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Mabat - Zahav Israeli National Health and Nutrition Survey

Ages 65 and over 2005-2006

Background

The First National Health and Nutrition Survey of the elderly aged 65 and over in

Israel ("Mabat Zahav") was carried out over a one-and-a-half year period, between

July 2005 and December 2006, by the Israel Center for Disease Control, together

with the Nutrition Department, Ministry of Health. The survey was coveyed with the

cooperation of the Israel Hypertension Society, the Geriatric and the Dental Health

divisions of the Ministry of Health, Maccabi Health Services, Clalit Health Services and

JDC-Eshel. The Mabat Zahav Survey is an additional stage in the first round of the

ongoing monitoring of the health and nutrition status of the population in Israel.

National health and nutrition surveys are an essential and efficient means to describe

the general health status, nutrition status and lifestyle of the population of Israel.

The "Mabat Zahav" national survey was planned to collect basic data, on a national

basis, on the health and nutrition status of a random sample of the elderly in Israel.

In this survey, food intake was assessed, as were health status, health behaviors

(physical activity, smoking, alcohol consumption, medication use, use of nutrition

supplements), knowledge and attitudes regarding nutrition, and utilization of health

services among this population.

Using the Survey data, it will be possible to estimate, with a greater degree of

certainty, the projected need for health services; to assure an appropriate

distribution of services for this age group; to decide on the kind of services needed

to prevent nutritional deficiencies; and to facilitate the provision of optimal nutritional

services to the elderly living in the community. In addition, it will provide the

information necessary for the formulation of appropriate guidelines for nutrition

services for the community-dwelling elderly, for the healthy population as well as for

those with chronic health conditions, and will facilitate the promotion of optimal

quality of life for the elderly in Israel.

The survey results will provide a scientific basis which will serve policy makers in the

formulation of policy and the planning of intervention programs. The findings will be

of value to the academic world, to the industry, to NGOs (non-governmental

organizations) and to volunteer organizations, and will facilitate the promotion of

programs designed towards a healthier Israel.

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Specific Aims of the Survey

1. To estimate the types and quantities of foods consumed among the community-

dwelling population aged 65 and over and to calculate the daily intake of energy,

carbohydrates, sugars, dietary fiber, protein, total fat, saturated fat,

monounsaturated fat and polyunsaturated fat, cholesterol, vitamins and minerals.

2. To compare the nutrient intakes of the elderly in the various sub-groups of the

population, with the accepted recommendations (DRI - Dietary Reference Intakes).

3. To describe meal compositions and foods consumed together in this population.

4. To assess the associations between nutrition status and variables such as health

status, illness, mental state, cognitive state, drug therapy, lifestyle, functioning,

utilization of medical services, sex and age.

5. To assess levels of knowledge and attitudes among the elderly regarding nutrition.

6. To assess the use of community health service and to identify the reasons for

non-use in order to improve these services for the benefit of the elderly.

7. To identify areas and sub-population groups at risk for nutrient deficiencies, in

order to plan nutrition services for the community-living elderly.

8. To assess the prevalence of lifestyle behaviors associated with health: physical

activity, smoking, alcohol consumption, use of medications and nutrition

supplements.

9. To describe the distribution of body measurements in the elderly population:

weight, height, waist circumference, mid upper arm and calf circumference, and BMI.

10. To develop an Israeli Food Frequency Questionnaire for the elderly population.

Survey design: Cross-sectional

Methods

Survey population

The survey population included 1,852 elderly (1,536 Jews and 316 Arabs) aged 65

and over, residing in Israel, in the community (in their homes or sheltered housing)

who had lived in the country for at least one year, and were defined as 'active status'

(alive, Israeli citizens, place of residence defined as Israel, and including new

immigrants up until December 2003). The elderly living in urban and rural

settlements with 20,000 residents or more were included.

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Exclusion criteria: Elderly not living in their own homes in the community for the

following reasons: being out of the country for six months or more, hospitalization

for more than 6 months, hospitalization in a psychiatric institution, hospitalization in

a long term care institution or an institution for mentally fragile; new immigrants who

arrived after December 31, 2003 and elderly with significant cognitive reduction.

Informed consent: The Survey was approved by the Ethics Committee of the

Chaim Sheba Medical Center and the Ministry of Health. Before commencement of

the interview, each interviewee signed an informed consent form for the

questionnaire and for anthropometric, blood pressure and pulse measurements.

Similarly, the interviewee was asked to sign, on completion of the interview, a

consent form for blood tests, urine tests, dental examination and for the retention of

his/her name in the database upon completion of the survey.

The sampling framework

Elderly aged 65 and over insured by the two major health funds, Clalit Health

Services and Maccabi Health Services, representing 86.3% of all of the elderly in

Israel, were sampled. Those living in Eilat, Kiryat Shmona, and East Jerusalem were

not included.

Due to the small percentage of elderly in the Arab population (6%), over-sampling

was carried out in this population, so as to ensure a sample large enough to carry

out statistical analyses and comparisons with the Jewish sector.

Sampling method

A random sample was generated, using the sampling frame described above, taking

the inclusion criteria into consideration.

The lists from each of the 2 insurers were divided into population groups (Jews or

Arabs), according to town of residence (in non-mixed towns). In mixed towns, those

insured were divided on the basis of name and identity number. Thereafter the lists

were combined, to create two new lists, one for Jews and one for Arabs, and

sampling was carried out in two stages.

First sample: 5,100 people were randomly sampled, with 4,250 from the merged

Jewish list and 850 from the merged Arab list. Interviewing of individuals from the

first sample commenced in July 2005.

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Second sample: An additional sample was drawn in January 2006, among Jews

and Arabs, since all lists with names selected in the first sample had been exhausted

at that stage by interviewers working in the selected areas. The size was based on

the compliance rate (lower than expected) found among those sampled in the first

round. An additional sample of 4,250 from the Jewish sector and 2,500 from the

Arab sector was drawn from the sampling frame used for the first round while

excluding those whose names had been drawn in the first sample.

Response rates (compliance)

The response rate was calculated based on the successful contacts. In total, 1,852

individuals took part (1,536 Jews, 316 Arabs).

In the first sample, the response rate (agreement to participate) was 29.7% among

Jews and 34.4% among Arabs. In the second sample, the response rate was 28.2%

among Jews and 35.5% among Arabs. The final response rate of all the contact

attempts, for both samples, was 29.1% in the Jewish sector and 35.4% in the Arab

sector. For 21% of the Jews and for 51% of the Arabs, no contact was made, as the

desired sample number had been achieved. However, in a separate telephone survey

the similarity between those sampled and those not sampled was examined.

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Compliance (absolute numbers) and Response rates

1. Contacts that did not succeed for various reasons; such as: no answer, answering machine/fax/temporarily disconnected/ engaged each time. 2. Did not participate for other reasons, including: meetings cancelled, repeatedly deferred the interview, refused to

sign informed consent; no common language for interview.

Contact with the interviewees

Research staff mailed preliminary letters with a description of the Survey, a request

to participate and an announcement that telephone contact with them would be

made in the near future. One or two weeks following mailing of the letter, the

interviewee was contacted by a telephone coordinator from the Israel Center for

Disease Control and asked if he/she would agree to participate in the Survey. An

interview appointment was set for those who agreed, and the name of the

interviewer given. These calls were made in Hebrew, Arabic, Russian and English.

Telephone contact was considered to have failed if, after 8 attempts, contact could

not be made (number disconnected, no answer, line busy, or answering machine).

Arabs Jews

Total 2nd 1st Total 2nd 1st

3350 2500 850 8500 4250 4250 First sample ( N) 0

746 474 272 1439 689 750 Number of unsuccessful contacts1

1712 1553 159 1787 1425 362 Number of people not contacted

892 473 419 5274 2136 3138 Number of successful contacts (n1) 1

78 40 38 352 152 200 Did not meet inclusion criteria 1.1

33 16 17 142 69 73 Death

36 19 17 26 12 14 Long term hospitalization

9 5 4 24 8 16 Temporarily abroad

0 0 0 8 4 4 Left Israel

0 0 0 152 59 93 Permanently institutionalized

239 119 120 1856 740 1116 Refused to participate because of

communication difficulties

259 146 113 1530 641 889 Did not participate for other reasons 2

316 168 148 1536 603 933 Those agreeing to participate (n2) 2

1 0 1 6 1 5 Questionnaires not included because of

partial information

2.1

15 10 5 31 12 19 Questionnaires not included in final

analysis because of low cognitive score

2.2

300 158 142 1499 590 909 Total number of questionnaires

included in final analysis(n3)

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% compliance 4

9.4 6.7 17.4 18.1 14.2 22.0 % compliance among total sample (n2/N) 4.1

35.4 35.5 34.4 29.1 28.2 29.7 % compliance among successful contacts

(n2/n1)

4.2

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Check on representativeness of the sample

In order to check for the possibility of selection bias as a result of the sampling

methods, a comparison was carried out between those interviewed and two

additional groups: the "refusers" and individuals whose names had been selected but

had not been contacted (the "remainders"). The comparison was carried out by

means of a short telephone survey of these groups, including questions on

demographics and health status.

A. Telephone survey of the refusers

1856 (37.6%) Jews and 239 Arabs (29.3%) (hereafter: "refusers") had refused to

take part in the Mabat Zahav survey , for various reasons (for example, lack of time,

illness of the interviewee or his/her spouse). The telephone survey was carried out

on a sample of 187 refusers, 146 Jews and 41 Arabs.

The telephone survey included demographic details (sex, age, personal status,

religion, level of religiosity, education and income), and health parameters.

Interviewees were also asked about functional status, smoking, height and weight,

(from which BMI was calculated).

Jewish sector: Differences were found between the refusers and the Mabat Zahav

interviewees with respect to level of religiosity, education, income, diagnoses (heart

attack, cancer, osteoporosis), level of mobility and BMI. Details are presented in

Appendix 1.

Arab sector: Differences were found between the refusers and the Mabat Zahav

interviewees with respect to several variables. Details are presented in Appendix 2.

B. Telephone survey of interviewees not contacted during the survey

("Remainders")

On completion of the survey in December 2006, there remained 1778 Jews (20.9%

of the sample) and 1706 Arabs (50.9% of the sample) with whom no telephone

contact had been made. In order to define this population a sample of 10% was

taken from each sector (187 Jews and 181 Arabs). A telephone interview was

carried out and certain variables, similar to those in the Refusers Survey, were

examined.

Jewish sector: Differences were found between the "remainders" and the

interviewees with respect to level of religiosity, education, income, general state of

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health, diagnoses (heart attack, cancer, diabetes, hypercholesterolemia,

hypertension), level of mobility, smoking and BMI. Details are presented in Appendix

1.

Arab sector: Several differences were found between the "remainders" and the

interviewees, with respect to level of age, religiosity, income, general state of health,

diagnoses (heart attack, Parkinson's disease), level of mobility, and BMI. Details are

presented in Appendix 2.

Survey tools and organization

The interview

A personal, face to face interview, was conducted in the interviewees' homes using a

structured questionnaire and carried out by trained interviewers. Interviews were not

carried out with proxies. The average interview time was one hour and 40 minutes.

The questionnaire

The questionnaire was translated from Hebrew into Russian, Arabic and English, and

back translation to Hebrew was performed, as is current practice for foreign

language versions. 1277 (69.0%) interviews took place in Hebrew, 257 (13.9%) in

Russian, 2 (0.1%) in English and 316 (17.0%) in Arabic.

The questionnaire included demographic details, questions on health status, dental

health, functional, cognitive and emotional state, use of medications and nutrition

supplements, alcohol consumption, physical activity, smoking habits, eating and

dieting patterns, nutrition knowledge and attitudes and sources of nutrition

information. The questionnaire also included a 24 hour dietary recall. The collection

of data was planned to reflect the eating habits of the elderly in all seasons and on

all days of the week.

Assessment of Functioning level

The examination of function was based on the Katz et al scale of Activities of Daily

Living (ADL), which was an integral part of the questionnaire. Function was assessed

based on ability to dress, shower/bathe, sit down and rise from a chair, eat and use

the toilet. The maximum score is 15, with a score of 5 indicating "no functional

limitations", a score of 6-10 indicating some functional limitations, and a score of 11

or more indicating several functional limitations.

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Cognitive assessment

Cognitive assessment was carried out using the Minimental State Examination

(Folstein et al.) which was an integral part of the questionnaire. The maximum score

is 30. The MMSE scores were adjusted for education and age as is routinely done,

using the Crum tables. Those with adjusted scores of less than 17 were not included

in the analysis, because of doubt as to reliability.

Mood assessment

The assessment of mood (depression) was carried out using the 12 item General

Health Questionnaire (GHQ) which was an integral part of the questionnaire. The

maximum score is 12. A score of less than 4 indicates no mood disturbance; a score

of 4-8 indicates mild disturbance and a score greater than 8 indicates significant

disturbance.

Nutritional status assessment

Nutritional status was evaluated with the aid of two nutrition screening instruments

commonly used in the elderly: DETERMINE and the Modified Mini Nutritional

Assessment – short form (MNA-SF), which were an integral part of the questionnaire.

Some of the questions in these two instruments were not asked in the exact format,

and other questions in the questionnaire were used as proxies. In the short form of

the MNA a score of less than 11 points indicates risk of malnutrition. The

DETERMINE has three categories of points: 0-2 good nutrition status, 3-5 moderate

nutrition risk and 6 or more, high nutrition risk.

Food Security

Household food security is defined as the situation whereby all household members

have access at all times to a food supply which is adequate for a healthy active life.

Food security is checked using the 18 item food security USDA questionnaire, or

using the shortened 6 item form. In the current survey, the short questionnaire was

used.

Twenty-four hour dietary recall

In order to estimate the dietary intake of the population, interviewees were asked to

recall all that they had eaten and drunk in the 24 hour period that preceded the

interview. In order to assist the interviewee in identifying food types and quantities

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during the food recall, a “Food and Food Quantities Guide” was prepared, based

partly on the Food Information Booklet of the United States Department of

Agriculture. The Guide includes detailed questions about food and many photographs

of Israeli foods. The first version of the Guide was published by the Israel Center for

Disease Control in November 1998. Another version of the guide was prepared in

Arabic, adapting it to the eating habits of the Arab population of Israel and including

also photographs of foods common in Arab cuisine. It was used in the survey. The

interviewers also used cards and measuring aids such as a measuring cup, a

tablespoon and a teaspoon to facilitate quantification of foods consumed.

Drugs

Medications were coded using the ATC (Anatomical Therapeutical Chemical)

classification system, developed by the WHO.

Checking the effect of oral and dental state on mood, function and food

intake

The Oral Health Impact Profile questionnaire (OHIP), a validated questionnaire which

examines the effect of oral health on mood, function and food intake was completed

as part of the survey questionnaire. "Impact" is a dichotomous variable based on the

OHIP total score. There is "impact" when there is at least one problem associated

with the teeth or false teeth either often or very often. This questionnaire was

completed for 1,006 persons (836 Jews and 170 Arabs).

Blood pressure and pulse measurements

Following the interview, the interviewers carried out blood pressure and pulse

measurements using an electronic monitor - Digital blood pressure monitor, A&D

Instruments Ltd, UK, model UA-767. Compliance was 93.5%. The blood pressure and

pulse measurements were carried out according to a protocol based on

recommendations of the American Heart Association (AHA). Both standing and sitting

blood pressure and pulse were measured on the right arm and each measurement

was carried out twice, with a minute's rest between measurements. Where there was

a difference of 10% or more between measurements of either systolic or diastolic

pressure, a third measurement was carried out. The final value was the average of 2

measurements (where three measurements were carried out, the average was

calculated based on the two closest measurements).

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Anthropometric measurements

Following blood pressure and pulse measurements, anthropometric measurements

were carried out. Compliance was 92.4%. All measurements were carried out twice

(and the average calculated) according to a protocol and included: standing height

and weight, knee height, ulna length (these were used to calculate height, using

recognized formulae), waist, mid upper arm and calf circumference. All

measurements were carried out in light clothing. Weight and height were measured

without shoes, though if the interviewee refused to remove his/her shoes, this was

noted. Weight measurements were carried out using an analog scale suitable for

weighing up to 130 kg, with accuracy of 0.5 kg. The scales were placed on an

uncarpeted floor and calibrated before weighing. If the measurements differed by

more than 1.0 kg, a third measurement was carried out. Height was measured using

a spring coil measuring tape. A rigid aluminum angle was used to determine the

meeting point of the top of the skull with the wall/door, and stickers were used to

mark the height. If the two measurements differed by more than 5 mm, a third

measurement was carried out. As some of the elderly people are unable to stand

erect for standing height measurements, knee height and ulna length measurements

were carried out, to assist calculation of standing height. Knee height was measured

on the left leg, while sitting, using a knee height caliper (Ross Laboratories). Knee

height is the distance from the heel to the top of the front of the knee with the leg

bent at an angle of 90 degrees. If the two measurements differed by more than 5

mm, knee height was measured a third time. If the interviewee did not remove his

shoes, knee height measurement was adjusted by 2 cm before BMI was calculated.

Ulna length was measured using a flexible tape measure, from the end of the bone

next to the elbow protrusion to the protruding bone of the wrist. Ulna length was

measured to an accuracy of 5 mm. If the two measurements differed by more than

5 mm, the length was measured a third time. The height, as used for calculation of

BMI, was determined as the average of the measured standing height, height

calculated from knee height and height calculated from ulna length. Underweight,

normal weight, overweight and obesity are presented according to two definitions:

the categories of the WHO, and by BMI categories, based on assessment of mortality

risk.

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Waist circumference was measured using a flexible tape, capable of measuring to

150 cm, at the narrowest part of the torso, where a "fold" is created when bending

sideways. If the 2 measurements differed by more than 5 mm, a third measurement

was carried out. Mid upper arm circumference was measured on the left arm, using a

flexible tape, at the midpoint between the acromion and the edge of the elbow. If

the 2 measurements differed by more than 5 mm, a third measurement was carried

out. Calf circumference was measured using a flexible tape, on the left leg, while

sitting with the knee bent at an angle of 90 degrees. The measurement was carried

out at the widest point. If the 2 measurements differed by more than 5 mm, a third

measurement was carried out.

Blood and urine tests

Blood tests were carried out for 272 elderly (255 Jews, 17 Arabs), from a list of 567

people (518 Jews, 49 Arabs), who signed an informed consent form at the time of

the interview. Blood samples were taken in the homes of the elderly, at a time pre-

arranged by telephone. 240 elderly, although previously having signed consent

forms, refused the tests, either when telephoned, or on the day of the interview

when the person responsible for sample collection arrived. Fasting blood samples

were taken from the brachial vein, using a vacutainer. The blood tests included blood

count and blood glucose, triglycerides, total cholesterol, HDL cholesterol, LDL

cholesterol, creatinine, calcium, sodium, potassium, vitamin B12 and folic acid. Plasma

samples were kept for further tests: insulin, homocysteine, vitamin B6 and 2 vitamin

D derivatives - 25 hydroxy vitamin D and 1,25 dihydroxy vitamin D3. Urine samples

were checked for sodium and potassium. Blood and urine samples were transferred

to the Sourasky Medical Center (Ichilov) laboratory, in Tel Aviv. The results were

categorized according to the range of normal values used by the analyzing

laboratory.

In order to counter selection bias of the blood samples, characteristics of those who

gave samples were compared to those who refused (interviewees who either refused

to sign consent forms, or who signed but in practice did not give samples). No

differences in demographic, health and lifestyle variables were observed. However,

among those refusing blood tests, there was a higher prevalence of lower education

levels, and a higher degree of obesity.

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Dental examination

Dental examinations were carried out on 299 elderly (244 Jews and 55 Arabs), of a

total of 799 (721 Jews, 78 Arabs) who signed an informed consent form for this

examination. Due to technical difficulties, a dentist was not able to visit the other

interviewees who signed their consent.

The dental examination included a general examination of the teeth (decay, missing

teeth, gum disease and dentures) and of the state of the mouth (for oral cancer) and

was carried out by a dentist of the Dental Health Branch of the Ministry of Health,

using a standard WHO form.

The questionnaire versions

There were three versions of the questionnaire. The full version included all the

questions. There was an abridged version ("short questionnaire") and an

intermediate version ("intermediate questionnaire") which did not include some parts

of the full questionnaire. 867 sample persons answered the full questionnaire, 575

the intermediate version and 357 the short version. Below is a list of variables that

were not included in the short and the intermediate questionnaire:

Variables not included in shortened versions Abridged version Intermediate version

Section 2 questions 6,7 Section 2 questions 6,7

Section 3 questions 2-7

Section 4 questions 5.2, 5.3

Section 6 question 2 Section 6 question 2

Section 7 questions 2,7 Section 7 questions 2

All section 9 excluding questions 2

Section 10 questions 8 Section 10 questions 8

All section 11 All section 11

Section 13 questions 6,7,13 Section 13 questions 6,7,13

Section 14 questions 6,7,10 Section 14 questions 6,10

Section 16 questions 4-6

Section 17 questions 3

Section 20 questions 5.2-5.6 Section 20 questions 5.2, 5.3, 5.6

Section 21 questions 4,5,15,16,18

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Questionnaire Data entry

Questionnaire numbers were allotted, in an Excel file, upon receipt of questionnaires

at the ICDC. Data entry was carried out using two programs. The general data were

entered into especially developed screens prepared using the SAS Program (version

9.0).

Food data entry was carried out by means of the Tzameret program, which enables

recording of food intake and calculating of nutrients intake and comparison with

recommendations. The program was developed by the Nutrition Department of the

Ministry of Health. The program uses the nutrient data in the BINAT nutrient

database, which is maintained and updated by the Nutrition Department of the

Ministry of Health.

Quality assurance

Quality assurance was carried out in a variety of ways. The Survey directors directly

observed interviews (at least one interview within the first month of the interviewer's

work). After the questionnaires had been received and preliminary information

recorded, both parts of the questionnaire (the general questionnaire and the 24-hour

food recall) were checked separately prior to data entry. Quality control of the data

entry into the SAS program was carried out in three main ways: 1. checking of

outliers after generating frequency distributions and determining ranges for

continuous variables. 2. creation of logic queries and correction of errors. 3.

comparison of printed outputs with original questionnaires by two examiners. Where

discrepancies were found, these were recorded on the output and correct values

entered.

The 24-hour food recall check included: time sequence check, completeness of

information on definitions of meals and where they were consumed, matching of the

items in the "Quick List" with those in the "Comprehensive List", listing of the

combinations in a logical manner, correct detailing of items in the comprehensive list,

based on the instructions of the “Food and Food Quantities Guide” and making

certain that amounts were recorded for each food item or beverage. After the 24-

hour food recall had been checked, weights (in grams) were added to the items

reported where needed.

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Further quality assurance on the food data was carried out following data entry into

the Tzameret program. Reports summarizing food intake were prepared in Excel

files. These reports were checked for outliers, inappropriate quantities, lack of

correlation between meal times and types, missing quantities and incorrect coding.

All errors found were corrected.

Statistical analysis

Statistical analysis was carried out using the SAS program (version 9.0). Analysis of

nutrient intakes was performed using the Tzameret program. Final Excel reports

were generated, and merged in the SAS program, with the general data.

Statistical significance of continuous variables was checked using the Students T

Test. Statistical significance of categorical variables was checked using the Chi

square test.

1,799 elderly (1499 Jews and 300 Arabs) were included in the final data analysis, out

of the 1,853 persons interviewed. 46 persons (29 Jews and 17 Arabs) had a MMSE

score of less than 17 (after adjustment for age and education) and were therefore

excluded from the statistical analysis. In addition, 8 questionnaires were not included

as they were only partially completed. 1786 24-hour dietary recalls were included in

the statistical analysis.

During the data processing a number of variables/response categories were added

following partial coding of the text responses. New variables/response categories in

the questionnaire were marked with the word "added" next to the appropriate

variable/response, and in the code book with an appropriate comment in the

remarks column.

The Israeli Nutrient Data Base (“BINAT”)

The existing Israeli Nutrient Data Base (“BINAT”), was expanded and updated from

various sources (see below), concurrently with the collection of data, by means of

the "Tzameret" program. The database is continuously being updated on the basis of

changes in the information provided by the various data sources, which are also

continually being revised. This may in the future lead to changes in some of the data

presented in this publication.

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The Israeli Nutrient Database is based on the following data sources:

1. The USDA (United States Department of Agriculture) database. This database

is the basis for the structure, the classification and identification of the foods.

All the other sources are integrated into this structure.

2. Databases of other countries, such as England, Italy and Lebanon.

3. The Israeli Food Industry.

4. Laboratory tests performed by the Ministry of Health to determine the

nutrient components of certain local (Israeli) foods.

5. Imputation - a method for calculating nutrient values of a local product on

the basis of the nutrient values of an existing similar product, for which all

the nutrient values exist.

6. Optimization - A method that enables the calculation of all nutrient values of

a certain food item, after defining the components and constructing a

"recipe" (a recipe is a food item consisting of a number of foods, such as:

salads, soups or cakes). If some or all of the components undergo a cooking

process, changes that may affect the nutrient values during this process are

taken into consideration.

Data Entry

Data from all parts of the questionnaire were entered (general questionnaire,

anthropometric measurements and the 24 hour food recall).

Data entry was carried out using two programs. The general data and

anthropometric data were entered into especially developed screens prepared using

the SAS Program (version 9.0).

Food data entry was carried out by means of the Tzameret program, developed by

the Nutrition Department of the Ministry of Health.

24 hour food recall data entry

At first, the food recall questionnaire was entered with the interviewees' identifying

details; subsequently, food data were entered including all the details (meal, time,

combination and place).

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The "Tzameret" program enables, at any stage, the production of 3 different files

(reports):

a. "Eat" file, which summarizes what was eaten (names, codes and quantities of

items consumed, meals, combinations, times and places of meals) from the

"Tzameret" program. This file is imported to the "SAS" program for further

analysis.

b. "Grow" file, which sums up the total nutrient intake of each individual from the

"Tzameret" program. This file is imported to the "SAS" program, for further

statistical analysis.

c. The "Food" file, which consists of a list of all the food items existing in the data

base and includes nutrient values per 100 grams of food. The file is produced in

CSV format, where for every item in it there is a name, code and values of 49

nutrients. It can be saved in Excel format. This file is imported to the "SAS"

program for further analysis.

After completion of entry of the 24-hour food recall data, reports summarizing the

food intake were produced in an Excel format. These reports were checked for

outliers, inappropriate quantities and hours that did not match meals, missing

quantities and incorrect use of codes. In all instances where data entry errors were

found, they were corrected. After completion of food data entry and corrections,

final Excel reports were prepared. The SAS data entries were merged with the Excel

files, and final analyses were carried out using the SAS program.

Comparison of Data with Nutrition Recommendations

Data on nutrient consumption was compared with international recommendations.

As a basis for the recommendations, the Dietary Reference Intake (DRI) was used.

The DRI consists of 4 values for each nutrient:

1. Estimated Average Requirement (EAR) - The daily intake level estimated as

adequate for the requirements of 50% of the healthy population of a specific

gender and age group.

2. Adequate Intake (AI) - Adequate/Suitable intake level when the information is

not sufficient for the estimation of EAR.

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3. Recommended Daily Allowance (RDA) - The daily intake level estimated as

adequate for the requirements of almost all (98%) of the healthy population of a

specific gender and age group.

4. Tolerable Upper Intake Level (UL) - The maximum daily intake level which will

not harm most of the population of a certain gender or age group.

For the comparison of the intake levels with the recommendations, EAR levels

were generally used; these are measures which are appropriate for comparison

of populations. In cases when there is no EAR, AIs are used as a basis for

comparison. RDAs are used in cases of nutrients for which there are no EAR or

AI recommendations.

Note: When using the survey data in publications, please mention the data source as

specified -

Source: Data is based on the "Israeli National Health and Nutrition Survey Ages 65

and over" (Mabat Zahav): 2005-2006. The Israeli Center for Disease Control, (ICDC)

The Department of Nutrition.

First published: August 2010.

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מגזר יהודי -: השוואת נתונים נבחרים בין נדגמי סקר מב"ת זהב לבין "מסרבים" ו"שארית" 1נספח Appendix 1- Selected statistics - Comparison between Mabat Zahav interviewees,

"Refusers" and "Remainders" - Jews only

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N=146 N=187 N=1,499

גיל65-74 45.2

45.5

52.2 65-74

Age +75 54.8 54.0 47.8 75+

מין 41.8 זכר

49.2

46.2 Male

Sex 53.8 50.8 58.2 נקבה Female

מצב משפחתי

1.4 רווק/ה

0.5

2.5 Single

Personal status

Married 62.5 60.4 68.5 נשוא/ה Divorced 4.8 6.4 2.1 גרוש/ה Widowed 29.3 31.6 28.0 אלמן/ה

Living alone 0.6 - - חי/ה בנפרד Other 0.2 - - אחר

דת

100 יהודי

97.3

97.6 Jewish

Religion

Muslim Arab 0.2 - - ערבי מוסלמי Christian Arab 0.1 - - ערבי נוצרי

נוצרי שאינו 1.8 1.6 - ערבי

Christian (not Arab)

Druze - - - דרוזי Other 0.3 - - אחר

רמת דתיות

47.9 חילוני

P < 0.05

54.0

P < 0.05

53.2 Secular

Religious Observance

Traditional 32.6 26.7 39.7 מסורתי Orthodox 12.9 13.9 7.5 דתי

Ultra-orthodox 0.9 4.3 4.8 חרדי Other 0.5 - - אחר

השכלה

-שנות לימוד 10.2 ממוצע

P < 0.05

11.0

P < 0.05

12.7 Years of education -mean

Education

תעודת בגרות 11.5 6.4 19.9 )תיכונית(

High School certificate

תואר אקדמי 11.5 11.8 7.5 ראשון

1st academic degree

תואר אקדמי 9.3 12.8 4.8 שני

2nd academic degree

תואר אקדמי 2.4 3.2 5.5 שלישי

3rd academic degree

Trade 19.6 25.1 2.7 תעודה מקצועיתcertificate

Other 5.3 - 0.7 תעודה אחרתcertificate

No certificate 39.7 39.6 54.1 אין תעודה

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הכנסהחודשית

נטו מעבודה )בש"ח(

5.5 1,744עד

P < 0.05

57.2

P < 0.05

14.3 To 1,744

NetMonthly

income from work (in NIS)

1,745-3,484 28.8 25.1 31.4 1,745-3,485 3,485-5,254 18.5 9.6 15.0 3,485-5,254 5,255-6,974 9.6 2.7 9.9 5,255-6,974 6,975-8,719 6.2 0.5 8.3 6,975-8719

8,720-10,459 3.4 - 4.5 8,720-10,459 10,460-12,204 0.7 - 2.2 10,460-12,204 12,205-13,949 - - 1 12,205-13,949

or more 13,950 2.6 0.5 0.7 ויותר 13,950 Don't know 3.3 1.1 11 לא יודע

Refuse 7.6 1.6 15.1 מסרב

מצב בריאות

9.6 טוב מאד

4.3

P < 0.05

9.1 Very good

Health status

Good 43.4 41.2 40.4 טוב Not so good 35.9 37.4 41.1 לא כל כך טוב לא טוב בכלל,

רע8.2 17.1 11.7 Not good at all,

bad

אבחון מחלות

התקף לב, אוטם שריר הלב,

מחלת לב אחרת 22.6 P < 0.05 12.3 P < 0.05 30.1 Heart attack,

MI,Heart disease

Disease

diagnosis

שבץ / אירוע Stroke 9.1 8.6 8.9 מוחי

מחלת כליות / 10.7 7.5 6.2 קראטינין גבוה

Renal disease/high creatinine level

מחלה ממארת, כגון סרטן

8.2 P < 0.05 3.7 P < 0.05 13.1 Neoplastic disease e.g.cancer

2.3 2.7 1.4 פרקינסוןParkinson's Disease

P < 0.05 27.8 Diabetes 34.8 24.7 סוכרתאוסטיאופורוזי

P < 0.05 24.6 26.9 Osteoporosis 34.9 ס

P < 0.05 46.0 P < 0.05 54.3 42.5 כולסטרול גבוהHyper-cholesterolemia

P < 0.05 59.5 Hypertension 65.8 52.7 יתר לחץ דםהאם יכול בד"כ לערוך

קניות לבד? )כן(76 65.8 P < 0.05 78.6

Do you usually do your own shopping? (Yes)

בד"כ להכין האם יכול ארוחותיך לבד? )כן(

74 P < 0.05 73.3 P < 0.05 86.4 Do you usually prepare your meals on your own?(Yes)

האם מסוגל בד"כ לנוע בתוך הבית? )כן(

93.2 P < 0.05 93.6 P < 0.05 99.4 Are you able to move in your home? (Yes)

עישון 6.2 מעשן כיום

5.9

P < 0.05 9.7 Current smoker

Smoking מספר סיגריות 15.7 12.6 8.7 ליום )ממוצע(

Cigarettes/day- mean

BMI

23.7 23-מתחת ל

P < 0.05

19.0

P < 0.05

16.7

20

מגזר ערבי - מב"ת זהב לבין "מסרבים" ו"שארית" : השוואת נתונים נבחרים בין נדגמי סקר2נספח Appendix 2 - Selected statistics - Comparison between Mabat Zahav interviewees,

"Refusers" and "Remainders" - Arabs only

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N=41 N=181 N=300

גיל65-74 53.7

P < 0.05 56.3

P < 0.05 72.1 65-74

Age +75 46.3 43.7 27.9 75+

מין 29.3 זכר

P < 0.05 51.9

49.3 Male

Sex 50.7 48.1 70.7 נקבה Female

מצב משפחתי

4.9 רווק/ה

P < 0.05

3.3

4.1 Single

Personal status

Married 65 67.4 53.7 נשוא/ה Divorced 1.3 0.6 2.4 גרוש/ה Widowed 29 28.7 39 אלמן/ה

Living alone 0.6 - - חי/ה בנפרד Other - - - אחר

דת

- יהודי

P < 0.05

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- Jewish

Religion

Muslim Arab 59.9 65.2 29.3 ערבי מוסלמי Christian Arab 37.9 29.8 58.5 ערבי נוצרי

נוצרי שאינו 0.3 0.6 2.4 ערבי

Christian (not Arab)

Druze 1.6 2.2 4.9 דרוזי Other 0.3 2.2 4.9 אחר

רמת דתיות

- חילוני

P < 0.05

6.7

P < 0.05

16.9 Secular

Religious Observance

Traditional 36.3 38.3 58.5 מסורתי Orthodox 46.8 46.1 41.5 דתי

Ultra-orthodox - 7.8 - חרדי Other - 1.1 - אחר

השכלה

-שנות לימוד 5 ממוצע

P < 0.05

5

7.4 Years of education - mean

Education

תעודת בגרות 4.8 6.6 12.2 )תיכונית(

High School Certificate

תואר אקדמי 2.9 2.8 - ראשון

1st academic degree

תואר אקדמי - 1.1 - שני

2nd academic degree

תואר אקדמי 0.3 - - שלישי

3rd academic degree

Trade certificate 8 6.1 - תעודה מקצועית Other certificate 0.3 1.7 - תעודה אחרת

No certificate 83.4 81.2 87.8 אין תעודה

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הכנסהחודשית

נטו מעבודה )בש"ח(

17.1 1,744עד

P < 0.05

33.9

P < 0.05

32.5 To 1,744

Net Monthly income from work (in NIS)

1,745-3,484 53.7 46.1 40.1 1,745-3,485 3,485-5,254 12.2 12.2 9.6 3,485-5,254 5,255-6,974 7.3 0.6 4.8 5,255-6,974 6,975-8,719 2.4 0.6 1.3 6,975-8719

8,720-10,459 - 0.6 1 8,720-10,459 10,460-12,204 - - - 10,460-12,204 12,205-13,949 - - - 12,205-13,949

or more 13,950 - 1.1 - ויותר 13,950

Don't know 8.3 2.8 7.3 לא יודע

Refuse 2.5 2.2 - מסרב

מצב בריאות

9.8 טוב מאד

P < 0.05

7.3

P < 0.05

8.9 Very good

Health status

Good 52.2 40.8 31.7 טוב Not so good 28 40.2 29.3 לא כל כך טוב

,Not good at all 10.8 11.7 19.5 לא טוב בכלל, רעbad

אבחון מחלות

התקף לב, אוטם שריר הלב,

מחלת לב אחרת 31.7 39.8 P < 0.05 31.5 Heart attack, MI,

Heart disease

Disease diagnosis

שבץ / אירוע P < 0.05 8.3 7.3 Stroke 14.6 מוחי

מחלת כליות / קראטינין גבוה

9.8 13.8 8 Renal disease/high creatinine level

מחלה ממארת, 3.5 3.3 - כגון סרטן

Neoplastic disease e.g.cancer

P < 0.05 0.3 Parkinson's 3.3 4.9 פרקינסוןDisease

Diabetes 37.4 36.5 31.7 סוכרת P < 0.05 27.4 19.1 Osteoporosis 34.1 אוסטיאופורוזיס

-Hyper 48.4 43.7 43.9 כולסטרול גבוהcholesterolemia

Hypertension 44.4 54.1 48.8 יתר לחץ דםהאם יכול בד"כ לערוך קניות

לבד? )כן(76 P < 0.05 55.8 P < 0.05 68.5

Do you usually do your own shopping? (Yes)

האם יכול בד"כ להכין ארוחותיך לבד? )כן(

74 P < 0.05 60.8 P < 0.05 74.1 Do you usually prepare your meals on your own?(Yes)

האם מסוגל בד"כ לנוע בתוך הבית ? ) כן(

93.2 P < 0.05 79.6 P < 0.05 93 Are you able to move in your home? (Yes)

עישון 4.9 מעשן כיום

P < 0.05

11.0

17.8 Current smoker Smoking מספר סיגריות

18.2 18.1 14 ליום )ממוצע( Cigarettes/day- mean

BMI

15.4 23-מתחת ל

P < 0.05

11.8

P < 0.05

7.4