the percentages of older adults who skipped breakfast, lunch, dinner, or snacks were computed across each sex and age group. Vitamins and/or mineral supplements consumed were recorded and analyzed as well. Methods of analyses. — Because the data collected in RLEDS were obtained through a complex sample design, specific computer programs were used that incorporated the sample weights and provided the ability to estimate the complex sample design variances [SESUDAAN for means and RTIFREQS for proportions (17-18)]. From standard errors computed using SESUDAAN and RTIFREQS, multiple contrast analysis was performed by using a z-statistic to determine significant differences between mean intakes or percentages. Differences in mean intakes or percentages between men and women and between age groups within each sex were considered statistically different at the .05 alpha level. RESULTS
Description of sample. — The unweighted and weighted counts of individuals according to selected sociodemographic characteristics are shown in Table 1. The unweighted sample of 180 men and 294 women aged 65 years and older represented national population estimates for 12,696,640 men and 18,349,900 women. Approximately one-third of the individuals reside in the southern portion of the United States. Over 90% of elderly Americans are White; approximately 63% are 65 to 74 years of age. The unweighted and weighted percentages of individuals within each sociodemographic subgroup were similar. Energy intake. — Across each age group, elderly men had significantly higher mean energy intakes than did women
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contract with the Human Nutrition Information Service (HNIS), USD A, and conducted the RLEDS. National Analysts designed the sample of RLEDS; trained the interviewers; collected the information using CSFII questionnaires as guidelines; edited and checked the data; coded and keyed the data; and prepared the final data tape. A dietary recall questionnaire was used to report all food, beverages, and dietary supplements ingested during the 24hour period of the day before the interview. Questions were directed to the respondent (or the main planner/preparer if the person was not able to speak for him/herself) concerning what was eaten, in what quantity, with whom, where, and when. Interviewers used a USDA-type instruction guide and measuring cups/spoons to aid respondents in reporting the kinds and quantities of foods consumed. A nationally representative sample of households consisted of 120 Primary Sampling Units (PSUs). The sample was stratified by nine Census Regions and three levels of urbanization. In these 120 PSUs, a total of 130 smaller geographical areas representing groups of blocks or Census Enumeration Districts were selected with a probability proportional to size for surveying. In these areas, all housing units were listed in sequence and formed the sample frame from which the households were chosen. The design was a quote-in-segment approach. Interviewers were given a starting point from which to contact each household unit in turn, and to attempt an interview in eligible households (i.e., those with at least one household member aged 65 years or older). National Analysts identified 482 households that were eligible for interview. Interviews were completed in 355 households. In the households where interviews were not taken, eligible respondents were not available or unable (e.g., too ill) to be interviewed. In the 355 eligible households, 493 persons qualified for food intake reporting and 474 provided food consumption information.
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DIETARY PATTERNS OF OLDER AMERICANS
(Table 2). Comparisons with the RDA for recommended energy intake revealed that 37% to 40% of men and women reported energy intakes less than two-thirds the RDA (Table 3). Across each age group, a higher proportion of elderly women than men had energy intakes below two-thirds the RDA.
Table 1. Characteristics of Sample Unweighted Characteristics
%
n
%
180 294
38.0 62.0
12,696,640 18,349,900
40.9 59.1
115 93 160 106
24.3 19.6 33.8 22.4
6,634,770 5,123,920 10,763,900 8,523,950
21.4 16.5 34.7 27.5
435 32 15
93.2 6.8 3.2
27,878,000 2,792,070 1,055,190
90.9 9.1 3.4
293 181 474
61.8 38.2 100.0
19,447,160 11,599,380 31,046,540
62.6 37.4 100.0
Table 2. Mean Nutrient Intakes and Their Standard Errors for Elderly Americans, 1990 Females
Males >74 Years n == 65
65-74 Years n -= 115
>74 Years n -= 116
65-74 Years n == 178
Nutrient
Mean
SE
Mean
SE
Mean
SE
Mean
SE
Energy (kcal/day) Protein (g/day) Vitamin A (RE/day) Vitamin E (Al-TE/day) Vitamin C (mg/day) Thiamin (mg/day) Riboflavin (mg/day) Niacin (mg/day) Vitamin B6 (mg/day) Folate ((jig/day) Vitamin B,2 ((xg/day) Calcium (mg/day) Phosphorus (mg/day) Magnesium (mg/day) Iron (mg/day) Zinc (mg/day) Total fat (g/day) Saturated fat (g/day) Monounsaturated fat (g/day) Polyunsaturated fat (g/day) Carbohydrate (g/day) Total fiber (g/day) Carotenes (RE/day) Copper (mg/day) Sodium (mg/day) Potassium (mg/day) Cholesterol (mg/day)
1954.5 76.7 1135.8 9.4 105.5 1.6
(113.2)t (3.9)t (82.2) (0.8) (8.4) (0.1)
(95.4)t (4.2)t
1.9
(O.l)t
1812.4 73.8 1073.0 9.2 100.3 1.5 1.8 20.5 1.8 247.5 4.2 716.8 1153.0 272.0 13.5 11.0 75.7 24.6 28.3 15.2 215.6 16.6 469.9 1.3 3279.6 2769.6 273.5
1425.7 61.5 1251.7 8.8 111.9 1.4 1.6 19.8 1.7 268.2 7.1 626.8 991.2 262.2 14.1 9.5 51.8 17.5 19.6 10.6 182.9 14.4 583.8 1.2 2546.7 2486.2 200.4
(34.8) (1.9) * (124.7) (1.5) (6.4) (0.1) (0.1) (1.5) * (0.1) (17.8) (2.2) (25.3) (27.9) (19.3) (1.4) (0.8) (2.2) (0.7) (1.0) (0.7) (4.9) (0.7) (67.9) (0.1) (88.9) (95.7) (16.2)
1395.4 54.3 1242.5 7.1 100.6 1.2 1.4 15.4 1.5 228.2 3.8 564.3 892.6 220.4 11.8 7.7 53.2 18.3 20.0 11.1 180.8 12.9 679.1 1.0 2533.8 2237.0 177.8
(64.8) (2.6) (168.2) (0.8) (8.8) (0.1) (0.1) (1.1) (0.1) (18.6) (0.9) (36.2) (46.3) (12.6) (1.4) (0.5) (3.2) (1.4) (1.2) (0.7) (9.9) (0.9) (125.6) (0.1) (167.6) (104.9) (10.7)
22.4 1.9 277.4 7.1 713.7 1201.9 289.2 14.9 11.3 76.4 25.7 29.7 15.0 239.0 16.3 484.0 1.4 3199.5 2882.4 282.1
(1.3) (0.1) (22.0) (1.7) (51.9)
(56.8)t (15.0) (0.9) (0.6)
(5.7)t d-9)t (2.3)t (1.4)t (14.0) (0.9) (57.5) (0.1) (115.7)t (142.3)t (28.7)t
•Significantly different {p < .05) between age groups within sex. tSignificantly different (p < .05) between sexes within age group.
(123.4) (1.6) (13.6)
(0.1)t (0.2) (1.6)t (0.2) (31.7) (0.5)
(68.7)t (67.3)t (18.9)t (1.2) (0.7)
(5.3)t (1.6)t (2.0)t
d-9)t
(13.8)t (2.4) (76.7)
(O.l)t (263.4)t (165.4)t (35.1)t
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Sex Male Female Region Northeast Midwest South West Ethnic background White Black Hispanic Age 65-74 years 75-98 years Total
Weighted
n
Nutrient intake. — As shown in Table 2, 65- to 74-yearold men consumed significantly higher mean intakes of protein, riboflavin, phosphorus, total fat (including saturated, monounsaturated, and polyunsaturated), sodium, potassium, and cholesterol than did women in the same age group. Men in the > 74 year age group reported significantly higher intakes of protein, thiamin, niacin, calcium, phosphorus, magnesium, total fat (including saturated, monounsaturated, and polyunsaturated), carbohydrate, copper, sodium, potassium, and cholesterol than did women in the > 74 year age group. Among women, those in the 65 to 74 year age group had significantly higher mean intakes of protein and niacin than did women in the > 74 year age group. As Table 3 shows, substantial percentages of those surveyed reported vitamin and mineral intakes less than twothirds the RDA. Over 40% of men in both age groups had intakes of vitamins A and E, calcium, and zinc below twothirds the RDA. For women, over 40% had intakes of vitamin E, calcium, and zinc that were below two-thirds the RDA. A significantly higher proportion of men in the 65 to 74 year age group than in the > 74 year age group had intakes of protein and niacin below two-thirds the RDA. For women, a significantly higher proportion of those in the > 74 year age group than in the 65 to 74 year age group had intakes of phosphorus below two-thirds the RDA. Table 3 also indicates that a significantly higher propor-
RYAN ETAL.
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Table 3. Percentage of Elderly Population With Nutrient Intakes Below Two-Thirds the RDA Males 65-74 Years Nutrient
> 74 Years
65-74 Years
> 74 Years
%
SE
%
SE
%
SE
%
37.8 14.6 46.6 44.8 23.2 16.2 17.9 13.1 38.1 21.6 8.7 42.6 7.3 37.3 12.5 47.0
(6.4) (3.4)* (3.9)t (6.4) (4.5) (4.4) (4.0) (3.8)* (5.7) (4.5) (4.6)t (5.3) (1.8) (6.3) (3.5) (5.0)
37.5 6.2 41.8 48.0 22.2 12.0 12.4 3.8 30.9 21.3 15.4 44.1 3.6 46.6 7.1 49.9
(4.8) (2.1)t (8.3) (9.2) (7.5) (5.1) (4.5) (2.8)t (7.2) (7.4) (4.9) (6.7) (2.5)t (7.5) (4.1)t (6.3)
40.1 10.4 28.7 42.8 19.9 13.0 10.0 10.8 28.2 15.3 19.7 47.3 8.4 28.6 17.1 56.0
(3.9) (2.0) (3.1) (4.1) (4.0) (3.2) (2.5) (2.3) (3.8) (3.6) (2.8) (4.5) (2.1)* (4.9) (3.0) (3.2)
37.7 19.0 33.5 43.4 28.1 15.7 13.3 17.9 38.3 27.2 17.3 54.0 18.5 38.3 23.1 60.3
SE (4.6) (5.4) (6.1) (6.5) (6.1) (4.5) (3.5) (4.7) (5.3) (5.9) (2.9) (6.2) (4.0) (6.3) (4.2) (5.1)
•Significantly different (p < .05) between age groups within sex. tSignificantly different (p < .05) between sexes within age group.
tion of men aged 65 to 74 years than women of the same age group had intakes of vitamin A below two-thirds the RDA. The reverse was true for vitamin B12. A significantly higher proportion of 65- to 74-year-old women than men had intakes of vitamin B12 below two-thirds the RDA. Notably, in the > 74 year age group, a higher proportion of women than men consumed less than two-thirds the RDA for protein, niacin, phosphorus, and iron. No statistically significant differences were observed in the proportions of persons who consumed less than twothirds the RDA for at least 5 of 16 nutrients by age group and sex (Table 4). Nevertheless, approximately 40% of men and 36% of women consumed less than two-thirds the RDA for at least 5 of the 16 nutrients considered in this study. Men in the > 74 year age group had the least favorable nutrient pattern. Dietary pattern. — In general, the dietary patterns of men and women were similar; no statistically significant differences were observed. Men received a slightly greater percentage of their energy intake from eggs, meat, fish, and poultry than did women. Women, on the other hand, received a relatively greater percentage of their energy intake from fats and oils, and fruits and vegetables. Food group intake. — Across each age and sex group, fruits and vegetables, and breads and cereals were the food groups least likely to be consumed less than once a day (Table 5). All the men surveyed indicated that they consumed at least one serving of a vegetable or fruit. Proportionally more men and women in the 65 to 74 year age group than those in the > 74 year age group reported consuming less than one serving of milk products. Skipped meals. — Across each age group, fewer persons skipped breakfast or dinner (Table 6). A higher proportion of men than women skipped breakfast or lunch. Across each age group, proportionally more women than men skipped a
Table 4. Percentage of Elderly Population Consuming Less Than Two-Thirds the RDA for at Least 5 of 16 Nutrients 65-74 Years % Males Females
> 74 Years
SE
%
38.4 (5.3) 33.8 (4.1)
SE
40.9 (7.1) 37.5 (7.1)
Table 5. Percentage of Elderly Population Consuming Less Than One Food Per Day From Different Food Groups 65-74 Years % Males Milk products Meat, poultry, fish Fruits and vegetables Breads and cereals Females Milk products Meat, poultry, fish Fruits and vegetables Breads and cereals
SE
> 74 Years %
SE
16.9 (6.1) 6.0 (2.2) 0.0 2.9 (1.1)
10.1 (5.2) 4.1 (1.6) 0.0 2.3 (0.8)
16.4 (4.0) 8.8 (2.6) 0.0 1.8 (1.0)
11.9 (2.3) 11.8 (5.2) 4.0 (1.6) 0.0
snack. Approximately 30% of men and 21% of women reported that they skipped lunch. Vitamin and/or mineral supplement use. — Considering both age groups combined, 36% of the men and 44% of the women surveyed indicated that they consumed vitamin and/ or mineral supplements daily. Compared with supplement nonusers, supplement users had a relatively higher proportion of persons who consumed amounts of nutrients less than two-thirds the RDA (Table 7). For supplement users, over 40% received less than two-thirds the RDA for vitamin E, calcium, and zinc from food intake. These inadequacies also were evident among the diets of supplement nonusers.
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Energy Protein Vitamin A Vitamin E Vitamin C Thiamin Riboflavin Niacin Vitamin B6 Folate Vitamin B,2 Calcium Phosphorus Magnesium Iron Zinc
Females
DIETARY PATTERNS OF OLDER AMERICANS
DISCUSSION
Table 6. Percentage of Elderly Population Who Skipped Meals, 1990 65-74 Years Meal Breakfast Males Females Lunch Males Females Dinner Males Females Snack Males Females
%
> 74 Years
SE
%
SE
7.9 4.2
(3.2) (1.6)
11.2 1.9
(5.2) (1-0)
28.9 21.0
(5.0) (4.0)
30.7 20.6
(5.5) (4.6)
7.8
(2.6) (2.2)
7.0
5.3
8.9
(3.8) (2.3)
32.6 40.7
(6.5) (3.9)
34.8 40.5
(7.7) (6.8)
As shown here, calcium, zinc, and vitamins A and E were the nutrients most often consumed in amounts below twothirds the RDA. Other surveys also have reported marginal mineral and vitamin intakes among older persons (5,6,19,21). The marginal and/or low dietary intakes of minerals in this population are of concern because the elderly are at risk for mineral deficiencies from other factors besides inadequate food intake, including drug-nutrient interactions and effects of chronic disease. The relationship between vitamin and/or mineral supplementation and the proportions of persons with intakes below two-thirds RDA indicates no real pattern of supplementation. In other words, some who consumed diets higher in nutrient intakes also supplemented their diets, whereas some individuals with inadequate intakes did not supplement their diets. While it is clear from intake data that some elderly individuals require supplementation to bring nutrient levels closer to recommended intakes, random supplementation may result in relatively excessive intakes of certain nutrients while not ensuring adequate intakes of other nutrients. There is a need for nutrition educators to focus their attention on increasing food awareness among elderly persons and on emphasizing methods of making appropriate food choices. Certain methodologic issues need to be considered in interpreting the dietary data presented here. Although the 24-hour dietary recall is a simple and rapid method of obtaining dietary information, it relies on the ability of the subjects to recall accurately, does not account for day-to-day variation, and tends to underestimate energy intakes (2224). Recently, Brown et al. (25) described a videotape assessment of the validity of the 24-hour dietary recall from elderly women in a retirement home. These authors indicated that the 24-hour dietary recall underestimated food quantities by an average of 6%. However, many researchers tend to agree that the 24-hour dietary recall is adequate for
Table 7. Percentage of Elderly Population (With Nutrient Intakes Below Two-Thirds the RDA) Taking and Not Taking Vitamin and/or Mineral Supplements Males Taking Vitamins n = 64 Nutrient
%
Energy Protein Vitamin A Vitamin E Vitamin C Thiamin Riboflavin Niacin Vitamin B6 Folate Vitamin B12 Calcium Phosphorus Magnesium Iron Zinc
42.9 16.3 44.6 50.5 22.6 20.1 23.5 15.1 39.3 22.4
SE (5.4) (2.8)* (3.9)t (7.1) (4.1) (5.4) (5.0) (3.9)* (5.6) (4.1)
7.1 (3.7)t 47.4 5.2 38.9 15.3 45.7
(5.2) (1.2) (6.3) (3.4) (5.1)
Females Not Taking Vitamins n - 116 % 34.6 8.8 45.0 43.3 24.8 11.6 11.5 6.7 33.4 21.0 13.4 40.6 11.6 29.8 19.7 59.9
*Significantly different (/; < .05) between age groups within sex. tSignificantly different (p < .05) between sexes within age group.
SE (5.1) (l.l)t (7.1) (8.2) (7.4) (6.1) (4.4) (4.1) (7.1) (7.4) (5.1) (6.7) (2.5) (7.1) (7.1) (6.3)
Taking Vitamins n = 128 % 34.8 15.5 25.7 44.5 27.5 16.8 9.0 14.7 35.6 21.4 18.4 48.0 34.8 28.5 25.7 44.5
SE (2.9) (1.4) (3.1) (4.1) (3.1) (3.2) (2.5) (3.4) (4.4) (2.8) (3.6) (4.6) (4.9) (4.8) (3.2) (4.3)
Not Taking Vitamins n = 166 % 42.2 13.4 34.7 42.0 20.7 12.3 13.3 13.4 32.5 20.1 18.7 52.0 14.0 35.3 19.9 56.5
SE (5.1) (5.6) (6.1) (6.5) (5.1) (3.5) (3.5) (4.7) (5.3) (4.9) (2.9) (6.3) (4.0) (6.2) (4.1) (5.4)
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This study provides a dietary profile of a representative sample of free-living Americans aged 65 years and older. The data considered here reflect the dietary patterns of elderly persons who are residing in the community rather than in long-term care facilities or hospitals. The data clearly document that a high proportion of these older Americans consume an inadequate diet. Previously, national nutrition and food consumption surveys have reported low energy intakes among the elderly (5,6,19). The results of this current survey indicate that energy intakes of free-living elderly Americans remain below recommended intakes. Approximately 40% of persons 65 years of age and older had mean energy intakes below two-thirds the RDA. Lower than recommended energy intakes also have been reported for the institutionalized elderly (20).
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20. ACKNOWLEDGMENTS
We thank Booker Smith and Jeffrey Wysong for their statistical and programming advice. A detailed description of the survey design and weighting procedure is available. Address requests and correspondence to Dr. Alan S. Ryan, Ross Laboratories, 625 Cleveland Avenue, Columbus, OH 43215. REFERENCES
1. U.S. Bureau of the Census. Statistical abstracts of the United States, 1991. 111th ed. Washington, DC: U.S. Government Printing Office. 1991:16. 2. U.S. Department of Health, Education and Welfare. Healthy people: the Surgeon General's report on health promotion and disease prevention. DHEW Publ. No. (PHS) 79-55071. Washington, DC: U.S. Government Printing Office, 1979:71-80. 3. U.S. Department of Health and Human Services, Public Health Service. The Surgeon General's report on nutrition and health. Washington, DC: U.S. Government Printing Office, 1988:616-7. 4. Abraham S, Carroll MD, Dresser CM, Johnson CL. Caloric and selected nutrient values for persons 1-74 years of age: First National Health and Nutrition Examination Survey, United States, 1971-1974. Vital and Health Statistics, Series 11, No. 209. DHEW Publ. No. (PHS) 79-1657. Hyattsville, MD: National Center for Health Statistics, 1979. 5. Carroll MD, Abraham S, Dresser CM. Dietary intake source data: United States, 1976-80. Vital and Health Statistics, Series 11, No.
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Received October 24, 1991 Accepted January 31, 1992
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obtaining the mean for a group with a large sample size (2324). Another concern is the potential for seasonality bias because the RLEDS was conducted during the spring and summer months (May-August). In the CSFII (11), six days of dietary information was collected at two-month intervals over a one-year period. The nutrient intake levels did not substantially vary over time and between the two-month intervals of data collection. Finally, there is concern that the RDAs for adults over 50 years of age are similar to those for persons 25 to 50 years. Because so few of the data used to develop these recommendations were obtained from older persons, the appropriateness of this information as a comparison standard for older Americans is questionable (26). The potential impact that socioeconomic and psychologic factors have on the dietary patterns of older Americans has been explored (8,9,16,27,28). Social isolation may adversely affect dietary quality (9). Type of living arrangements also influences the quality of nutrient intakes (15,16). As shown by Davis et al. (15) and Ryan et al. (16), more men living alone consumed a poor quality diet than did men living with a spouse. For women, income was more strongly associated with dietary patterns than living arrangement. More poor women than poor men had poor-quality diets. The impact that these sociologic variables have on the dietary patterns of the elderly persons considered in the present study needs further evaluation. Elderly persons' risk for inadequate dietary intake is well established. The results presented here bear witness to the fact that the dietary quality of older U.S. adults has not recently improved. The dietary problems are related to a multitude of physiologic, economic, and social factors; some of these factors are inevitable, but others may be ameliorated through intervention. Appropriate strategies must be designed and applied so that elderly men and women can be helped to maximize their quality of life.
