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The effectiveness of nutritional counseling in nutritional status and behavior in the elderly

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The effectiveness of nutritional counseling in nutritional status and behavior in the elderly

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Content THE EFFECTIVENESS OF NUTRITIONAL COUNSELING IN NUTRITIONAL STATUS AND BEHAVIOR IN THE ELDERLY by Marie-Claire Cuillerier A Thesis Presented to the LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA in Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY June 1981 UMI Number: EP58886 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertatton PubI s h » n q UMI EP58886 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106 - 1346 U N lV B R S n V O f SOUTHERN CALIFORNIA LEONARD DAI/IS SCHOOL OF GERONTOLOGY U N JV E R S n V PARK LOS ANGELES, CALIFORNIA 90007 G e ron C ^ é ê c:9 y 9 c ^ t ^A/ TIvu iOAÂJXm by Marie-Claire C u ille rie r undeA the, dOizcXoA h er ComnuJX^d, and appAovdd by a J U L À X â mmbeA6, ka^ bzdn p/te- ^dnted to and accepted by th e Vean The LeonoAd VavXs Schoat GeAontoZogy, tn p a A tta Z ^uZ^tZlmeyX o{) th e AeciüJjimewU ioA th e degAee Master of Science in Gerontology, M.S.G. ___ Vean date THESIS OCMMXTTEE /S', /ffà Ru±hp_B.,_iAleg Lha<Aman Robert Wiswell ' m V David A. Peterson Chapter Page V. DISCUSSION . 69 Nutritional Status and Physiological Parameters of Treatment Group in Comparison with Control Group Before the Experiment Nutritional Status and Physiological Parameters of Treatment Group in Comparison with Control Group After the Experiment Nutritional Status and Physiological Parameters of Control Group Before and After the Experiment Nutritional Status and Physiological Parameters of Treatment Group Before and After the Experiment Correlation Between Changes in Eating Habits and Changes in Physiological Parameters Within Treatment Group VI. SUMMARY, FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS ........................ 81 Summary Findings Conclusions Recommendations BIBLIOGRAPHY............................... 87 APPENDIXES............. 97 A. Table of Recommended Daily Dietary Allowances ........... 98 B. Food Intake Recall Questionnaire .... 100 C. Social Questionnaire ..................... 102 D. Five Commandments for Healthy Habits . .104 111 LIST OF TABLES Table Page 1. Food Energy, Protein, Fat, Carbohydrate Per Capita Civilian Consumption ......... 5 2. Change in Per Capita Consumption in the United States Between 1963 and 1975 . 9 3. Decline in Age-Specific Cerebrovascular Mortality, 1963-1975 « 11 4. Some Risk Factors Associated with Heart Disease ...... 19 5. Mean Heights, Weights and Recommended Energy Intake ..... ... ... ... 27 6. Physical Description of Subjects = 13, n^ = 9) . ........... 48 7. Social Description of Subjects (n,^ = 13, n^ = 9) .. . .. . . . . . . . 50 8. Mean Comparison Between Treatment and Control Groups' Pre-Nutrient Analysis (n^ = 13, n^ = 9) . . ... ......... 53 9. Mean Comparison Between Treatment and Control Groups* Post-Nutrient Analysis (n^ = 13, n^ = 9) ............. 55 10. Percentage of Total Calories Absorbed in Pre- and Posttests by Treatment and Control Groups ................. 56 11. Mean Comparison Within Treatment Group on Pre-Post-Nutrients (n,^ = 1 3 )...... 57 12. Mean Comparison Within Control Group on Pre-Post-Nutrients (n^ = 9) ..... 60 13. Mean Comparison Between Treatment and Control Groups on Pre-Physiological Parameters and Age (n^ = 13, n^ =9) . . 62 IV Table Page 14. Mean Comparison Between Treatment and Control Groups on Post-Physiological Parameters (n^ = 13, n^, = 9 ) .............. 63 15. Mean Comparison Within Treatment Group on Pre-Post-Physiological Parameters Analysis (n^ = 13) 64 16. Mean Comparison Within Control Group on Pre-Post-Physiological Parameters Analysis (n^ = 9) 66 17. Correlation Between Nutrients and Physiological Parameters Within the Treatment Group (n^ = 13) 67 V CHAPTER I INTRODUCTION Almost 25 million Americans are 65 years of age or older (U.S. Bureau of Census, 1977). This population, our "Senior Citizens," is increasing rapidly every day due to the fact that health issues at young ages are focusing on trying to lengthen life. This is reflected in the change in the median age from 27.9 years in 1970 to 29.8 years in 1979. "Getting old is not getting sick, but . . ." (Weg, 1979, p. 3). Aging is a process that continues throughout adult life in health as well as in sickness. It is accompanied by the decline in function of renal, gastrointestinal, cardiovascular, muscular, skeletal and mental functions (Masaro, 1976; Shank, 1976). Aging, therefore, can be one of the major biological factors underlying the increase in susceptibility to disease among the elderly. Few people die of old age. Mortality increases rapidly with age because the elderly, being more suscepti ble to disease, die prematurely from cardiovascular diseases, cancer, or strokes, to mention only the most important causes. Cardiovascular diseases, especially coronary heart disease, cause two-thirds of all deaths among people over 65 years of age, or approximately 160,000 deaths annually in the United States (Lalonde, 1977; U.S. Dept, of Health Education and Welfare, 1977). Even if, in the past 15 years, deaths due to cardiovascular diseases have declined by 25 percent, this still leads all other causes of death and disability in the United States (Di Girolamo & Schalant, 1977). In Canada, by the age of 35, cardiovascular diseases become the principal cause of death and hold this position in increasing ascendancy through all subsequent age groups (Statistics Canada, 1976) Other chronic degenerative diseases, such as atheriosclerosis, arthritis, rheumatism, emphysema, and hypertension, also increase with age. Close to half of the elderly have some degree of limitation on their activities, and over 15 percent are unable to carry on any major activities (Shank, 1976; U.S. Department of Health, Education and Welfare, 1975). Individuals differ greatly in the rate at which deterioration occurs. This depends on their heredity and their exposure to environmental insults. We cannot do anything about heredity, but surely we can influence the environment in such a way that we can reduce the burdens that the elderly must bear. Furthermore, it may be possible to postpone the processes that lead to the physiological state we presently define as "old age." So we must seek ways of slowing individual biological aging as well as seeking methods to structure the environment of those reaching old age, to provide them with optimal health and well-being. Nutrition is an important component of the environment. As Watkins (1977) pointed out in an article entitled "Aging, Nutrition and Continuum of Health," The interrelations of aging, nutrition, and the continuum of health care in modern societies, is not only desirable, but in the light of the alternative, practically mandatory. The attention must be directed at all human life from conception to death. Properly applied throughout life, the attention can dramatically decrease the misery and waste currently imposed by life-style diseases and disabilities. Pro fessionally trained scientists concerned with nutrition are keys to the catalysis of societal comprehension of the triad's interrelations. (p. 291) Statement of the Problem and Hypotheses Over the past century, agricultural technology and the food industry have brought profound changes in the American diet. With the concomitant reduction in the demand for physical work as a result of advances in industrial technology, the problem of overnutrition has now replaced that of undernutrition in the Western world. Overconsumption of fat and saturated fat in particular, as well as of cholesterol, sugar, salt, and alcohol, have been related to six of the 10 leading causes of death; heart diseases, cancer, cerebrovascular diseases, diabetes, arteriosclerosis and cirrhosis of the liver. It is estimated that at least 20 percent of all adults in the United States are overweight to a degree that may impair optimal health and longevity (Kelly, 1978). The Center for Science in the Public Interest (1978) reports on the changing American diet between 1910 and 197 6. The creamy desserts, fast food, convenient packaged meats, cheeses, sugared cereals, and complete frozen dinners led to: 1. An increase in total fat consumption to supply 42 to 45 percent of total calories— a rise in fats of animal origin. 2. A drop in the total carbohydrates from 56 to 46 percent of the daily caloric intake. Complex carbohydrates have decreased from 37 to 21 percent of the total daily calories. A rise of 50 percent in the intake of refined sweeteners (mostly sugar) has been calculated with a change from 12 to 18 percent of total calories consumed. 3. Proteins remained about the same at 12 to 14 per cent. The source was primarily animal. This diet, low in fiber/whole grain, fresh fruit and vegetables, and with proteins low in essential amino acids, is potentially inadequate in micronutrients (vitamin^ and minerals) in proteins of high quality (essential amino acids), and in energy (see Table 1). Table 1 Food Energy, Protein, Fat, Carbohydrate Per Capita Civilian Consumption FOOD ENERGY. PROTEIN, FAT. CARBOHYDRATE Per Capita Civilfan Consumption 150 125 100 75 Food • - («olones) - : Fro»**n7 1 ^ CZTl, f : : U ti l ILI l .1 l„ t.i 1 1 U I ■lXtl.llXUL lIJLlI llJl ^Corbohydrofe n I I 11 u 11 n 1 1 1 l.HL IM tlLUUL 1910 1920 1930 1940 1950 I960 1970 1980 S.TIAI MOVING AVeiACf Source: B. Friend, Changes in Nutrients in the U.S. Diet Caused by Alternatives in Food Intake Patterns, Washington, D.C.; U.S. Department of Agriculture, Agricultural Research Service, 1974. ‘ A select committee was recently appointed by the American Society for Clinical Nutrition. Nine members, chosen for their wide experience in clinical medicine, human nutrition and animal experimentation, plus 24 additional world-recognized experts on today’s food and health issues, were appointees. They came to the following conclusions: In a proportion of 75 percent, there is a relationship between: (1) heart attacks and fats and oils, (2) high blood pressure and salt, and (3) sugar and tooth decay. (p. 64) This was reported by Lawrence Power, M.D. in "Food and Fitness," in The Los Angeles Times, Sunday, April 13, 1980. To this statement, he added: Defenders of our present food supply stress the proteins, the vitamins and the minerals. We do get those in abundance, but the big issue is; "F-A-T." Half of the 350 calories in a cheeseburger come from the fat that tags along with its proteins, vitamins and minerals. Of the calories in a breakfast omelet or sweet roll, 60 come from fat. In a typical frozen dinner entree, 50 percent of the calories are fat; ice cream calories are 50 percent fat; potato chips 60 percent fat, while 75 percent of the calories in chip dips and spreads are from fats. So it goes, TASTY but Troublesome, (p. 13) One of Joseph Califano's last acts as Secretary of Health, Education and Welfare, was the release of the first Surgeon General's report on health promotion and disease prevention (Richmond, 1979). The American people were called upon to change their diets as well as other life habits in exchange for better health and probability of a reduction of 20 to 35 percent in death rates in 1980 (Weg, 1980). Elderly persons in the United States, constituting a growing population, may be particularly vulnerable to nutritional problems. Dietary problems in old age may arise from changes in metabolic requirements due to the onset of senescence and factors related to it, or can result from decreased intake of nutrients that may be due to low income, loneliness, sickness, or even more probably to dietary habits arising from lack of knowledge. Nutrition education for the elderly, in the broad est sense, is necessary to ensure that recommended allowances are translated into familiar foodstuffs in appropriate quantities and combinations. It should also ensure intelligent marketing and hygienic storage, cooking, and serving of food in a relaxed, unhurried atmosphere at home. But it seems that health education alone is less than adequate, since the human condition is such that people can seldom be successfully motivated to give up that which they enjoy in order to achieve some future benefit. A motive for change could first be provided by presenting a clear description of the dangers or potential problems associated with maintaining current behavior. This could be done in a variety of ways, such as group sessions including audio-visual or written material. The threat or danger could be made personal to the individual through nutri tional counseling. Only after the need for change has been clearly perceived and accepted can these changes be facilitated. With this in mind, two specific hypotheses have been developed and can be formulated as follows: 1. Subjects receiving nutritional counseling will show a significant change in their eating habits after the experiment as compared to a group who do not receive any counseling. 2. Subjects receiving nutritional counseling will show a significant change in blood chemistry com ponents such as cholesterol, triglycerides, total lipids, glucose and uric acid, as well as in a few physiological traits such as weight and blood pressure. Significance of the Study Preventive approaches have had little success so far in achieving substantial and lasting changes in be havior patterns that contribute to cardiovascular diseases and deaths. On the other hand, a recent report indicated a decline since 1964 in per capita consumption of tobacco, animal fats and oils, butter, liquid milk, cream and eggs, with a concomitant increase in the consumption of vegetable fats and oils (Walker, 1977). (See Table 2.) __________________________________________________________________________ a Table 2 Change in Per Capita Consumption in the United States Between 1963 and 1975 Product * Change All tobacco products 22.4% decline Fluid milk and cream 19.2% decline Butter 31.9% decline Eggs 12.6% decline Animal fats and oils 56.7% decline Vegetable fats and oils 44.1% decline Note. Figures for calculating percentage changes were obtained from U.S. Department of Agriculture, Agricultural Statistics 1976 » Washington, D.C.: U.S. Government Printing Office, 1976, pp. 106, 142, 384, 414, and 561. Also New England Journal of Medicine, July 21, 1977, 297(3), pi 165. Since the Surgeon General’s warning in 1964, tobacco use and the intake of saturated fats and cholesterol have decreased somewhat among the American population. In addition, data on age-specific cerebrovascular and coronary mortality rates for the period between 1963 and 1975 in dicate a significant decline (U.S. Department of Health, Education and Welfare, 1975). (See Table 3.) Although it is not possible to infer a direct cause and effect between changing dietary habits and decreasing mortality rates, the correlation is suggestive. Other factors, such as altered exercise patterns, stress manage ment, and improved acute coronary care, require similar evaluation. Recent studies with communities (Maccoby & Farquhar, 1975; Maccoby, Farquhar, Wood, & Alexander, 1977) revealed statistically significant gains in knowledge about risk factors and changes in risk-related behaviors: cigarette smoking, weight, diet, and exercise. In those community studies, a "multifactor health education" program was de signed to provide a supportive milieu to the 35 to 59 year old target population. In order to teach them the skills necessary to achieve the self-directed changes, the authors used role models, provided face-to-face intensive instructions and, through the mass media, changed people’s living habits. The program developed by Maccoby et al. 10 Table 3 Decline in Age-Specific Cerebrovascular Mortality, 1963-1975 Age (Year) % Decline 35-44 19.1 45-54 31.7 55-64 34.1 65-74 33.2 75-84 21.9 85+ 29.4 Note. Vital Statistics of the United States, Vol. 2, Part A, Department of Health, Education and Welfare Publication No. (HRA) 76-1102, Rockville, Maryland National Center for Health Statistics, 1975. 11 (1977) helps people to learn how to change their behavior to reduce their risks of cardiovscular accidents. A similar goal was the objective in developing the evaluation experimental program for a group of elderly people. Exposing this population to experience with self-care practices could facilitate their decision-making in regard to accepting responsibility for their own health and encourage them to take positive steps to promote it. Definition of Terms Cholesterol; An alcohol lipid present in all animal fats and synthesized by the body; circulates in the blood as lipoprotein (normal range from 150 to 250 mg/ 100ml); is presently considered by some researchers to be one of the substances related to high blood pressure, atheroma (hardening of the arteries), gallstones, and other diseases. Fiber ; The sum of the indigestible carbohydrate and carbohydrate-like components of food, including cellulose, lignin, hemicellulose, pentosans, gums and pectins. "Dietary fiber" is a more inclusive term than "crude fiber," which includes only a portion of the cellulose and lignin in foods. These non-digestible sub stances provide bulk in the diet and aid elimination. Glycemia: Obtained by the hydrolysis of the seven carbon sugars found in the blood (starch, sucrose, maltose 12 lactose; a monosaccharide occurring'in fruits and honey, destrose and grape sugar), the metabolic breakdown of which generates energy in all cells ; the blood glucose level is maintained homeostatically at a reasonably constant level (between 70 and 120 mg percent). Hyper1ipidemia; A non-specific term referring to ar excess of fat in the blood. Kilocalorie (kcal): The amount of heat required to raise the temperature of 1,000 grams of water one degree centigrade; also known in nutrition as the large calorie (C or Calorie). Lipids ; An inclusive term for fats and fat-like substances characterized by the presence of one or more fatty acids (fats, cholesterol 1icithins, phospholipids and similar substances), which do not mix readily with water. Osteoporosis : A disease in which the chemical composition of the bone remains unchanged (normal), but both mineral and supporting matrix are lost from the bone, which becomes thinner, lighter and more porous. Polyunsaturated fatty acids : Fatty acids contain ing two or more double bonds ; linolenic and arachidonic acids. Recommended dietary (or daily) allowances (RDA): The amounts of 15 vitamins and minerals plus protein and 13 calories estimated to be necessary for both sexes through out the life cycle; allowances will maintain good nutrition in essentially all healthy persons in the United States under current living conditions; designed to afford a margin of safety above average physiological requirements to cover variations among individuals in the population. The recom mendations were first established by the Food and Nutrition Board of the National Academy of Sciences--National Research Council in 1943 and have been revised several times as new research data became available. Risk Factors : In general refers to specific characteristics— age, life-style, diet, income, habits (smoking or exercise), use of alcohol, or even where people live or work— that are associated with a higher than average incidence of a specific health problem. Risk factors are usually identified by nutritionists, statisticians, epidemi ologists, and those health professionals who look carefully at the reports describing the incidence of various diseases in various population groups. If it is determined that one group of people, who have something in common, also have a higher incidence of a certain disease, they begin to study the possibility that the common factor among these people may either cause, or help to cause, the disease. Triglyceride; An ester of fatty acids and glycerol in which the glycerol molecule has three fatty acids 14 attached to it occur in over 98 percent of the fat found in foods. Limitations As with any study involving behavior, a number of limitations were encountered. The most important of these were time limitations, sample size, research tools, and communication, Time Limitation A period of 10 weeks was available for the selection of the participants, the administering of the program and the obtaining of results. A second posttest after four to six months would have given the program more significance. The Research Tool The food recall questionnaire for a 24-hour period is an excellent tool if completed adequately. But for the elderly population we have to accept certain biases due to inadequate memory. A piece of paper and pencil are not always handy at meal and snack time. In addition, reporting on eating habits is quite a threat for these elderly people; they want to appear at their best, so they report their best menu on their best day. Because some of the foods eaten by these people were not listed in the "Nutrition Value of American Foods" (Adams, 1975), it was necessary to derive the nutritive value of an uncommon item from a standardized item. 15 Communication The communication and consequently comprehension could be limited when there was a language deficiency existing. This is particularly true when the client, as well as the investigator, wag utilizing a second language Often an accent, coupled with the use of unfamiliar words, is confusing to people. 16 CHAPTER 2 LITERATURE REVIEW This review is divided into four major subsections. These are: (1) the role of nutrition in the prevention of cardiovascular accidents ; (2) the nutritional status of the elderly, some national surveys; (3) the recommended daily dietary allowances of nutrients; and (4) nutritional counseling. The Role of Nutrition in the Prevention of Cardio vascular Accidents The most disabling and devastating disease of older people in American society is atherosclerosis, with its many manifestations and complications. One area of great concern is coronary heart disease because it is a disease which characteristically strikes with little warning, in which the first symptom may be sudden death. Coronary heart disease can also be silent in its most dangerous form. It would appear that only a preventive approach can be expected to achieve a substantial reduction^ in mortality and morbidity. 17 Possible means for prevention of coronary heart disease have been discerned by the identification of factors which contribute to its occurrence. In the pre- clinical phase, a number of risk factors have been shown to be predictive in adults who subsequently develop clinical coronary heart disease. Studies have shown that there is a gradient of risk of coronary heart disease that is associated with serum concentration of cholesterol, level of blood pressure, degree of obesity, lack of physical activity, and cigarette smoking (Kannel & Dawber, 1972; Paffenbarger & Wing, 1967). (See Table 4.) Clinical and experimental investigations suggest that atherosclerosis caused by hyperlipidemia is initiated by a diet high in saturated fats and cholesterol (Inter- Society Commission on Heart Disease, 1970). The seven countries study, the best known example, has found a well- established, consistent and strong association between coronary heart disease and both hyperlipidemia and certain dietary factors, particularly the proportion of energy derived from saturated fats (Keys, 1975). Hyperlipidemia is also influenced by overconsump tion and obesity. Similarly, the occurrence of adult hypertension, a primary risk characteristic for coronary heart disease (CHD), is related to the nutritional factors of obesity, weight gain, and habitual salt intake 18 Table 4 Some Risk Factors Associated With Heart Disease Risk Factors Physiological Results End Results Eating and drinking too much Overweight Not exercising enough High total consumption High saturated fat consumption Low polyunsaturated fat ratio Elevated blood pressure High Risk of Heart Disease High cholesterol consump tion High salt consumption Overweight Elevated blood pressure Diabetes Accelerates Smoking the ateriosletic process Atheroscle rotic Source: Select Committee Dietary Goals for Washington, D.C.: Office, December on Nutrition and Human Needs. the United States, 2nd Ed., U.S. Government Printing 1977, p. xxiv. 19 (Blackburn, 1978). Dietary composition and energy balances are central to the public health issue of hyperlipidemia and to the public health burden of atherosclerosis vascular disease. There is also direct evidence from experiments in animals and from metabolic studies in humans that specific alterations in the nutrient content of the diet can produce predictable changes in the serum lipid content and pattern (Hartroft & Thomas, 1963; Kuo, 1967; McGandy, Hegsted, & Stare, 1967). Changes in nutritionally influenced characteristics and in habitual eating patterns would appear to be essential for a significant reduction in hyperlipidemia and for the regression or prevention of atherosclerosis. The concentration on the dietary aspects of pre vention of cardiovascular complications should not be interpreted as a denial of the importance of other factors such as smoking, raised blood pressure, and physical activity, which have equal importance. The Nutritional Status of the Elderly; Some National Surveys In order to assess the nutritional status of the general population in the United States, the U.S. Department of Agriculture in 1965 obtained information on the nutrient intake of 14,500 persons from 6,174 households. The survey 20 did not include those living in institutions and rooming houses, and thus omitted many of the aged who were ill or disabled. The results showed that, except for calcium, the average nutrient intake per day for men aged 55 and over was adequate, whereas the intake of thiamine, riboflavin and calcium of women in this age group was 87 percent, 84 percent, and 64 percent, respectively, of the recommended dietary allowances (National Academy of Sciences/National Research Council, 1974), The Ten State Nutrition Survey conducted by the U.S. Department of Health, Education and Welfare (1972) was designed to assess the nutritional status of groups considered to be at risk of undernutrition. These groups included those living at poverty levels and below; migrant workers, Spanish-speaking people in the Southwestern United States, inner-city residents, and individuals in industrial states who had migrated from the South in the previous 10- 20 years. It was concluded that persons 60 years of age and older consumed far less food than is needed to meet the nutritional standards for their age, sex, and weight. No subgroup met the caloric standard and other inadequate nutrients were protein, iron and vitamin A. Similarly, Kelsay (1970) compiled the results of approximately 60 individual dietary intake studies pub lished between 1957 and 1967 on over 30,000 subjects. Only 21 10 of these studies were directed toward evaluating the nutrient intake of the elderly. The dietary intake data from these 10 studies showed a high percentage of groups with markedly inadequate intake. There was evidence of consumption of less than recommended levels of certain nutrients. Those likely to be low included protein, ribo flavin, niacin, thiamin, iron, and, particularly, vitamins A and C. Davies, Gershoff and Gamble (1969) reviewed the studies of vitamin and mineral nutrition in the United States reported during the years 1950-1968. Examination of these findings did not suggest severely deficient consump tion in the over 50 age groups. The first Health and Nutrition Examination Survey (HANES) for the United States population in 1971-1972 (U.S. Department of Health, Education and Welfare, 1975) represented civilian, non-institutionalized persons from 1 to 74 years of age. The preliminary results included data on 72.8 percent response of the individual selected for sampling. The results indicated that among persons over 60 years of age, with incomes above the poverty level, 16 percent of the white and 18 percent of the black popula tion consumed less than 1,000 calories per day. In those with incomes below the poverty level these percentages rose to 27 and 36 percent, respectively. The intake of protein 22 as well as of calories in this age group was also related to income in both races. Protein intake per 1,000 calories showed no variation with race or income, indicating that it was closely related to caloric consumption. Calcium intake was less than the standard for 37 percent of all persons over 60. The intake of vitamin A was below standard in 52 to 62 percent and consumption of vitamin C was low in 39 to 59 percent in all adults of this age group. Taken as a whole, these surveys do not indicate consistent evidence of poor nutritional status or of marked deficiencies in nutrient intake among older members of many population subgroups in the United States. However, significant percentages of many of the groups studied consumed less than the recommended amounts of certain nutrients, especially of protein, calcium, ascorbic acid and vitamin A. The elderly, especially women, had a very high incidence of osteoporosis, possibly due to long term dietary inadequacy of calcium and vitamin D, The elderly frequently have an aversion to milk, a major dietary source of calcium and vitamin D (Theuer, 1971). One of the most consistent findings was that low intake was more likely to occur if income was low and that obesity was more prevalent in higher income groups. Aging is a reflection of many molecular, cellular, and systemic processes that take place with time. A number 23 of physiological changes occur which may modify or be affected by an adequate nutritional status. Gastrointestinal functions decline with age, as summarized by Weg (1979) in her book Nutrition and the Later Years : a. the parietal cells of the stomach diminish in their capacity for HCL secretion, b. there is a reduction in secretion of digestive juices, c. there is a decrease in the mobility of the gastrointestinal tract, d. a decrease in calcium absorption is measurable, e. there is a reduction in the re sponsiveness and speed of the neurons in the autonomic nervous system of the digestive tract. (p. 25) Therefore, a number of processes basic to the digestion and absorption of nutrients are impaired by age and suggest careful evaluation of nutritional requirements for the elderly. Renal functions also decline with age which leads to a decrease in: 1. the glomerular filtration rate, 2. an effective plasma flow, 3. tubular absorption and excretion. It appears that the decreases in renal function accelerate with advancing age,(Lindeman, 1975), and it has been suggested that this decline is related to loss of nephrons. At 70, one has half to a third fewer nephrons than at age 30 (McKeown, 1965). 24 Physiological changes should be known and under stood before an adequate nutritional program can be ration ally developed. The Recommended Daily Dietary Allowances of Nutrients During this century, the proportion of people aged 65 and above has increased faster than knowledge of the effects of aging on nutritional requirements for health maintenance. Unfortunately, careful research aimed at the determination of requirements of most nutrients, especially for the elderly, is just beginning. At present, neither current United States nor international dietary allowances have included any separate recommendations for nutrients for the elderly. Energy Requirements The maintenance of desirable body weight throughout adulthood and old age is dependent upon achieving a balance between energy intake and energy output. It is evident, from studies of adult populations, that body composition changes throughout life, with fat increasing and metabol- ically active tissues being slowly reduced. This reduction accounts for the fall in basal energy metabolism along with which there is often an ever greater reduction in physical activity. As a result, less food is needed to meet energy requirements and unless food choices are made with great 25 care, the amounts of essential nutrients consumed are likely to be less than during the more active years and may fall below desirable levels. Also, the limited and monotonous social environment of many older people often fails to afford the usual stimuli for a good appetite. For this group in particular, it is important to ensure that the smaller quantities of food consumed are selected to provide the needed amounts of essential nutrients. Efforts should be made to stimulate appetite by providing an environment that makes eating a pleasure rather than a necessity. In addition, physical activity should be con tinued in adult life and into old age. Proteins All proteins consist of a mixture of amino acids. There are more than 20 such acids, slightly under half of which cannot be synthesized by man and are known as essential amino acids. Every protein is unique in pattern and its quality is almost more important than its quantity. Most good sources of protein are also carriers of important vitamins and minerals. The importance of proteins is related principally to their function. All enzymes identified thus far are proteins. Enzymes, which are the catalysts of all metabolic reactions, enable an organism to build up the chemical substances necessary for life (proteins, nucleic 26 rH k O C D r - • • • • T l t ) O C O C D 0 G 5 rH fd C D M H Td O rd • n C D Ü 4 - » X 'd < ■ H 0 C D rH 0 C O g Id C O ^ C D g S 3 TJ ( U s , s , C D rH 0 0 d J tp%-~ o o o O Xi 0 ü ■rl d) C ! rH o L D o o 4 - » O 4 - > !3 rd (d 00 C N o • n A fd M Ü (N (N C N C N C O 0 s > i A: 1 1 1 1 rd rH C D tj>Xi o O o o -H • U -P o o O ID o o o o T3 ^ 1 — 1 • • rd (U -H o o ID V £ > O O C N C D -rl • C 5 T f C N O rH 00 1 — 1 C D 1 — 1 C O C N Ü u a M < N '— C N rH ' rH 0 • 0 • H 0 a C O 0 >1 •rl M H u ■ s tn 0 0 U C D Xi q C D 1 — 1 4 - > Ü -p C 0 0 p C P • w O O TT TT 0 C D rd S 3 C P •H r ' r - C D C D ■o 1 — 1 C D •rl TJ -P rd C O 43 (p Q ) V , > C D C O 1 — i TJ tP C D •P rd -H q 0 12 *' ( U ( U 0 C P rH rH ffi ^ C D C D rd •P § G C O 00 C D C D •P S 3 •• Ü 0 r - r~ C D C D Ü >1 0 C P S 3 Ü 1 — 1 1 — 1 1 — 1 1 — 1 C O rH -rl 0 ID C D C D 44 • 0 p :; C H 4 - » (d Td U C D 0 rd g H 1 — 1 TJ G \ 43 n c C O -rl C O Td Ü rd fd ^ **«v C D X C D C D P r ) rp O O Xi O Ü C O fd -P rH ID ID C N C N 0 u 0 -p C D C O Xi rH 1 — 1 1 — 1 1 — 1 0 Q* C D > C O 4 - > tP Id 04 -rl C D C D X5 •H M rd Ü K K C n O J 43 W -H 12 ^ C O • 1 — 1 ( U tn O O ID ID U •H 44 fd 12 r - r~ ID ID C D I d 0 C O S 3 Xi C D S C D 0 w 4 - » -rl >1 Ü •p C O 0 P G S 3 4 - > -p 0 C D C D rd rd d rH rH nd > % tp •P rd 0 r d 0 \ -rH Ü 0 Ü rH C O ( U Q ) C O C O 0 m I— 1 C D K tP U ID C D (d rH rd Ü < rd r - r - -rl CP rH S 3 d C D 1 + 1 + rX C D rd >1 C D rd 1 — i y £ > 1 — 1 C D }2 G 0 p •P ( U ID ID r - B C D O rd Ü s: 0 rH -H -P C / a O 4 - > C D C D II r d -iH 44 r — I % a O 0 • - n >1 o >i44 U C O •r-> C P •• 0 C D rd P O C D P C O 1 — 1 C P C D o Ü C D C D fd Q )0 O P -P 1 — 1 G Z C D r4 0 rd rd C D rd 0 U S P 4 C / a C D 4J 0 27 acids, carbohydrates and lipids), to convert them into other substances and to degrade them. Life without enzymes is not possible. In addition, the quality of the protein should be such that it is rich in the essential amino acids and it should be supplied in a form that is easily digestible. Thus, fish, soft cheese, and lean meats, as well as vegetable proteins, are good choices. On the basis of current knowledge, the recommended intake of proteins is 0.8 g/kg of body weight per day. Thus, the allowance for a 70 kg man is 56 g of protein per day and for a 55 kg woman, 44 g per day. But special consideration has to be given to the elderly, whose energy intake and needs tend to be low. On the basis of the intake of protein recommended by the Committee on Dietary Allowances for persons 50 years and over, some 12 percent of the calories are provided by the protein allowance (National Academy of Sciences/National Research Council, 1979). Young (1978) advocates one gram of protein per kg body weight per day for older persons in compensation for the reduced efficiency of gastrointestinal activity, infection and/or changed metabolic patterns of disease accompanying age. In making recommendations for protein consumption by the elderly. Harper (1978) mentions two opposing 28 considerations must must be kept in mind: 1. Many high protein foods, such as meats, are excellent sources of minerals and iron, and in sickness they are particularly valuable sources of nutrients when caloric intake is low. The National Academy of Sciences/National Research Council emphasizes that protein intake in excess of the RDA is desirable for this reason. 2. On the other hand, renal function tends to deteriorate with age so the work of the kidneys is increased by the need to eliminate a large quantity of nitrogenous end products when protein intake is high. The logical, practical solution is to keep a balance between the two precautions by recommending that the protein content of the diety be kept close to 12 percent of the calorie total. (p. 75) The appropriate intake of protein cannot be over emphasized; the aging person is particularly vulnerable to nutritional deficiency imbalances because of chronic diseases that put added stress on the body systems. Severa]. studies suggested that the demands on the body during stressful periods may not only lead to nutritional im balance but to illness, and finally may affect the rate of age changes (Moss, 1973; Rahe & Arthur, 1978; Selye, 1970; Weg, 1980). Extreme environmental or physiological stress increase nitrogen loss (Cuthbertson, 1954) and there is evidence that less severe stress may do so as well (Masek, 1962). Infections, fevers, and surgical trauma can result in substantial urinary nitrogen loss and greatly increased energy expenditure (Border, 1970). Severe infections and 29 surgery should be treated as clinical conditions that require special dietary treatment. Carbohydrates Consumption of sugars increased during the first part of this century; since about 1925 sugar has remained fairly stable at 16 to 17 percent of total dietary energy. Complex carbohydrates, present in starchy foods, have gradually declined 43 percent from 1909 to their present 2 9 percent of dietary food energy. In the same interval, the consumption of fats has increased from 32 to 42 percent of food energy because of increased use of separated fats and oils and, less importantly, of meat (Page & Friend, 1978) . The principal carbohydrates in foods are sugars, starches and cellulose. The sugars include the mono saccharides and disaccharides in refined sugars, jams, jellies, syrups, honey, fruits, soft drinks, and milk. The starches are the polysaccharides of cereals, flour, potatoe^ and other vegetables. Man, like most mammals, is capable of converting amino acids and the glycerol moiety of fats to glucose, and as a consequence there is no specific dietary require ment for carbohydrates. A large proportion of the caloric intake should be derived from complex carbohydrates such as 30 fruits, vegetables, and whole grain cereals and there are also generally good sources of other nutrients (vitamins, minerals). Fiber Dietary fiber is generally defined as the sum of the indigestible carbohydrate and carbohydrate-1ike components of food, including cellulose, lignin, hemi- celluloses, pentosans, gums, and pectins. These non- digestible substances provide bulk in the diet and aid elimination. Dietary fieber consumption has decreased in developed countries since the turn of the century. It has been claimed that the incidence of a number of diseases— most notably diverticulosis, cardiovascular diseases, colonic cancer, and diabetes--is inversely related to dietary fiber consumption. Many hypotheses have been proposed to explain a possible etiological role for the lack of dietary fiber in the development of these diseases Although these hypotheses are plausible and suggestive, they have not been proven experimentally. The subject has been extensively reviewed in recent monographs (Burkitt & Trowell, 1975; Reilly & Kirsner, 1975 ; Roth & Mehlman, 1978; Spiller & Amen, 1976). No specific quantity has been determined, but a moderate increase in dietary fiber is desirable and achievable by increased consumption of vegetables, fruits and whole-grain cereals (National Academy of Sciences/ National Research Council, 1979). Fat Dietary fat provides fatty acids which are essential components of every cell membrane and for the absorption of the fat-soluble vitamins. Except for these needs, which can be met by a diet containing 15 to 25 mg of appropriate food fats, there is no specific requirement for fat. Besides, a large intake of fats may repress the appetite for more nutritious and essential foods (National Academy of Sciences/National Research Council, 1979) . Vitamins and Minerals Vitamins are organic compounds that the body is un able to synthesize and that must be supplied in the diet or from synthetic sources. They are intimately involved in metabolic pathways as co-enzymes in hundreds of enzymatic reactions. Small quantities are necessary for normal health and growth in higher forms of animal living. If a vitamin is absent from the diet, or is not properly absorbed by an organism, a specific deficiency disease may develop. Major diseases have been associated with dietary lack of vitamins but during the last 70 years most of these have ceased to be of major importance. But even if the major diseases have disappeared, many sub-clinical nutritional 32 deficiencies may result from our life-style. Dealing with health and nutritional problems, professionals must be aware of the serious consequences for human nutrition of food processing, particularly the removal of essential micro-nutrients from grains and sugar. The large losses (20% to 90%) of the micro-nutrients in refining, processing canning, and cooking of foods may be among the major con tributing causes of the poor nutritional status and poor health of many older persons (Schroeder, 1971; Weg, 1979). Recent animal and human studies have also suggested critical roles for a number of major minerals and trace minerals that are lost in the processes of refining foods (Schroeder, 1971; Weg, 1979) . The dietary requirement of each water soluble vitamin has to be taken regularly because a reserve cannot be built up in the tissues. Calcium Because osteoporosis is a condition often met with in the later years, and as there is a lot of controversy on the subject, it is important to mention what the National. Academy of Sciences/National Research Council (1979) recommends as the RDA requirements : In view of accumulating evidence that it is impossible to prevent osteoporosis in adult life with dietary calcium alone, there is no longer reasons, provided vitamin D intake is adequate, to recommend so relatively high an average level as 800 mg/day of calcium for this purpose, per se. (p. 25) 33 It has been suggested that osteoporosis may, in part, be due to chronic calcium deficiency because of the customary low intake of calcium in the population. Foods rich in calcium, and a supplement of a gram a day of calcium, for those who have symptoms of osteopororsis are recommended during adult life (Winick, 1977). Mineral deficiencies in serum and tissue levels have also received some recent attention. In congestive heart failure, muscle biopsies show evidence of body depletion of magnesium (Lim & Jacobs, 1972; Weg, 1979). Chromium has been found deficient in persons who have died of heart attacks. Chromium deficiency in animals is characterized by symptoms similar to the degenerative diseases associated with age, such as impaired glucose tolerance, diabetes or cardiovascular diseases (Levander, 1975; Weg, 1979). The addition of zinc to the diet of wounded persons speeds the healing of the wounds (Lear, 1970; Weg, 1979) . Current recommendations for appropriate nutrients, especially micro-nutrients, are in terms of prevention of depletion instead of prevention of specific diseases. In the World Health Organization's reports (1970), the target is the maintenance of body stores, e.g., the iron require ment is such that it prevents not only the anemia that could result from a lower intake of iron but prevents also 34 a diminution of the desire level in various parts of the system, blood, liver, etc. There is little iron that is eliminated and the stores of Fe need to be in a retriev able, usable form. Water Without water survival of the human being is considered limited to four days (Labuza, 1977; Weg, 1979). All metabolic reactions in the body occur in an aqeous medium and even small changes in tissue and fluid content can interfere with normal metabolism. The composition, concentration and volume of body fluids, with water as a base, are dependent upon the appropriate body monitoring of the electrolyte and fluid balance (Weg, 1979). About 65 percent of a normal body consists of water distributed between three compartments (1) within the cells, (2) be tween the cells, and (3) within the circulating system. Requirements vary from one individual to another. A requirement of one liter per 1,000 kilocalories consumed has been calculated, so approximately two liters of water a day are recommended (McDermott, 1971) . In healthy people water is lost by evaporation from the lungs and skin, through the urine, and stool. Lung and skin losses are increased by work that causes sweating, particularly in a hot, dry climate. The kidneys usually excrete between one or two quarts of urine per day. The 35 intake of water should be encouraged for efficient func tioning of the organism. Nutritional Counseling The diet of many elderly people is low in essential nutrients, possibly because of undesirable dietary habits such as undereating, overeating, or monotonous meals. Often the diet is primarily composed of easily prepared foods with empty calories, low in vitamins A and C and iron (Krehl, 1974). A study was made of the effects of community nutrition services on 234 non-institutionalized elderly people aged 65 or older. Many of the problems were related to overweight and long-standing inappropriate habits. The results indicated that counseling can stimulate an in creased awareness of nutrition and improvement in the knowledge of nutrition and food selection. These elderly persons seemed to have a definite desire to achieve good health and were receptive to the nutritionist's recommenda tions. However, economic and physical limitations often influenced their ability to adhere to the recommendations (Rae & Burke, 1978). During counseling, the therapist may also determine more adequately the nutritional status of the aged person by physical assessment and comprehensive evaluation of food 36 consumption and activity such as: poor dentition, reduced income, reduced social contacts, and mobility. Julius B. Richmond, M.D., Assistant Secretary of Health, said at a Congressional hearing of the Select Committee on Nutrition and Human Needs in October 1977: Many experts now believe that we have entered a new era in nutrition, when the lack of essential nutrients no longer is the major nutritional problem facing most American people. Evidence suggests that the major problems of heart disease, hypertension, cancer, diabetes, and other chronic disease are significantly related to diet. Although improved nutrition alone will not prevent these diseases, more attention is being focused on the underlying dietary habits which may be antecedent or contributing causes of these conditions. We view this as a positive sign of the progress that has been made thus far and that undoubtedly will continue . . . we believe it is essential to convey to the public the current state of knowledge about the potential benefits of modfying dietary habits, without overstating the benefits that could possibly result from the adoption of alternative dietary practices, such as reducing excessive caloric intake and eating less fat, less sugar, and less salt. (p. 155) 37 CHAPTER III METHODOLOGY The purpose of this study was to determine the effect of nutritional counseling on the eating habits of the elderly. The secondary purpose was to determine if a change in eating habits could possibly modify physiological parameters such as weight, blood pressure, cholesterol, triglycerides, total lipids, uric acide, and glucose. This chapter describes the procedures used to gather the data. It is divided into five subsections: (1) design, (b) setting, (c) selection of subjects, (d) experimental treatment, and (e) measurement instruments Design This evaluation experimental design includes pre- and posttests with an intervention or a treatment between the two. There were two groups involved : one group which participated in the intervention and another group which served as a control. Both groups were pretested and post tested at the same time, before and after the experiment. 38 Setting The investigation was conducted at the Andrus Older Adult Center in Hollywood, California. This center was sponsored by an Administration on Aging (AoA) IV-C grant, and serves a high density of elderly population in Los Angeles. The center offers different services to the elderly population of Hollywood, including primary health services which are dispensed by two retired physicians and a nurse on a free basis. Selection of Subjects Volunteer subjects were randomly selected from the clientele of the center as they presented themselves. A complete physical examination— including weight, height, blood pressure, and a complete blood analysis which in cluded cholesterol, glucose, triglycerides, total lipids, and uric acid— was completed on each subject before group assignment was made. At the time of the physical, a food record questionnaire was given to each subject, on which they were invited to record all the food and drinks they consumed during a 24-hour period. This questionnaire was to be filled out for three separate days. The days did not have to be consecutive, but were to reflect a typical day's menu. Written and oral instructions were provided (see Appendix B), and the subjects were asked to return the questionnaire as soon as it was completed for analysis. 3^ The physical assessment was required prior to the evalua tion and was used to eliminate subjects for whom the pro gram could have been an above-average risk. The sample was composed of 30 subjects, 10 men and 20 women aged 59 to 89 years old. The first 15 subjects composed the treatment group and were invited to meet together with the investigator in the fourth week for the presentation of the program. The remaining 15 subjects made up the control group and were invited to come back for a second blood and food analysis in the tenth week. Experimental Treatment Description of the Program The program was divided into three parts : 1. the pretest, including physical examination with blood analysis and food recall questionnaire; 2. the treatment sessions; 3. the posttest including blood and food analysis. Pretest Physical examinations and blood analyses were done as soon as the subjects joined the program. At the same time, the food record questionnaire was given with an oral and written explanation encouraging the subjects to return it in the fourth week. The treatment group was invited to come to their first treatment session in the fifth week. 40 Treatment Sessions The treatment sessions were divided into two parts: (1) formal educational sessions, and (2) individual nutritional counseling. The formal education took place in group sessions and consisted of a brief discussion of the goals, the diet suggested (low-fat/cholesterol) in accordance with the RDA recommendations for men and women 51 to 75 years old and the results expected of such a program. Exercise was discussed at length, together with the benefits of non smoking. Physiological change with aging was discussed, in addition to common and normal problems encountered by the elderly, such as constipation, retarded digestion, malabsorption, and intolerance to foods. Lists of foods containing cholesterol and proteins, some common complex carbohydrates and their sources, the fiber content of some common foods, and sources of the different vitamins and minerals were furnished at these sessions. These helped the subjects in planning their shopping and menus. A rough draft of the Pritikin diet (see Appendix D) was given at the first session as a guide for developing changes in eating habits. This diet was to help them reach the goals more rapidly and efficiently. It was not a "must" but a strong suggestion. The diet consisted of 41 approximately 10 percent protein (which meets the RDA), 10 percent fat (most difficult point to attain) and 80 percent complex carbohydrates, with a total calorie intake of 2,100. Pritikin's (1974) apparent success was reported to the subjects as it appeared in the Journal of the American Medical Association (J.A.M.A.). Particular results included 10 to 30 percent drops in both systolic and diastolic blood pressure, as well as a decrease in blood cholesterol in a five-week period. On one occasion, a taste panel was held. Foods consisted of low-calorie beverages, vegetable and salad dressings. Simple recipes and sample menus were passed out for optimal use. The individual nutritional counseling was geared specifically to each individual's needs. Weekly, for five weeks, the treatment group met with the counselor. At this time, each subject was weighed, blood pressure taken, and food ingested reviewed, together with problems encountered. Discussion of outside activities such as hobbies, sports, exercises, or classes was also included. Special attention was given to helping participants meet the requirements of the essential nutrients. Personal problems, such as living arrangement difficulties with husband/wife, mother/father. 42 inadequate income to buy proper foods, the degree of comprehension of the participants, accessibility of food stores, and health problems such as poor vision, poor dentition, indigestion, allergies, or reaction were dealt with individually. A simple questionnaire was used to obtain other data, including ethnicity, country of birth, marital status formal education, yearly income, and living arrangements. This was a tool for further investigation but the subjects were free to avoid particular questions if they wished. Posttest The tenth week was devoted to the collection of the second food record questionnaire and'the repetition of the blood analysis as in the pretest for both groups. Description of the Control Group The control group subjects were submitted to the same physical examination as the subjects, including blood tests and food record questionnaires before and after the intervention. When the experiment was over, the remaining control subjects were given special nutritional counseling in relation to their blood results and their food consump tion. They received the same "package" (different lists, Pritikin*s diet, recipes, etc.) as the treatment group. 43 Measurement Instruments The dependent variables, the basic nutrients and some physiological parameters were measured before and immediately after the experiment. The measurement instru ments included: (a) food record questionnaire; (b) laboratory blood tests; (c) sphygmomanometer; (d) scale; and. (e) statistical treatment. Food Record Questionnaire This tool is designed as a measure of the nutrient calorie content of food which is adaptable to computer use in making quantitative and qualitative analysis of foods, meals and diets. Dietary data were obtained from three days* food records in which subjects were asked to write a description of all foods and beverages consumed, the quantities eaten (1 teaspoon, 1 glass, 1/4 of a pound, etc.) at what time (night or day), the ways of cooking and the recipe whenever it was a homemade dish. After the three days were completed, each respondenij: was personally contacted, and the food intake records were examined for completeness and clarity. If details had been omitted on the questionnaire the respondent was asked to complete the instrument to the best of his/her ability with the help of the counselor. Because some of the foods eaten by these people were not listed in the Agriculture Handbook (Adams, 1975), 44 more details were obtained in order to assess their content This was done on an approximate basis. In rare instances, it was necessary to derive the nutritive value of an un common item from a standardized item. Blood Tests; Biochemistry Biochemical blood tests prescribed by the physician were first performed by him on a sample drawn from a fasting participant. The second specimen was taken by a nurse under the same condition. Blood samples were obtained by venipuncture of a prominent vein in the cubital fossa (the bend of the arm). Fifteen ml of blood were drawn into a vacutainer, then cetrifuged for 20 minutes to separate the serum from the fibrin and cells. A minimal> relative cetrifugal force of 1000 G is adequate to effect the separation of serum from cellular material and allow the material to form a barrier. Speed in revolutions per minute (rpm) may be related to relative centrifugal force -5 2 (G) by the following formula: G = 1.12 x 10 (rpm) where Vr," expressed in cm, is the radial distance from the center of the centrifuge head to the bottom of the tube. The blood specimens were refrigerated until the laboratory (Met Path) picked it up a few hours later. Results were mailed back within a week. 45 Sphygmomanometer This is an instrument,for measuring blood pressure. Also, a stethoscope (an instrument used in auscultation) was employed here to hear the arterial beat. Scale An upright doctor scale was used to weigh in kilograms, and height in centimeters. Statistical Treatment A t test, Pearson correlation, and a descriptive analysis were used. 46 CHAPTER IV RESULTS The study is an evaluation experiment consisting of a pre-posttest design. There were two groups involved, one group being submitted to a course of dietary interven tion and the other group serving as controls. This chapter contains the results of this study. Physiological variables and food record data were trans ferred to data processing cards for computer analysis. The statistical program employed was the Statistical Package for the Social Sciences (Nie, Hull, Jenkins, Steinbrenner & Bent, 1975). All the statistical analyses were done at the Computer Center at the University of Southern California, Los Angeles. The accepted level of sig nificance for the study was p = .05. The results of this investigation are presented as they relate to the research questions and hypotheses. Treatment Group The experimental group consisted of 15 participants, 5 males and 10 females aged between 59 and 77 years. A physical description of the subjects is presented in Table 6. 47 u n Vû 00 I—I o i n o 00 i n o o t H -H VD KO •n ■ n i n m m c r > i n i n VO VÛ KO I—I p H rH i n i n I—I i n I—I -H ■H r~ KO o o ■H ■H -H ■H r o r o k O KO i n c r > i n L f > pH rH rH -M Ü pH I—I I—I I—I ■H 48 All were Caucasian except one female who was of Japanese background. Nine among them were of the Jewish faith, and five were from other sources. (National origin is presented due to the fact that there may be ethnic biases related to food intake.) Four subjects were single, five were widow(er)s and six were still married. Three participants received less than a high school education and twelve received more. Three persons had incomes under $5,000 dollars a year and nine received over $5,000/year. Two failed to answer this question. Five, among the group, lived alone, ten lived with their spouses or others. Two members (who happened to be a couple) had a death in the family, and had to leave the country for an undetermined period. Thirteen subjects completed the experiment (see Table 7). Control Group The control group consisted of 5 males and 10 females aged between 60 and 89 years. A physical descrip tion of these subjects is presented in Table 6. All members were Caucasian, nine of them were of Jewish origin, one German, and the other English. Two were single, seven were widow(ers) and seven were still married. Two received less than a high school education and thirteen received more. Two subjects received less than $5,000 income a year and thirteen received more. Three lived in 4 9 Social Table Description (n^ = 13, n 7 of ' Subjects c = Treatment Group Control Group = 13) ("c 9) Before After Before After Sex Males 5 4 5 1 Females 10 9 10 8 Ethnic Background Jewish 9 7 6 3 German 1 1 1 1 Italian 1 1 2 1 Irish 1 1 0 0 English 2 2 6 5 Oriental 1 1 0 0 Marital Status Married 6 6 7 4 Widow(er)s 5 3 7 5 Single 4 4 1 0 Formal Education < high school 3 3 2 1 > high school 12 10 13 8 Income < $5,000/year 3 3 2 1 > $5,000/year 9 7 13 8 no answer 2 2 0 0 Living Arrangements alone 5 5 7 4 with spouse or Other 10 8 8 5 50 boarding houses, seven lived alone, and eight lived with their spouses or others (see Table 7). Six members of the group abandoned the experiment for various reasons: two members became sick and refused to come for their posttest, one found it impossible to travel to the center, one started a new job and was not available, another had visitors in town and did not have the time to record her dietary intake. With these absentees, the group was left at nine. An effort was made to gather a control group similar to the treatment group regarding origin, education, marriage, etc. Comparison of Diets Between Treatment and Control on Nutrients A t-test analysis was used to evaluate each of the nutrients recommended by the RDA in order to compare the diets of the two groups before and after the experiment. Another t-test was performed on each nutrient before and after the experiment within each group. They are presented in tables which show the X, the standard deviation, the t value, and the statistical p significance of each test. 51 Mean Comparison Between Treatment and Control on Pre-Nutrient Analysis Before the experiment there was a significant difference between the groups regarding calories, fats, and carbohydrates. When these figures are converted into percentages the results shown in Table X are obtained. The high percentage of fats consumed by the control group explained the 440 Kcal difference between the groups even though their groups' consumption of CHO was lower. It can also be seen that the treatment group had better sources for their calories ingested at the beginning of the experiment. Fiber and all other nutrients did now show any significant difference. (See Table 8 for mean comparison of these two groups on pre-nutrient analysis.) Mean Comparison Between Treatment and Control on Post-Nutrient Analysis After the experimental regime there was still a significant difference between the groups regarding calories, fat, and CHO, for the same reasons as in the pre test. The treatment group reduced their consumption of fat from 27 percent to 21 percent, while the control group did not change. In addition, the consumption by the treatment group of less protein (2%) and the increase of 2 percent 52 { / ) C L 3 O i- C3 O' — S- en 4 - > c II o o o c *o c • ' ns CO 1 — 1 4 - J C I I C D 0 0 E h - 4-> C C D 03 C D X i S - C D ro h - h - C D C C D C D ro 5 C +-> «st C D Cû 4-> C e C D o C D L + 3 s - 3 C O Z CL 1 E C D O S- c_> c fO C D Cl. Xi O & - Û- q - Q Q CO l x “ o CO Ix C D X » m fO * - K -K - l e -K UDOi—lOLOUDCDOr—<C3^0 rx.oi—•o o o O'ï I'C xcsjcot—« o o o o o o o o o o o e nL O 0 0L O 0 0 r o C M C M 0 0 C M < ± o o Oo o O o o L O L O 1 — 1 0 00 0 L O < 3 - 1 — 1 o C M L O <y\ c y > C D o 1 - H r o OL O Oo r H L O r o 0 0 r H 1 — 1 C M 1 — 1 1 — 1 O i r o 1 r H r o i 1 C M i o o o 1 — 1 1 o r H o 1 — 1 1 1 — 1 i o o 1 1 — 1 1 o i L O o L f ) i i CM ir> 1 — 1 l O r -x r o C M C M r o C D C D O r H L O r o « d - L O r o o O o o O o L O r o C M C M 1 - H C M 1 - H r -xL O L O i i i I r o t— I i i i r o L O L O C D ■ s d - r ~ . L O i-H 0 0 r ol O L O C O C D (M C D 1 — 1 r o r o r oL O L O 1 — 1 C M O O o o L O C O 1-H 0 0 0 1-H C M I X r o L O r x . L O L O C M r o r o C D r o 1-H • 3 " « 3 h r o■ 53- « 3 - L O L O C M 0 0« 3 - C D 1-H L O 1 — 1 r o r o L O r or< r -xO r o L O rH. 1 — 10 1 — 1 r o L O O0 0 C D r -x C D C M 1 — 1 C O C D rH C M C D ç n C D C M CO L O ■ c j - LO 1 — 1 0 0 1 — 1 1-H 1 — 1 C M r o C D 1-H L O n x . L O C D r~ . C M « 3 - L O r - x Or o r o « s i - C M 1 — 1 L O C M r o 1-H O0 0 0 C M 1-H 1-H o 1 — 1 C M C M L O ■ 5 3 -o L O ■ 5 3 -LO C D • 5 J - 1-H L Or -xC M « 3 - CM CD 1-H CD ■ 3- 0 <3- ■ 3- 0 0 0 r-xLO ■3- ro LO 1 —11 —1 ■3 «3- r-x CD 1-H i-H iH 1 — 1ro 00 ■ 3-M. M. ■ 3-CD CD LO 1-H 1-H LO ro CM CO CD ro <3 1 — 1 LO ro CM CD ro 1 — 1 LO 1 — 1 r H 1 — 1 ro CM 1-H 1-H 1— i C / î Z3 U) s - O X i i — o CM (O s - fo n z - i— 03 X : eu mcjn-u-ou-oû-u- I i n « = C < / J (O *<0 0 +-> 4 - i • r — X3 ro o *1 ” - C "I— z o _ > I— ( X c ( _ ) o • ro 4-J • r — . | — z > JZ u CD c -r- • r — C D M 3: LO 1 —I o o V V o . C L - K - K - K 53 in the protein consumed by the control group accentuates the differences between them. Fiber in the treatment group showed a significant difference which was a desirable goal for the treatment group as the control group showed a small decrease. The calcium, phosphorus, riboflavin and zinc diminished in the treatment group significantly in relation to the control group. Vitamin C showed a significant increase in the treatment group versus the control group, which was also desirable. (See Table 9 for mean comparison of these two groups on post-nutrient analysis.) Mean Comparison Within Treatment Group on Pre- Post-Nutrients Although the decrease of the protein and fat in the diet of the treatment group was not significant, it showed a decrease in the expected direction. There was also a gooc. increase of carbohydrates. But the most significant change was in the fiber category (p = .01). (See Table 11 for mean comparison within treatment group on pre-post- nutrients.) Mean Comparison Within Control Group on Pre- Post-Nutrients The mean comparison within the control group showed no significant change between pre- and post-nutrient 54 t o a . 3 o s - C D C D X J CO C t - H ro sV Î - r o ID ( U • ! — 6 - ( D I — >) C ro <v c <D <C 4 _ > 4J a> c CO c u c % O +J ( D 3 T ? ro 4 - ) O . ( D §2 O c ro C J X ) o S - C L Q OO 1>0 Q CO Ix (U - K * - K - K 4 ( - K - K - K 4 ( 4 ( 4 ( - K C D i— It— lO C D lX O O V O LO O r^O C O C O C M ^O LOOOOI^OOO»-iOL03'3-OCOOOLO 4 • 4 4 4 4 4 4 4 4 4 4 4 o o o o o o o o o o o o o o o o o o CDcor^Lnr^coor^LOCDCNjLOLOoooorocMCD ror^r^CDCMOCOCD«3CDLor^oorocD'3-r>ovo ocMcMLnocsi'3-ro I I I I I II rH O O O C M O C M C M O I I I I I I I ro L O ro » - H «3 *3 L O ro o « 3 ro cO L n co o o ro r-iro io O r-H ro < N JC M C M L O 3- C M ro ro L O c d c m lo c d ro 3 " 3 " lO 3 " L O 1 — 4 I I L O 00 lO 3 - L O L O L O 00 C M L O C D C M r>«3-L03-3-cMCMLOLOOOLoroOr-H3-3-roro r H 0 0 1 -4 1 -4 3 - r o 0 0 C O C M L O 3 - C M O 1-4 3 - C M 1 — 4 C M C D O O 3 - 1 - 4 C M C D 3 L O L O r o 0 0 1 — 4 r o1 — 4 C M r o 3 3 C D L O 0 0 L O 1 — 4 0 0 C M 1 — 4 L O o 1 — 4 C M 1 — 4 L O 3 C M 0 0 L O C M L O L O 1 — 4 0 0 1 — 11 — 1 1-4 r o C M 1 — 4 C M C M C D L O C D 0 0 C M 3 L O L O 1 — 4 O O C D C M 1-4 1 — 4 O O 1 — 4 C M L O L O L O L O OOC D 3 1-4 L O r o C M C M 1-4 O O r o 1 — 4 C D C D C M ro 3 1 — 4 M s C D 1 — 4 3 C D L O O 3 CD OO 1 —I r— 1 —1 1 —1 L O r o C D 3 r o C M M . C D r o O O 1-4 C D 3 L O 3 0 01 — 4 1 — 4 C D L O C M M . L O 1 — 1 L O C M 3 1 — 4 O r o C D 1 — 4 O 3 0 0 L O 1 — 4 C M M . 1 — 4 (D C D ( D 3 L. O X .r~ 3 X (D <C c L _ D 4 - > ro c u S - X ID X o 4 - > c uo (D r O ro Oo a CD U O r— O 4 - > O X O 4 - i 4 - > X ro4 - >c fO CM ro L . ( O □ r ro X C D ro O X > Z C _ )o _U - o Ll. CD o _ L i . Z o_ > Od z > M l 3: L O 1- 4 o o V V CL. CL - K - K 4 c 55 Table 10 Percentage of Total Calories Absorbed in Pre- and Posttests by Treatment and Control Groups Pre Treatment Group Control Group kcal Pro 304 21% 364 18% Fat 396 27% 657 33% Cho 772 52% 972 49% Total 1,472 100% 1,993 100% Post kcal Pro 252 19% 348 20% Fat 279 21% 576 32% Cho 82 8 60% 860 48% Total 1,359 100% 1,784 100% 56 ç o X 3 O s - CD CO 4-> C r— ï Ë II 4-3 H - <o C o> c C eu X X rt3 4-3 s - h - 4-3 3 3 Z C 1 o 4-3 to to O s - X ns 1 X eu E s - O X o c rt3 Z 4 e 4 e X 3 o ro o 3 rH M in 00 . o KO 3 f-H T — t LO O CM rH 00 & _ X O O o o O O O o o Ms Ms o LO C O LO . LO o 3 3 CO LO Ms 3 O rH LO rH 4 - 3 O o rH rH O ro rH iH o 1 1 1 1 ro 4 - <4- vn 00 ro ro 3 3 CM ro o LO m rH 1-4 rH 3 o Q rH CM 3 1 1 1 + CD Ms 00 O o CO CM CO rH Ms rH LO O CO CM rH CM LO LO e n O CO rH CM CM CM CM 1-H tn < 3 0 T— 1 3 o ro 3 CO 3 3 rH CD CM | x CO 3 M. CD L O ro 3 rH CO M. tO rH CM O CM CD 3 3 3 rH Ms rH Ms LO 3 ro CD o rH C D m LO LO rH rH ro 3 3 CO iH CM L O 3 ro C D rH rH rH rH rH 4-3 4 - 3 4 — ) ■4-3 4 - 3 4 - 3 4 - 3 4 - 3 4 - 3 e u to e u to e u to e u to e u to e u to p to p to p to S - o S s . o S s . o S s . o s- p S s . o S s . o S s . o S s . O X X X X X X X X X X X X X X X X X X to e u 3 to S s . X e u c E o <o . 3 X s- e u s- X %. o 4 - 3 p u to to o o 4 - 3 o X o > CM f O s- f O H Z to X p rc o X X o X o X X u n r H O O V V X X ■ K 4 e 4 e 57 -o 4 - 3 O O P X P CO ro LO LO CM 3 LO LO t - H rH 3 o O 00 LO LO 3 CM 00 X o o o O O O o O O o s . X 1 — 1 LO CD ro CM LO Ms O ro 4 - 3 00 o CD CM LO 3 Ms ro CM O CM 1 t - H 1 O 1 O O O 1 1 - H o 1 ro CD Ms 3 Ms LO 00 o r -H LO LO 00 3 4- LO M- CD o o CM LO O 00 Q LO LO O CM CO r - 4 O LO t - H 1 LO 1 1 1 1 LO LO 3 LO CM t - H Ms 1 - H 00 LO Q CM LO CM 3 O 3 o o o o 00 CD CM 3 CM t H O 3 oo LO 1 - 4 3 Ms LO O CD O Ms CM LO t - H Ms Ms CM CD 1 — 4 3 3 t - H 3 CD CM LO CD O r - 4 3 O O 3 CO 3 00 00 3 O rH |x 3 LO Ms 3 00 Ms 1 —4 t - H r - 4 t - H t - H CD O LO ro C M 00 LO t - H LO LO CM ro 3 CM rH 00 o CD ro CM LO CD O ro 00 1 - H CM LO Ms ro 1 —4 CM 3 t - H to 1- H rH t - H t - H 4 - 3 4 - 3 4 - 3 4 - 3 4 - 3 4 - 3 4 - 3 4 - 3 4 - 3 p ( O P to P to P Ü O P to P to P to P z X > h- X z > Ml 3 tio t-H O o V V X X 4 < * * 58 analyses. (See Table 12 for mean comparison within control group on pre-post-nutrients.) Mean Comparison Between Treatment and Control on Pre-Physiological Parameters and Age There was no significant difference between the groups before the experiment except in age. The treatment group was significantly younger than the control group. (See Table 13 for mean comparison between groups on pre- physiological parameters and age.) Mean Comparison Between Treatment and Control on Post-Physiological Parameters and Age There was a significant decrease in the Systolic Blood Pressure of the treatment group after the experiment. (See Table 14 for mean comparison between groups on pre- physiological parameters and age.) Mean Comparison Within Treatment Group on Pre- Post-Physiological Parameters Analysis There was no significant change except in Systolic and Diastolic Blood Pressure and Weight. (See Table 15 for mean comparison within treatment group on pre-post- physiological parameters analysis.) 59 C V J e u X f O o X =3 o s ---'. CD CD t— U g o 4-3 c c- O o t o 4-3 ce •I— Q) •r— 4 .J 3 : 3 z c I o 4 - 3 V> to % 2 cO I X (U §2 O cO X X O X CD o CM 3 4-3 o 1 t-4 o 1 — 1 r-4 o o O o 1 rM X 4 - X M - 3 CD CD o o X o 4 - M . CM CM r-4 CM CM Q 1 i 3 3 X r-4 X O CD CM 3 CD X 1 —1 LO CO 3 CO CM CO CM X O X X LO 0 0 T-4 3 0 0 r— 1 « —1 CM r-4 X 3 CO CO CO 3 CO CM X CD X e n | x t—1 X 0 0 t— 4 M . CO 3 CO 3 X X CO CO M . CM M - CO O 0 0 X CD 0 0 X 3 r-4 CD 0 0 CM O r— 4 r-4 3 3 CD CM CM CO 0 0 X X t—1 T — 4 « —1 r-4 r-4 r-4 4-3 4—3 4-3 4-3 4-3 4-3 4-3 4-3 4—3 (U to 3Z C J X U- C J X < j X X 60 r—4 C D C M r—4 0 0 X C D M. X JO M. C D r—4 M- o C M r-H r-4 M. o s - O O o O o o o O O X • ; ■ 00 T—4 C O O O M- C M r-4 00 O ro o M. C O C D C M 3 3 C O 4-3 O 1 o i r-4 1 o r-4 1 r-4 1 1 — 4 r—4 1 O 1 X C O o 00 00 00 y- C D 0 0 X o o C M 00 o C O M- C D M. C O M. o 1 1 C M 1 1 1 1 r—4 1 x> 4-3 C o C O M. X C O X C O C M X X X C D 00 C M C X I r-4 o r-4 C O r-4 X C M o o O r-4 X 3 f M C O r-4 C O o cn X X C O O X C M X X C M M. r o o J = C U Z X > h- X Z > Ml 3 61 c o to X g è e u o CD s- < + 3 c *o o c C J ro ■a to c S -- e u 4 - 3 + 3 e u OO C E r-4 eu ro E &_ C U 4 - 3 ro (O X X ) e u fO s- 1 — 1 — ro U c e u CD e u O s 4 - 3 O e u CO (O > > c JZ o X to 1 « (— e u s. S- fO X X E o o O c OO f O O ) 4 c J 3 e v j 3 3 O X X rH e v j e v j O o ro M . r-4 X 0 0 CO 3 e v j & - X o o O O O o O o o M . X CO O X 0 0 3 C V J X 3 CD CO 0 0 3 1-4 O 0 0 C V J 4-3 C V J O O r-4 O o rH o r H 1 1 i 1 1 1 1 M - CD 0 0 C V J O C V J o O 3 X r — 1 C V J r-4 O O O 0 0 0 0 o X e v j O CO 3 (vO r-4 r o CO en r H r H C J X M . en r-4 r-4 X CD 3 CD | X M - 0 0 o 3 CO M - X C V J r-4 C V J rH o X X C V J O r-4 C V J M - « H CO LO 3 r-4 C V J rH T — # rH h- M . CD X r-4 CD X CD O en X X X O rH C V J M . X C V J r-4 C V J r H e u e u 10 s - i- t o e u 3 3 X J *o t o to X O (O t o o S- X %- X J e u U (U e u e u e u o & - • r - S - 4-3 e u _l u CJ • r - X r — Ol - V JD ( / ) t o > > < c O 4-3 tO e u O O X 3 4-3 X 3 J Z u rO CD o 4-3 O (O O CD X s - e u " o 3 4-3 C O O r ç j o 4 e rO CD J Z O S - s - •T— r— e u > o C J 3 1 — 1 — u LO CÛ O CÛ 3 62 C O to X ' — 3 CD g II CD O C O S - + 3 CO c «H o o II - o H - c C fO ------ + 3 to 3 c s . 1 —1 eu eu E 4 3 0 ) + 3 e u ro E X I eu ro fO î - S - h - h - ro C eu X eu l ô u + 3 eu CD OO O c " o o C O C O > ï S - X ro X X 1 E 4-3 O C O O O c ro 1 X 4 c M- O t H X C D X X t - H ja X C D t - H C M 0 0 C D X C M o s- O o O O O . O O O X C M en 3 M - 3 C M C D X 3 t — H X t - H r H X C D X 4 - ) O 1 O t — H 1 t — 1 1 C D 1 C M 1 C D 1 t - 4 1 t — 1 4 - 00 r - 4 O X C D X 3 4 - 3 t — r Q C M Q X X C D rH C M M. C D X X 3 r H C D t - H t - H rH M - , O en O C D X X r H OO C D | x X O X X X X C M r H C M t - H t H Q r - 4 3 O C M C M X C D M - X X C M X t - H X r H . 1 — T — r t — H C D O X X 3 C M | x X O C D t - H X X C M 1 — 1 r H t - H e u e u C O S - S - C O e u 3 3 -o X J C O C O O C O C O S- X s - X 3 e u o e u e u c u c u u s- H - S - 4-3 e u _ J o O • r — Q. r— O— X 3 C O C O > > <c O 4 3 (O 0 ) o O - O 4 3 - O SZ u ro en o 4-3 O C O O C D s - o 3 4 - 3 C O O rO O r rO X : O s _ s _ — e u > CJ) C D k- h- 3 ) . X X Q Cû 3: X o V Cl 4 « 63 LO Q ) X J t a C to o < /) C L >> 3 O « 3 S - C o <c + - > to c S - o > 0} E 4-) + - > Q) ns E Q> m . S - s-<-^ h- as CO C L « — » C r— Il X: as ■ 4 - > O H- •r- C 3 O C O O (/) to S - < o X: C L C L E o C J to o c C L r t J i o » 0) z s- C L - K ■ K 4 c XJ en to en O O O L O C O O C M < d - r-i C M r H o o o s- C L CD o CD O O o o O en to to C M O en to o C O C M to C M r H C O T T — 1 o 1 — 1 r H 1 — 1 C O C M C M O O C M 00 C M C M 00 C M o C M C O to C M 4 - 4 - 00 o O O C M L O r-4 «r C O r-4 es o rH r H r H r H r H en 0 0 o to en 00 L O Q L O « — » C M O o O C M r H i H to C O o 00 r > ^ to OO LO rH C M C M 00 r - 4 T — 1 r H r-4 C M 00 to LO CO r H | x e n o LO « —» CD CD en en to to 0 0 to en C O CO 1 — 1 to to O O r H O O C M « H to to to to C M C M » H » H C M t H r H r H +J + - > 4 - > 4 - > + - > 4 - > 4 - > + - > (U to e u to (U to e u to e u to eu to (U to eu to S- o c. o S - O S - o S - o S - o S - o S - O C L C L C L C L C L C L C L C L C L C L C L C L C L C L C L C L to C L (/) e u C L X J X J C û o C O s _ C L & - X J U e u (U e u o 4-) e u ü u XJ t/) to >> <c O + - > f O e u o o +J X tu < 1 3 en u 4 - > to en c. o 3 4 - > to < 1 3 0 3 X O s- s- eu > o C 5 H - f - =0 en CD 3 V V Q . C L ■ K * ■ K 64 Mean Comparison within Control Group on Pre- Post-Physiological Parameters Analysis The control group showed a significant decrease (p = .02) in cholesterol and a decrease (p = .05) in diastolic blood pressure. (See Table 16 for mean compari son within control group on pre-post-Physiological para meters analysis.) Correlation Between Nutrients and Physiological Parameters Within the Treatment Group A Pearson correlation test was used for this analysis and the results reported in Table 17. It was not possible to establish any relationship between changes in eating habits and the physiological parameters examined in this study for the treatment group. Hypothesis 1 The members of the group receiving nutritional counseling will show a significant change in their eating habits after the experiment compared to a control group who did not receive counseling. t tests were performed on these data and the results presented revealed significant change at posttest in many nutrients analyzed as compared to a control group who did not show any change. 65 t o C t o o > î o . ( O 3 c O s - « a : C D t o & _ e u O + J s _ O ) +-> E c 0 3 o C . L O o 0 3 « — 4 Q _ , c e y » e u X ( t3 I I ss 4 - >o ( K S •r— C _ h- 3 C 7 > C O - - - - C OO « /) t o s - >ï l O X C L a . E 1 O4-) o to O c CL l O 1 e u e u s : c . CL . - K -K SS CM LO en c y» CO LO to o O LO r-4 O O en CM CD to S- CL CD O O o CD O CD o CM 1 — 1 en r - . to 4 -i to 1 —4 CD CM CM CM O r-4 O CD 1 r-4 CM o P'- CM O to CD CM CO CM 4- CO O LO O 00 LO o 4 - r - 4 ; 1 Q «-4 en 00 r-t CM r-4 en CM LO M. en Q CM to CD CD LO CD 1 —4 1 —4 O to CM 00 «d- CO CO «d- r—1 00 CD CO T-4 r—1 1 —4 r—4 to en r--. to CM CM e n \x to e y» CO en o o O LO to to 00 o 00 00 00 00 to O en CO CO CO to to to CM CM 1 —4 CM CM 1 — 1 1 —4 4-> 4 -i 4-> 4 - > 4-> 4-> 4-i 4-> eu to eu to eu to eu to eu to eu to eu to eu to S- o S- o i- o S- o S- o S- o S- o s- O Q. Q. CL CL CL CL CL CL CL CL CL CL CL CL CL CL to CL to eu CL *o XI 00 O T - CÛ S- CL S- XJ o eu eu eu O 4 - > eu —1 eu o ss to to X = 3 : o 4-i < a eu o o 4 J X eu t a " 5 ) eu 4 - i to e n c . o 3 4 -i to t a < o X O S- s- eu > C J ) C 3 1 — h- = D t / ) CD 3 LO O C L • J C 66 to to Cu. ■a cn OO to CO LO r-4 o_ OO Q Cl. CO CO to l O -O Q. CO CO D_ o 03 CO U T-4 CO CO II s - a o c to o_ o CO on < o £ = to Q. O "T - I — 3 Oi I— S - CD Q_ 4 - > _C < D 4 - i CO "I— O O to CVJ O t/> CJ CD I B CJ to CO « — II _C Q _ O CO 0 CO to +-> CJ Û - u _ <_> C J 67 Hypothesis 2 The members of the group receiving nutritional counseling will show a significant change in their blood chemistries y blood pressure, and weight compared to a control group who did not receive counseling. t tests were performed on these data. No sig nificant changes were registered except for a decrease in diastolic blood pressure in the treatment group as compared to a control group who did not show any change. 68 CHAPTER V DISCUSSION Discussion of the results will be organized into the following subsections; (1) nutritional status and physiological parameters of treatment group in comparison with control group before the experiment; (2) nutritional status and physiological parameters of treatment group in comparison with control group after the experiment; (3) nutritional status and physiological parameters of control group before and after the experiment; (4) nutri tional status and physiological parameters of treatment group before and after the experiment; and (5) correlation between changes in eating habits and changes in physio logical parameters within treatment group. Nutritional Status and Physiological Parameters of Treatment Group in Comparison with Control Group Before the Experiment In comparing the two groups involved, the first significant difference noticed is the age. The control group was nearly nine years older than the treatment group, which may explain some other differences encountered in the remaining variables. 69 Another factor which may have influenced the results was the small sample size. A loss of six subjects in the control group (nearly half of the group) may also have had an impact on the results. It appears that as a person grows older, his physical capacities diminish and the elderly person is faced with institutionalization, demonstrating more or less dependence according to individual abilities. Twenty per cent of those older than 85 year are institutionalized (Weg, 19 79). Interestingly enough, three of the oldest participants in this program were living in a nursing home near the clinic. Most institutionalized persons are de prived of a certain autonomy regarding choice and prepara tion of foods, as well as usual activities normally carried out in the upkeep of a house. Unfortunately, these three elderly persons were all part of the control group and may have contributed to this age difference between the groups. These two factors (small size sample and institu tionalization) certainly influenced the other differences reported. The control group was significantly different from the treatment group in kilocalories, fats, and carbohydrates. Logically, an elevated intake of carbo hydrates and, especially fats, should increase the 70 kilocalories»,. But why a difference in carbohydrates and fats? Living in an institution has both good and un fortunate aspects; the elderly person may be more secure and well looked after physically but they lose some independence. The older person does not choose and buy food, does not choose the way of cooking it; they go to the dining room and have to comply with what is served. If it happens that he does not like the menu, or he is not hungry at the settled meal time, he may have the choice of eating food which contains fewer nutrients (jello, cakes, tarts), or of going to a fast food restaurant, or of not eating at all. Also, when the person does not have to prepare his own food, it is very tempting to go and eat more, which leads to overconsumption. Besides the nutritional aspect, living in an in stitution does not demand a great deal of energy expendi ture. Looking after the physical needs and keeping their rooms decently tidy is about the only physical activity which is expected of the inmates, the rest is done by employees who devote their energies not only to daily living tasks but to organizing the leisure time of their patients. Having less responsibility gives the elderly more leisure time to participate in social activities which include tea, coffee, biscuits, cakes; i.e., more foods. 71 Subjects who were not institutionalized (six of them) could have indulged themselves more easily by going to restaurants where the food is tasty but too high in fats. The reasons cited above may explain why the control group consumed more carbohydrates and fats than the experimental group. Nevertheless, the total caloric intake could have been in accordance with the RDA if the levels of protein and fat (33%) had been a little lower and complex carbohydrates higher, assuming that exercise was moderate. If exercise is at a minimum, the RDA recommends a caloric intake as low as 1200-1400 kilocalories for females, who constituted eight out of nine subjects in the control group. If this was the case for these people, 1993 kilocalories were really too many. The intake of protein was also too high (18%) compared to the RDA, which recommends a protein level of 12 percent of total caloric intake. The problem in the diet of the control group was the distribution of their food. The quantity was there (enough calories), but the quality (less fat, more complex carbohydrates) was not. The treatment group in comparison did a little better but the difference was not enough to be significant. The percentage of protein was 21 percent, the CHO was 52 percent, but fat was 27 percent, 6 percent less than the 72 control group. But the total caloric intake was 1472 kilocalories, which could be acceptable in elderly people who do not practice any physical activity. These people were living at home so we may assume they practice a certain degree of activity. This would seem to require a higher kilocaloric level. The intake of calcium was below the recommendation of the RDA. This is possibly due to a low intake of calcium (milk) by people in modern society. Coffee is served everywhere for adults, while milk is reserved for children. Non-fat milk is not yet accepted in our life style. The intake of zinc was also below the RDA's recommendations. This micro-nutrient deficiency has been as common as iron and vitamin C deficiencies and appears to be of equal importance, particularly in the healing of wounds (Pullen, Pories, & Strain, 1971; Weg, 1979). Zinc may be involved in atherosclerosis, since high Zn/Cn ratios have been found in hyperchoiesteronemia patients (Klevoy, 1975; Weg, 1979). The recommended intake of water is one ml per kilocalories consumed. The treatment group was close to that goal in the pretest and went over in the posttest. But this is only water contained in foods. In both groups, the intake of drinking water was overlooked. 73 Even if the treatment group was lower in total caloric intake, the quantity recommended for the different nutrient intake was approximately met, except for calcium and zinc. This deficiency was probably due to a low intake of dairy products and whole grains, proteins of high biologic value. The control group did meet all the RDA's recommend ations on vitamin and mineral intake except in the case of zinc. This confirms that with a higher intake of calories it is easier to meet the levels recommended by the RDA. Nutritional Status and Physiological Parameters of Treatment Group in Comparison with Control Group After the Experiment There were many significant differences noted in post-nutrients between the treatment and control groups, revealing an intervention effect. As on the pretest, a difference in fat, protein, and carbohydrates, but not on total kilocalories, was expected. The goal for total calories was set at 1800 kilocalories. The members of the treatment group, as well as the control group, changed their intake of foods for different reasons. The treatment group had to change their menus to contain less meat, more fruits and vegetables, and non-fat dairy products which were recommended in order to reduce fat. When the results 74 were examined, it seemed obvious from the decrease in calories that instead of getting used to the non-fat dairy products, they preferred to refrain from dairy products altogether. If they had increased their consumption of non-fat dairy products they would have improved their low intake of calcium and zinc. But in the other nutrients, they obtained good results. They decreased their fat intake from 27 percent to 21 percent and their protein from 21 percent to 19 percent, and increased their intake of carbohydrates from 52 percent to 60 percent. Moreover, the increase in vitamin C, in fiber, and in water surely reveals an increase in the consumption of fruits and in part of vegetables and grains (because of the large intake of vitamin A). Low consumption of zinc, niacin and phosphorus could be the result of the total intake being too low. It 'is difficult to assure a nutritional adequacy of diet that is low in energy content (less than 1800-2000 kilocalories) unless fats, sugar, and alcohol are more rigidly restricted than is customary in most American households. Even if the control group had not been exposed to intervention between pre- and posttest, the members were conscious of their participation in a nutrition survey. Automatically, therefore, they made an effort to improve their food intake according to their own beliefs and 75 knowledge in order to improve their health status as well as to show their good living standards. The results of the post-nutrients intake test did not show any sig nificant changes except that the total caloric intake diminished by 227 kilocalories. As most of the subjects were females at a mean age of 75 years, the RDA recommends 1800 kilocalaries/day, or less, depending on physical activity. The intake of fat (33% to 32%), of protein (18% to 20%), and carbohydrates (49% to 48%) did not change in proportion to the total caloric intake. The consumption of meat, grains, and vegetables probably increased as there was an increase in vitamin A, niacin, riboflavin, zinc and water. Even if there was an increase in zinc, it still did not meet the RDA requirement. The decrease in intake of vitamin C and a slight decrease in fiber would suggest a decrease in the consumption of fruits. The few physiological parameters that might be expected for us to look for change, such as systolic and diastolic blood pressure, weight, and blood biochemistries (cholesterol, triglycerides, total lipids, glucose and uric acid), did not show differences between the groups after the experiment, except for a significant decrease in systolic blood pressure in the treatment group. Two reasons could explain this difference: (1) since the mean 76 age of the control group was higher than that of the treatment group, a higher level of blood pressure could be expected (Weg, 1979), and (2) a decrease in sodium consump tion could have lowered the blood pressure. As the post-physiological parameters involved in this study for both groups were examined, it was surprising to notice the decreases in nearly all parameters sustained by each group between pre- and posttesting. This could explain why there were not many differences between the groups before and after the experiment. Although a change in the cholesterol level could be expected in the treat ment group, the reason for a similar change in the control group is not clear. Nutritional Status and Physiological Parameters of Control Group Before and After the Experiment As stated before, no significant changes were noted in the control group. But a significant change in blood cholesterol and a significant decrease in diastolic blood pressure were noted. Even if the quantity of nutrients recommended by the RDA was met, the quality of the nutrients must have been improved (i.e., choice of food with less cholesterol). Perhaps an element such as pectin in apples regularly eaten could have brought about this 77 change (Weg, ]979). Gr maybe the substitution of satur ated fats with unsaturated fats? Nutritional Status and Physiological Parameters of Treatment Group Before and After the Experiment The most important change within this group was in the fiber intake. Recently, considerable attention has been directed to the possible importance of dietary fiber. These non-digestible substances provide bulk in the intestine and aid elimination. Among the elderly popula tion, the problem of constipation is very commonly ex perienced. Furthermore, it has been claimed that the incidence of a number of diseases, such as diverticulosis, cardiovascular diseases, colonic cancer and diabetes, is inversely related to dietary fiber consumption (Burkitt & Trowel1, 1975; Reilly & Kursner, 1975). The consumption of lOOmg of fiber per kg of body weight per day (Guthrie, 1975), which could reach 5 to 6 grams of fiber a day has been recommended. Labuza (1977) advised 10 to 12 grams of crude fiber intake a day. The RDA does not recommend any specific level of fiber because of possible reduction in absorption of mineral elements induced by high dietary fiber intakes (Reinhold, Farad]i, Abadi, and Ismail-Blige, 1976). In general, a moderate consumption of dietary fiber is recommended (National Academy of Sciences/National Research Council, 1979). ________________________________________________________________________ j b J Correlation Between Changes in Eating Habits and Changes in Physio logical Parameters within Treatment Group The short period of five weeks for the experiment could be responsible for the lack of correlation between changes in nutrients and changes in physiological para meters within the treatment group. The lack of control of the intake is another factor. To obtain significant changes, the food intake restrictions should have been rigorously followed without indulgence which was not the case with these participants. Deep rooted habits take more than five weeks to modify. There were some changes, but few of these were significant. The experience was worthwhile for the participants, as they wanted information about the best diet for them, which indicated that older people are indeed concerned about their nutrition and well-being. Clients* comments also indicated the need for nutritional counseling Many persons showed'concern about the relationship between food and degerative diseases with questions such as, * * Which foods should I eat to prevent arthritis?" Some clients stated that they were avoiding all milk, citrus fruits, or breadstuffs because they had heard that these foods "cause arthritis." Avoiding these foods could result in 79 nutritionally inadequate diets. Nevertheless, the ex perience was of some benefit to them. Relatively healthy, non-institutionalized elderly persons have dietary and nutritional problems and can benefit from nutritional counseling. Since physical, psychological, socioeconomical and cultural factors may affect nutrition, the diet should be individualized to the patient's own particular needs. Rogers and Shoemaker (1971) stated that interpersonal relationships allow a two-way exchange of ideas and can be effective in changing strongly held attitudes and habits. Working together, the client and the nutritional counselor can often devise a diet plan that will help the client live a longer and healthier life. 80 CHAPTER VI SUMMARY, FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS Summary The purpose of this study was to evaluate the nutritional status of a group of elderly people and to find out if it was possible to change eating habits with the help of nutritional counseling. This change in eating habits should consequently bring about some positive changes in several physiological parameters, such as cholesterol, triglycerides, glucose, total lipids, systolic and diastolic blood pressure, and weight, in order to diminish risk factors connected with cardiovascular disease in the old age population. In this investigation two groups of elderly people, males and females, aged from 59 to 89, participated in a nutrition program; one group was submitted to treatment sessions and the other group served as a control. A statistical analysis was conducted on the data collected to determine the significant changes registered. 81 Findings Before the experiment it was found that the treat ment and control groups were significantly different in the following respects: 1. The treatment group was younger, 2. The treatment group had a lower intake of kilo calories, fats and carbohydrates, 3. The treatment group showed a lower systolic pressure; the control group showed very little change. After the experiment, the comparison between the treatment and control groups revealed significant differ ences on the following points : 1. The treatment group had a lower intake of kilo calories, proteins, fats, calcium, phosphorus, riboflavin, and zinc when compared to the control group, which showed very slight changes, 2. The treatment group had a higher intake of fiber and vitamin C. 3. The treatment group showed a decrease in systolic blood pressure. Within the groups, significant changes were observed in the pre- and posttests : 1. The treatment group showed a significant increase in fiber intake when compared to the control group which did not show any change. 82 2. The treatment group showed a significant decrease in systolic and diastolic blood pressure and weight. In the control group, no change in fiber intake and a significant decrease in cholesterol and diastolic blood pressure. It was not possible, therefore, to establish any correlation between altered eating habits and those physiological parameters looked at in this study for the treatment group. Conclusions From these findings it may be concluded that eating habits can be modified to some extent in a relatively short time. It may be concluded that some physiological parameters can also be influenced in a relatively short time. The results obtained in five weeks suggest that if the experiment had been carried out over a longer period the changes would have been more significant Nonetheless, there was significant changes within the groups in the desired direction. The benefits that the participants gained from the experience were even greater. It seems clear that nutritional counseling stimulates an increase of awareness of nutrition and an improvement in knowledge concerning food selection, as well as aging (Rae & Burke, 1978). It was realized that improving the 83 quality of food does not necessarily mean purchasing expensive food. Changing eating habits under encouragement support and guidance can give old people better nutrition without starving them. Recommendations Nutritional counseling was found to be a useful tool in effective nutrition education as a change agent in nutritional status and behavior of the elderly. However, the time factor would be of prime importance to be sure that habits have really changed and to notice significant changes in physiological parameters. A follow-up three months after the experiment would have been of great value. Changing habits in old age requires a lot of support and encouragement, as eating is one of the most enjoyable things in most old people's lives. It is suggested that changes be made individually, starting with the subject's least favorite tastes and finishing with the ones they like best. Exploring a talented use of herbs and spices as condiments instead of butter, margarine or oil was an enjoyable discovery for all the subjects. The taste panel was greatly appreciated. Following their progress in dieting, as well as their health improvement, was a great incentive to the participants; they saw the effectiveness of their efforts in the physiological parameters even if these were minimal. 84 It was also realized that buying less meat and more fruits and vegetables was not such a burden on the budget as they had imagined. Further research is needed to gather necessary biochemical details and information concerning the inter action between diet, nutrition, and disease between aging and nutritional status. In order to develop knowledge beyond the few measurements possible in this study, the following modifications are recommended: 1. Extend the program's period to at least four to six months. 2. Make assessment of food intake once a month and discuss it with the subjects. 3. Make physiological assessment of blood pressure and weight regularly, and of blood biochemistries every two or three months. 4. Carry out a simultaneous exercise program, if possible. 5. Perform skinfold measurements every two or three months. In summary, life styles can be changed through education. Life styles include eating habits, exercise, and positive thinking. This has to be done by health professionals in their daily routine. Specific issues with 85 which health professionals should be prepared to contend include the creation and support of motivational change in older patients, the advocation of social and political change to support the individual's desire for health improvement, and the provision of services in a manner sensitive to the special needs of the aged. 86 BIBLIOGRAPHY 87 BIBLIOGRAPHY Adams, C. F. Nutrition value of American foods. Agriculture Handbook, No. 456. Washington, D.C.: U.S. Department of Agriculture, 1975. Barlow, D. H ., & Tillotson, J. L, Behavioral science and nutrition; A new perspective. Journal of American Dietetic Association, April 1978, 7^(4) , 368-371. Blackburn, H. How nutrition influences mass hyper1ipidemia and atherosclerosis. Geriatrics, February 1978, 33(2), 42—4 6. Blake, A. Group approach to weight control: Behavior modification, nutrition and health education. Journal of American Dietetic Association, December 1976, 69(6), 645-649. Border, J. R. 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Los Angeles: Andrus Gerontology Center, University of Southern California Press, 1979. Weg, R* B. Changing physiology of age: Changing nutrition Presentation to Nutrition Symposium, USC School of Dentistry, February 29th to March 1st, 1980. Wilhelmsen, L., Wedel, H., & Tibblin, G. Multivariate analysis of risk factors for coronary heart disease. Circulation, 1973, £8_, 950. Winick, M. Current concepts in nutrition. In Mv Winick (Ed.), Nutrition and aging. New York: John Wiley and Sons, 1976. Winick, M. Nutrition and aging. Contemporary Nutrition, June 1977, 2(6). World Health Organization Technical Reports. Requirements of ascorbic acids, vitamin D, B.^* folate and iron. New York: World Health Organization, 1970. Young, C. Nutritional counseling for better health. Geriatrics, May 1974, 2^(5), 83-91. Young, V. R. Diet and nutrient needs in old age. In J. A. Behonke, C. E. Finch, and G. B. Moment (Eds.), The biology of aging. New York: Plenum Press, 1978. Zifferblatt, S. M., & Wilbur, C. S. Dietary counseling: Some realistic expectations and guidelines. Journal of American Dietetic Association, June 1977, 70(6), 591-59. Zimring, J. G. High-fiber diet versus laxatives in geriatric patient. New York State Journal of Medicine, December 1978, 2223-2224. 96 APPENDIXES 97 APPENDIX A TABLE OF RECOMMENDED DAILY DIETARY ALLOWANCES 98 5 "Z S - ^ - 5 X 00 3 0 00 o t o U a 5 s ill m ^ p o C O m » H-C. 3 0 3 . U CL 0 e O C î 00 ec 30 00 00 .11 sssss 90 00 CO CO 00 - c LU 0 *B u . c s u •a 99 appendix b FOOD INTAKE RECALL QUESTIONNAIRE 100 TOT # 0 p O 3 S U IB J 9 0 j: n S B 0 W p 0 % B d 0 a d S q . U 0 X p 0 j 5 u i % U B 3 a UT 0q.0ui MOH 0dTO0H. pus 0q.v q.unouiv -xxoxddv I %osus 0^s% pus 5uxu0Ag UOOUX0^JV 5 UOOH BUXUXOW 0UISJSI 0xxsuuoxq.s0nO %%SO0# 0%S^UI pooa APPENDIX C SOCIAL QUESTIONNAIRE 102 SOCIAL QUESTIONNAIRE Age: Sex: Ethnicity Country of Birth: I. Marital Status Married: Widowed: Single: II. Formal Education Less than 12 grades: High School Diploma or higher: III. Yearly Income Less than $5,000: More than $5,000: IV. Living Arrangements Alone : With spouse or others: 103 APPENDIX D FIVE COMMANDMENTS FOR HEALTHY HABITS 104 Five Commandments for Healthy Habits 1. DON'T EAT FATS OR OILS Avoid fatty meats: Fatty hamburgers, fatty steak and the like Avoid oils: Cooking oils, salad oils, shortening Avoid oily plants: Olives, avocados, nuts and the like Avoid: All dairy products, except non-fat products 2. DON'T EAT SUGAR Avoid: Sugar, honey, molasses, syrups, and so forth Avoid: Pies, cakes, and pastries Avoid: Breads, cereals, and the like which contain sugar 3. DON'T EAT SALT* Don't salt your plate or the cooking pot Avoid: obviously salty products such as crackers and salty herrings 4. DON'T EAT CHOLESTEROL Limit your meat intake to % pound of lean met per day Avoid: Animal organs (brains, liver and the like) animal skin, shellfish, eggs 5. DON'T DRINK COFFEE OR TEA (You can drink tea made from herbs) *You cannot live without some fat and some salt. On the other hand even if you try very hard to avoid both, you will get plenty of each in your vegetables. Source: Leonard, J. N., Hofer, J. L., Pritikin, N. Live Longer Now. New York: Charter Books, 1974. 105

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Creator Cuillerier, Marie-Claire (author)

Core Title The effectiveness of nutritional counseling in nutritional status and behavior in the elderly

School Leonard Davis School of Gerontology

Degree Master of Science

Degree Program Gerontology

Degree Conferral Date 1981-06

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