• Increase Font Size
  • Decrease Font Size
  • View as PDF

FNOA: Aging Programs (2012)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

The purpose was threefold: 

  • To determine the nutritional adequacy of Hispanic Northwest Indiana Title III(C) participants
  • To assess the site meal contribution to the total dietary intake
  • To identify nutrition-related health problems in this Hispanic population.
Inclusion Criteria:
  • Prior to selecting the sample and sites for the survey, meal locations were surveyed for their distribution of Hispanic participants
  • 50 participants at 10 meal locations with the largest Hispanic enrollment were selected for this survey
  • Selection criteria included participant and staff availability, willingness to participate in the study and active meal program participation for at least three months.
Exclusion Criteria:

One subject was eliminated from the data analysis because the liver he consumed on the one-day food record skewed nutrient means in this size sample.

Description of Study Protocol:

Recruitment

50 participants at the 10 meal locations with the largest Hispanic enrollment were selected for this survey. Selection criteria included participant and staff availability, willingness to participate in the study and active meal program participation for at least three months.

Design

  • Cross-sectional study.
  • Data was obtained using a one-day food intake record or a 24-hour diet recall, a guided interview and an interviewer-administered questionnaire. 

Intervention

Participation in the congregate meal program.

Statistical Analysis

Pearson correlations were calculated to determine the relationship between age and dietary intake of individual nutrients. A significance level of P<0.05 was accepted for all analyses.

Data Collection Summary:

Timing of Measurements

Intake data for one day was obtained, using a self-report one-day food intake record, face-to-face interview and questionnaire.

Dependent Variables

Calories, protein, carbohydrates, total fat, saturated fat, polyunsaturated fat, cholesterol, dietary fiber, vitamin A, thiamin, riboflavin, niacin, pyridoxine, folacin, ascorbic acid, calcium, iron, zinc, magnesium, phosphorus, potassium, percentage of calories from carbohydrates, percentage of calories from protein and percentage of calories from fat.

Independent Variables

  • Demographic characteristics of Hispanic participants included Sex, ethnicity, age, marital status, education, living situation and site meal participation
  • Self-reported health characteristics of Hispanic participants included  health ratings, health problems, prescribed diets, antacid use, laxative use, vitamin/mineral use, weight and height.
Description of Actual Data Sample:
  • Initial N: 50 congregate meal participants
  • Attrition (final N): 49 participants (34 females, 15 males); one subject was eliminated from the analysis for eating liver
  • Age: 57 to 86 years with a mean of 70 years
  • Ethnicity: Hispanic - 88% Mexican, 12% Puerto Rican
  • Location: Northwest Indiana, US.
Summary of Results:

Other Findings

  • Daily dietary intake:
    • Using two-thirds of the RDA as a standard, the nutrient intake of the meal participants is adequate, except for the energy intake for men
    • Mean daily nutrient intakes ranged form 68% for magnesium  for men to 170% for vitamin C for women
    • The average calorie intake was 1,393 calories for men and 1,435 calories for women
    • Only one male consumed 100% of the energy RDA and 10 men consumed less than two-thirds of the recommended energy intake
    • The mean dietary fiber intake was 14.3g per day for men and 15.7g for women
    • Only 11 participants reported individual daily intakes that provided at least two-thirds of the RDA for the 12 vitamins and minerals
    • 16 subjects consumed diets below 67% of the RDA for one to two nutrients
    • 11 subjects fell below the standard for three to four nutrients and 11 participants were low in five or more nutrients with zinc, magnesium, pyridoxine, vitamin A and calcium as the nutrients most likely to be below the selected standard
  •  Site meal:
    • 13 men and 26 women ate their noon meal at a congregate meal site the day preceding the survey
    • Participants consumed more than the required minimum one-third of the RDAs in the congregate meals except for energy and magnesium by men
    • Mean intake of most nutrients ranged from 40% to 58% of the RDA
    • Vitamin A and vitamin C were the nutrients consumed in the highest amounts and energy and magnesium by men were consumed in the lowest amounts
    • Women consumed a higher percentage of RDAs from from the meal than men, but distribution of energy intake was similar with 39% carbohydrate, 21% protein and 39% fat
    • 69% of the participants did not consume the site meal as offered. Changes included omitting an item or consuming smaller portions of the food.
    • None of the participants omitted the entree, but milk, one or more of the vegetables, dessert, bread and margarine were omitted by some participants. Some ate bread with no margarine.
    • For many participants, a lower than one-third RDA intake of a nutrient in the site meal resulted in less than 100% of the RDA daily intake of the same nutrient.

 

Author Conclusion:

The author compared the results of this study to the results of several other studies and found: 

  • Mean intakes:
    • Mean intakes for most nutrients in this study were similar to those of lower income Mexican Americans in the San Antonio Heart Study; Black recipients in the Hart and Little and Kinkel, Chestnut, Hoover and Roughead congregate meal reports; and for Title III(C) studies involving white participants
    • They were lower than those reported for Caucasian congregate meal recipients in three past studies
    • The Indiana Hispanic women were more likely to meet the RDAs, which is consistent with the report by Hollingsworth and Hart
  • Obesity:
    • Obesity is common among the elderly, particularly among Hispanics, but in this study, only 18% of women were overweight and 5% severely overweight compared to 54% and 6% respectively in the 55- to 74-year age group of the NHANES study
    •  For men in this study, none of the Indiana men were overweight, but in NHANES 36% of older men were overweight and 13% severely overweight
    • The lower prevalence of overweight in this study may be related to the poor nutrient intake or excess chronic illness of the participants. This sample had a higher mean age than NHANES and weight tends to decrease with age. Also, there may have been inaccuracies in self reporting height and weight.
  • Decreased consumption with age:
    • Many studies report that nutrient intake and calorie consumption decreases with age and this was not found in this study except for total fat. The reasons for this are not evident from the data.
    • Many studies show energy intake below the RDA for the elderly, but for the women in this study, it may be appropriate considering the low prevalence of obesity and the sample being shorter in stature than the RDA reference sample. 
    • The women's energy intake was higher than that reported for Hispanic and Caucasian congregate meal women by Hart and Little and comparable to non-Hispanic Title III(C) women in two other studies
    • The energy intake for men was consistent with the data in the Hart and Little study but lower than that reported in four other studies. There was no relationship found between energy intake and the variables that have been reported to influence elders' calorie intake.
  • Nutrient intakes:
    • Dairy foods are not emphasized in Hispanic diets and calcium intakes below the RDA have been reported in two studies. In this study, only 22% of diets were below 67% of the RDA for calcium. This was higher than reported in Hart and Little and the San Antonio Heart Study. It was similar to those amounts reported in three other studies. High calcium intake by this Indiana group is attributable to site meal milk and dairy foods, corn tortilla and green leafy vegetable intakes at home.
    •  Intakes of vitamin A and C ranged from 96% to 170% of the RDA, but the meal site contributes a high percentage of these vitamins. Other studies have varied by reporting both high and low intakes of these vitamins in the past. 
    • Low intakes of zinc, magnesium and pyridoxine were found in this study. This is common in some of the other studies of the elderly, many studies have not reported on these minerals.
  • Fat:
    • It is recommended that the total fat in the diet not exceed 30%. In this study, men's fat intake was 38% and women's was 33%. This was consistent with one study of Hispanic women, which showed lower daily fat intake than reported for low income Hispanic women in one study and the higher daily fat intake by men compared to women occurred in the San Antonio Heart Study.
    • In this study, the congregate meals averaged 40%  of the calories as fat. This is due to the unusual use of potato and chicken salads as well as whole milk and gravy on meats. At the time of the study, efforts were being made to use low-fat and low-cholesterol foods and recipe modifications.
  • Overall nutrient intake:
    • The lunches in this study, met the objective of Title III(C) by contributing 37% to 51% of most nutrients to the participant's daily intake. This confirms the findings of other research that these programs improve the nutritional content of the participant's diet.
    • The high intakes of vitamins A and C reported are important because other studies reported low intake of these nutrients by Hispanics
  • Omission of food items:
    • When participants omitted food items, this adversely affects the consumption of nutrients in the meal
    • Ethnic food preferences need to be taken into account in congregate meal planning to help avoid omissions
  • Overall conclusion: The Hispanic population is expected to grow during the 21st century and strategies for increasing the number of elderly Hispanic participants in congregate meal programs is vital.
Funding Source:
University/Hospital: Purdue University-Calumet
Reviewer Comments:
  • The author notes the following limitations:
    • The one-day food record was used for dietary assessment. This method may be limited by the participant's inability to estimate portion sizes, the subjects's failing to record their usual food intakes and the normal day-to-day nutrient intake variability.
    • The sample size was small
    • The subjects were not randomly selected from all program Hispanic participants, but chosen from ten representative program sites to maximize participant availability and staff resources
  • Blinding was not used in this study.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? N/A
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? N/A
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? N/A
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? No
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? No
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? ???
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? No
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? ???
  8.1. Were statistical analyses adequately described and the results reported appropriately? ???
  8.2. Were correct statistical tests used and assumptions of test not violated? ???
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? ???
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes