Diet Quality in Elderly Home Nursing

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Coll. Antropol. 34 (2010) 2: 577-585Original seientific paper

Diet Quality in Elderly Nursing Home ResidentsEv aluated by D iet Quality Index R evised DQI R)Ivana RiunbakS Zvonimir Satalic\ Irena KeserS Ines Panjkota Krbavcic\ Zlatko Gi^jevi^,Zvonko Zadro^ and Irena Colic Baric^^ Laboratory for Food Chemistry and Nutrition, Faculty of Food Technology and Biotechnology, Zagreb University, Zagreb, Croatia^ Division of Endocrinology, Dep artme nt of Intern al M edicine, Zagreb University H ospital Centre, Z agreb, Croatia^ Department of Anatomy, School of Medicine, Zagreb University, Zagreb, Croatia

STR CTTh eobjectiveof this resea rch was to evaluate diet quality in elderly nursing hom e residents andtopoint out the criti-cal dietary components. The participants (277females and 62 males) were recruited from all elderly nursing homes inZagreb andeachof elderly nursing homes w as equally represented in this study. Theageof subjects was ranging from 61to93years; most of the females (53.4 )and males(53.2 )w ere between70and 80 years old. The dietary data from thmiilti pass 24-hour recall were used to compute the Diet Quality Index Revised (DQI-R). DQ I-R is an instrument thatprovides a summ ary assessm ent of a diet's overall healthfulness and is based on ten different aspects,including recom-mendations for both nutrient and food types. Pearson correlation analysis was used to compare the total DQI-R scorewith dietetic param eters and t-test was calculatedbetweenm ean values of all the components of DQI-R as well as forto -tal DQI-Rscore for men and women. The mean DQI-Rscorefor the 339 sample was 62.1 11.7. The biggest number ofparticipants satisfied recomm endations abou t dietarycholesterol intake (88.5 ofparticipants) and dietary moderationscore(71.1 of participants) but nobody satisfied re comm endation about dietary diversity score.Only 3.2 of subjects

had an adequate calcium intake (6.5 of male participants and only 2.5 of female participants). Recomm ended serv-ings of fruit intakeweresatisfiedby19.8 ofpopulation, 30.4 satisfied vegetables recommendations and38.6 recom-mendations for grains. A ccording to DQI-R, beside positive dietary habits regarding dietary m oderation and dietarycholesterol intakethepopulation of elderly nursing home residents in the capital of Croatia needs improvement in otherdietary habits in order to enhance successful aging.Key words dietary assessment. Diet Quality Index Revised (DQI-R), elderly

IntroductionThe re a re estima ted 605 million older persons, i.e, age60 and over, in the world today, nearly 400 million ofwhom live in low-income countries. Within the next 25years E urope is projected to retain its title as the w orld'soldest region. Older persons currently represent around20 of the total population and the proportion is ex-pected to increase to 29 by 2025 ^Croatian p opulation is very old. In Ju ne 2004 Croatiaapproximately counted 4 439 400 inhabitants, whereofthe num ber of older tha n 65 years was 738 500 (16,64 )which represents a very significant and warning sheire.Demographic projections for the for the year 2025 showari increase in the percentage of elderly people up to2

Nu trition is one of the major dete rm inan ts of success-ful aging, defined as the ability to maintain three key be-haviours: low risk of disease and disease-related disabil-ity, high m enta l emd physical function, and active engage-ment oflife^.Because elderly people are grow ing segm entof the population, increasing attention is being paid tothe foods they eat. An unbalanced diet is a main risk fac-tor for several chronic diseases, among which are obesity,stroke, cancer and type 2 diabetes mellitus^'. These dis-eases contribute to pre ma ture d eaths, restrict life qualityand lead to enormous costs for health systems.Not only are foods consumed interrelated, but alsoare the n utrie nts. C onsuming m ore of some foods usuallyhas consequence of consuming less of other foods, so


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I. Rumbak et al.: Diet Quality in Elderly Nursing Home Residents, Coll. Antropol. 34 (2010) 2: 577-585mon itoring of single para me ter such as single nutri ent orsingle food could lead to wron g conclusions. In vivo nutr i-ent use and metabolism are also interdependent andcorrelated^'^. Almost 3 decades ago, it was suggested thatdiet quality indicators based on nutrient intakes, foodsand food groupings, or combination of nutrients andfoods ^ could be used to quickly ev alua te surv ey resu ltsand the efficacy of dietary programs^'^''^^. It has beenstated tha t by describing global dieteiry quality the se in-dices commun icate more about dietary adequacy and dis-ease ris k th an th e in tak e of single nu tr ie nt s or foods' ' ' *.The Diet Quality Index is an instrument used to assessthe overall diet quality of groups and to evaluate risk forchronic d isease re lated to dieta ry pattern^^-^^. It w as orig-inally published in 1994 and was hased on 8 dietary rec-ommendations from the National Academy of Sciencespublication Diet and Health: Implication for ReducingChronic Disease Risk^''. It was revised in 1999 to reflectthe developm ent of the Food Guide Pyram id, revisions inthe Dietary Guidelines for Americans, and the creationof the D ietary Reference Inta kes. The D iet Quality Indexscores diet on the basis of 10 indicators of diet quality.The first 3 indicators reflect macronutrient intake, thenext 3 reflect the Food Guide Pyramid's recommenda-tions for fruit, vegetable and greiin consumption, and the2 recommendations reflect relative intakes of calciumand iron. The last 2 indicators address the importance ofconsuming foods from a variety of food groups and hav-ing a moderate intak e of sugar, discretionary fat, sodiumand alcoholic beverages. Each of 10 components contrib-utes a maximum of 10 points to the total DQI score,which has a maximum of 100 points. The higher is thescore, the higher is the diet quality. The objective of thisresearch was to evaluate diet quality in elderly nursing

home residents and to point out the critical dietary com-ponents.

Subjects and MethodsThe dietary data from 339 elderly nursing home resi-dents (277 females and 62 males) were used to computethe DQI-R. The participants were recruited from thepublic elderly nursing homes in Zagreb during 2004 andeach of elderly nur sing hom es was equally represe nted inthis study. There are eleven elderly nursing homes inZagreb with 1828 mobile residents (a total of 3498 resi-dents). Medical stuff employed in nursing homes pro-vided us list of participants willing to participate in ourstudy. By random sampling from each nursing homewere selected particip ants to proceed th e trial. We de-cided to select 20% of total mohile nursing home resi-

dents (Tahle 1).All participants provided informed consent beforedata were collected. Twenty seven participants were ex-cluded because of difficulties while recording diet whichmeans that participants included in this research repre-sented about 19% of mobile elderly nursing home resi-dents in the capital of the Croatia. The age of subjectswas ranging from 61 to 93 years; most of the females(53.4%) and males (53.2%) were hetween 70 and 80 yearsold. All the nursing home residents had the same dailymenu (3 full meals). The snacks were not organized innur sing hom es so th at could slightly differentiate diet ofnursing home residents. The dietary assessment methodused was a multi pass 24-hour recall^^'^^. The multi pass24-hour recedl consists of three different passes to pro-vide the respondents opportunities to report their in-

TABLENUMBER OF RANDOMLY SELECTED PARTICIPANTS WHO ENTERED THE STUDY COMPARED TO TOTAL NUMBER OF MOBILE RESI-DENTS OF ELDERLY NURSING HOMES IN CITY OF ZAGREB

Elderly nursing home Num ber of mobile residents Number of participants enter the study(% of mobile residents)Nursing home No. 1Nursing home No. 2Nursing home No. 3Nursing home No. 4Nursing home No. 5Nursing home No. 6Nursing home No. 7Nursing home No. 8Nursing home No. 9Nursing hom e No. 10Nursing home No. 11

18164

12619018982

139141181337198

36 19.9)13 20.3)25 19.8)38 20.0)38 20.1)16 19.5)28 20.1)28 19.9)36 19.9)68 20.2)40 20.2)


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1. Rumbak et al.: Diet Quality in Elderly Nursing Home Residents, Coll. Antropol. 34 (2010) 2: 577-585take. This procedure includes a quick list, detailed de-scription, and review of intake.

Trained interviewers who helped the participants toremember the amount of single foods and dishes con-sumed in the past 24 hours interviewed the participants.Quantity of consumed food and drinks was estimated us-ing food photograph s^ (3 portio n sizes - sm all, mediumand large) and units of serving (piece, cup, glass, tea-spoon, tablespoon, etc.). Mixed dishes were converted torecipes with food no rmativ e used in nurs ing hom es to ob-tain food ingredient data. C onversion of food inta ke datainto nutrient and food serving measures was accom-plished through use of food composition tables^' and pjrr-amid servings database.

According to metho d ofHedneset al.^^ the first 3 com-ponents of the DQI-R reflect macronutrient distributionrecommendations: to restrict relative dietary fat to lessthe n or equal to 30% of energy, to restrict satu rate d fatinta ke to less then or equal to 10% of daily energy and toconsume less than 300 mg of cholesterol daily. For per-centage of energy from total fat and saturated fat, andfor milligrams of cholesterol scoring based on the 3 levelsshown in the Table 2, so participants were categoricallyscored with 0, 5 or 10 points.

The next 3 DQI-R indicators measure relative differ-ence in consumption of servings of fruit, vegetables andgrains. Tbe recommended number of servings from theFood Guide Pyramid depends on recommended energyintakes. Because in our study most participants reportedenergy in take with m ean close to 6694 kJ/d (1600 kcal/d)and because 1600 kcal is an adequate energy intake tosome older adults^^, we used recommendations for thisenergy range. Scores for fruit, vegetables and grainswere limited to range 0 to 10 points depending on per-centage of recommended servings (e.g. if recommenda-tion for fruit group is 2 servings, and the person con-sumes 1.7 servings which is85%of recommendation, thescore for fruit group is 8.5).

Tbe nex t 2 DQI-R indicators reflect relative intak es ofcalcium and iron . The calcium is included inste ad of serv-ings of dairy prod ucts to consider calcium intak e for peo-ple who are not consuming dairy products for some rea-sons.Iron is measured directly because measurements ofmineral status would contribute more in explaining vari-ation in diet quality t ha n would inclusion of me at or pro-tein status factors. The percentage of the RDA for iron(10 mg)^^ and perc entag e of the A I value for calcium(1200 mg)^'' were scored as continuou s v ariables rangin gbetween 0 and 100%, or 0 to 10 points.

The final 2 components of DQI-R are 2 new scores de-signed to measure the constructs of diversity and moder-ation. A dietary diversity score was developed to reflectdifferences in consumption across 23 broad categories.Six of groups reflect grain-based produc ts: non-whole-

-grain bread, quick breads, pasta, wbole-grain bread, ce-reals a nd rice; 6 categories of vegetable are included: po-tatoes, tomato products, starchy vegetables, dry beans,

of fruit and juices: citrus, berries, m elons and other fruit;and 7 groups of animal based products: beef and pork,milk, poultry, cbeese, eggs, fisb and yogurt. Minor cban-ges were made to tbe su bgroups because of the specificityof food intake for population in this area. To be countedas a consumer for any of the food group categories, arespondent needed to consume one-half serving, as de-fined by Food Guide Pyramid quantity criteria, at anytime during the 2-day survey period. We used the samecut off as Newby et al.^^ because 24-hour recall providedonly data for oneday.Partic ipan ts received point if theyconsumed Vi serving/day of the foods within each sub-group (alone or in combination) an d 0 points if they con-sumed


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1. Rumbak et al.: Diet Quality in Elderly Nurs ing H ome R esidents, Coll. Antropol. 34 (2010) 2: 577-585TABLECOMPONENTS OF DIET QUALITY INDEX REVISED AND SCORES DISTRIBUTION. AI-ADEQUATE INTAKE VALUE, RDA-RECOMMENDEDDIETARY ALLOWANCE

ComponentTotal fat 300 and 4 0 0 =0

>10050

100

50100

50100

50100

5063

< 3>7

4< 4

Female '

69157

5 192

10679

24618135297

12885

11 7

759 7

127

5 37

121149

66179

320

116161200

743

Female

24.956.718.433.238.328.588.8

6. 54.7

18.835.046.230.742.227.135.145.819.1

2.543.753.823.864.611.6

0. 041.958.172.226.7

1.1

Male

2 12417222 31754

53

15143 31822

223418

104

253 32535

20

18444 1192

Malein subgroup

33.938.727.435.537.127.487.1

8.14 .8

24.222.653.229.035.535.554.929.016.1

6.540.353.240.356.5

3.20. 0

29.071.066.130.7

3.2

Population

90181

68114129

96300

231667

111161103139

97131145

6 311

14618 2

9 1214

340

1342052 4 1

9 35

Population

26.553.420.133.638.128.388.5

6. 84.7

19.832.747.530.441.028.638.642.818.6

3.243.153.726.963.110.0

0. 039.560.571.127.4

1.5

scores below 40, 13 of particip ants had scores between41 and 50,26 of particip ants betwee n 51 and6 0,33 ofsubjects betw een6 and 70,18 had scores rang ing from6) . Tbe highest correlation observed was between totDQI-R the energy percent from saturated fat (r=0.68),energy percent from total fat (r=0.65) and for servings


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L Rum bak et al.: Diet Quality in Elderly Nu rsing Hom e Re sidents, Coll. Antropol. 34 (2010) 2: 577-585TABLE 3

SCORE AND DAILY INTAKES FOR THE DIET QUALITY INDEX REVISED AND FOR INDIVIDUAL INDEX COMPONENTS (XSD). AI-ADE-QUATE INTAKE VALUE, RDA-RECOMMENDED DIETARY ALLOWANCE.

Component Score total(n=339) Intake/d total Score female(n=277) Intake/d female Score male(n=62) Intake/d maleTotal DQI-R (thehighest posssiblescore - 100)Total fat, :


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I.R umbak et al .: Diet Quality in Elderly Nurs ing Home Residents, Coll. Antropol.34 (2010) 2: 577-585TABLE4ELEMENTSOF DIETMODERATIONSCORE(COMPONENT10) OF THEDOI-R AND DITRIBUTIONOF SCORES

Moderationconsumptionan d scoring criteria/d Score Femalein subgroup (%) Malein subgroup ( Population in subgroup (%)

Teaspoonsadded sugar (tsp) 100%an d 150%a nd 200 %Discretionary fat (g)< 2 5 g>25 and < 150g> 150 and < 200g> 200 gSodiumin take (mg)2400 and < 3400 mg> 3400 mgAlcobolintake (drinks) 100%a nd 150% and 200 %

2.51.51.00. 0

2.51.51.00. 0

2.51.50. 0

2.51.51.00. 0

68.620.2

5. 85. 4

82.016.2

1.80. 0

19.125.355.6

97.81.80. 40. 0

72.612.99.74.8

79.0U .36.53.2

19.321.059.7

93.61.63.21.6

69.318.96.55.3

81.415.32.70.6

19.224.556.3

97.11.70.90.3

ing goals for sodium intake (more than 50% of partici-pants consume morethan 3400 mg of sodium/day ) (Table4) .The average sodium intake was 3615.4 mg. The aver-age value for discretioneiry fat intake was 16.7 g and foradded sugar was 4.6 tsp. There were 97.1 % of alcoholnon-consumers (Table 4), and average alcohol intake forconsumers was 0.1 drinks.

Discussion and ConclusionThe main purpose of this manuscript was to evaluate diet ac-cording to recently developed index, which take in account cer-tain foods and nutrients important for health status. Evaluation ofdiet according Dietary Reference Intakes for the same popula-tion was already observed and published elsewhere. Some ofour preliminary results publisbed elsewhere showed in-adequate calcium intake, intake of fruit and vegetablesbelow recommendation as well as dietary fibre, and ad-visable decrease in tbe energy fraction of fat and decreasein protein content^* ^ .The failure of single-nutrient supplementation to pre-

vent disease in intervention studies underlines the ne-cessity to develop a holistic view of food intake^'^ ^^. TheDQI-R consists of 10 components and provides overall

compliance with specific dietary recommendation, andthe variety and moderation in their diets.Last 10-15 years information about diet quality onursing home residents in Croatia were lacking. In review Eirticle published in Collegium Antropologicum fewyears ago^* amo ng nutritio nal studies in Cro atia, thonly mentioned study concerning older persons frompensioners' home was by Suboticanec et al.^- Analysis othe daily menus showed great nutritive deficiencies, liklack of pyridox ine in58%of persons, vitam inCfrom 21

-4:5.2 and riboflavin from 11.1-19.4%.The re sults of this stud y could help to identify and improve critical dietary parameters in elderly nursing homresident existing at the moment.The mean DQI-R score for all participants was 62.1out of 100, which meant that their diet needed improvement. Haines et al. found similar DQI-R score (63.4) inthe sam ple of32 2adults aged 18 and older p articip atinin the 1994 Continuing Survey of Food Intakes by Individuals wbo had completed two 24-hour recalls'^. TotaDQI-R score found by Newby et al. was ranging from62.0 to 69.5, although the participants were younge

men, aged 45-75 and DQI-R was calculated based on thfood frequency questionnaire^^. On the sample of oldecancer survivors (aged>65 years) D QI score was ran gin


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I. Rumbak et al.: Diet Quality in Elderly Nursing Home Residents, Coll. Antropol. 34 (2010) 2: 577-585intervention group, after implementation of dietary in-take and physical activity guidelines)^^.

We found tha t only 6.8 of partic ipant s had DQI-Rscore higher than 80 that could be consider as indicatorof good diet. Even the participants with total scoreabove 80 appeared to he less successful in meeting rec-ommendations for calcium intake and dietary diversity.Concerning was the fact that almost one quarter of allsubjects had DQI-R score helow 50.Th ere were nosignificant gender differences in DQI-R scores prohahly be-cause participants as nursing home residents usuallyconsume the same or similar foods.Most of the diet indices tend to relate positively to theintake of critical micronutrients hut the association withenergy and fat intake does not always go in the expecteddirection^'' . In this stud y th e total DQI-R correlated w ithenergy and with toted fat.Consuming a wide variety of foods is considered thebest way to ensure balance of nutrients and consumptionof appropriate amounts of healthful food components.The recommendation to consume fruit and vegetables tolower risk for chronic disease has heen and continues tobe a key component of dietary guidance^^. According tothis research 81.2 of female partic ipant s and 75.8 ofmale participants did not meet recommended intake offruit, 69.3 of female and 71 of male did not m eet rec-omm ended intake vegetables and 64.9 of female partic-ipants and 45.1 of male participants did not meet rec-ommended intELke of grains. Beside inadequate fruit,

vegetable and grains intake , DQI-R score had shown verylow dietary diversity score and it is obvious that diet di-versity of nursing home residents should he improved.Partly possible explanation of low diversity score couldhe in dietetic method used (24-hour dietary recall for oneday only). Other studies that showed greater scores mai-nly used 24-hour dietary recall for two

TABLEPEARSON CORRELATION COEFFICIENTS OF DIETETIC PARAM-ETERS WITH THE TOTAL SCORE FOR THE DIET QUALITY IN-DEX REVISED, p


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1.Rumbak et al.: Diet Quality in Elderly Nursin g Hom e Residen ts, Coll. Antropol. 34 (2010) 2: 577-585TABLEMEAN VALUES OF DQI-R COMPONENTS BY DQI-R SCORE CATEGORY

VariableNumber of subjects energ y from fat energy from satu-rated fatDietary cholesterol(mg) recommended serv-ings of fruitpe r da y recommended serv-ings of vegetablesp erday recommended serv-ings of grainspe r da y Al calciumper day RDA ironper dayDietary diversityDietary moderation

SampleSD339

34.6+7.711.63.6

179.7118.658.258.5

80.050.991.4150.650.1+22.184.631.4

2.80.77.71.6

0-409.049.019.1

192.86.5

34.820.633.547.4

1.68.3

4 1 ^ 515.039.215.0

309.925.8

44.146.451.071.4

2.57.9

46-5029.041.814.9

187.725.5

56.658.345.473.02.58.0

DQI-R Score Category51-5535.039.413.3

197.539.3

71.570.343.877.92.57.4

56-6053.034.912.2

189.546.0

69.486.151.477.82.77.8

61-6559.034.811.2

161.650.5

81.194.450.482.5

2.77.8

66-7053.032.710.3

171.861.6

88.0107.849.192.3

2.87.4

71-7532.030.2

9.7173.982.4

99.3107.4

54.891.3

3.17.8

76-8031.028.0

8.7151.5109.0

98.2118.254.799.2

3.17.4

>8023.027.5

8.4141.1

108.2

115.1130.7

56.6107.0

3.67.6

In the conclusion, the population of elderly nursinghome residents in the capital of Croatia according toDQI-R should improve calcium, fruit and vegetables in-take as well as include in tbeir actual diet variety offoods. Total fat and saturated fat intake sbould also beobserved. Positive dietary habits regarding dietary mod-eration and dietary cholesterol intake should be sus-tEiined.

AcknowledgementsStudy was approved and granted by City Office foHealtb, Labour and Socieil protection, Republic of Croatia, City of Zagreb in collaboration with Croatian Society for Osteoporosis (2004).

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/ RumbakLaboratory for Food Chemistry and Nutrition, Faculty of Food Technology and Biotechnology, Zagreb University,Pierottijeva 6, 10 000 Zagrebe-mail:icecic ^pbfhr

KVALITETA PREHRANE U OSOBA SMJESTENIH U DOMOVIMA ZA STARIJE I NEMOCNE OSOBEPROCIJENJENA INDEKSOM KAKVOCE PREHRANE DQI R)

S A Z E T A KCilj ovog rada bio je procjena prehrane starijih osoba smjestenih u Domovima za starije i nemocne osobe i utvr-divanje kriticnih nutrijenata u njihovoj prehrani, Ispitanici (277 zena i 62 muskarca) su probrani iz svih Domova zastarije i nemocne osobe na podrucju grada Zagreba pri cemu su svi domovi bili su jednako zastupljeni. Dob ispitanikabila je u rasponu od 61-93 godine; vecina zena (53,4 ) i muskaraca (53,2 ) bili su u dobnoj skupini od 70-80 godina,Podaci 0 prehrani prikupljeni su 24-satnim prisjecanjem i koristeni su za izracunavanje revidiranog indeksa kakvoceprehrane (DQI-R), Koristen je Pearsonov koeficijent korelacije kako bi se usporedili dijeteticki parametri s ukupnimindeksom ksLkvoce prehrane i t-test za usporedbu komponenti DQI-R i DQI-R vrijednosti medu muskarcima i zenama,Srednja vrijednost DQI-R sume za 339 ispitanika iznosila je 62,111,7, Najveci broj ispitanika zadovoljio je preporukeza prehrambeni unos kolesterola (88,5 ispitanika) i za umjerenost (71,1 ispitanika), medutim nitko od ispitanikanije zadovoljio preporuke za raznolikost u prehrani. Samo 3,2 ispitanika imalo je unos kedcija u skladu s preporu-kama, i to 6,5 muskaraca i2,5 zena, Preporuke za unos voca zadovoljilo je 19,8 ispitanika, za unos povrca30,4 ,aunos proizvoda iz skupine zitarica bio je u skladu s prepomkama u 38,6 ispitanika, Procjenom prehrane prema ka-tegorijama DQI-R, osim prihvatljivih vrijednosti za unos kolesterola i umjerenost, moze se zakljucit da je potrebnopoboljsati kvalitetu prehrane kako bi se doprinijelo boljoj kvaliteti zivota.


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