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Cultural influences and dietary patterns on nutritional health and quality of life in the elderly
Introduction
When considering the nutritional status of the elderly one has to consider just why it is that the elderly are a special case. Do they have different eating habits ? Do they have different physiological systems ? Do they have different nutritional requirements ? Do they have difficulty in getting their food ? Common sense tells us that the answer to all of these questions can be - yes. A review of the literature on the subject, however, goes rather beyond common sense and to those, not fully acquainted with the subject, it may come as something of a surprise as to just how different the elderly as a group really are from "Mr Average" in the general population.
A recent review of the nutritional status of the elderly (Finch et al 1998) shows us that the majority of the elderly are adequately nourished with sufficient intake of the major markers of nutrition - protein, vitamins and minerals, calories etc. What is of particular interest to us in this article, are the groups of the elderly who fall on either side of "The Norm" - the sub-groups whose nutritional status does affect their health. Those without their own teeth, those who are dependent, those who are vegetarian and those who have intercurrent disease processes which interfere with their ability to absorb nutrition to quantify a few such groups.
The recent Government Green paper - Our Healthier Nation (DH: 1998) recognised and highlighted that inequalities currently exist in the nutritional status of the elderly throughout the country. It comments on the fact that there is a marked socio-economic divide in terms of nutrition. It found a lower intake of a wide range of nutrients in the households of manual workers when compared to the households of non-manual workers. They single out for comment the intake of magnesium and potassium which was frequently found to be low, particularly so in elderly women.
A recent COMA report (DH, 1999) also highlighted dietary deficiencies in the elderly, notably in calcium levels and recommended that the current practice of fortifying flour with calcium should continue. The same survey also highlighted the low levels of Vitamin D in the elderly which, together with the low levels of calcium gave concern for the increased incidence of osteoporosis found in the elderly population.
Other commentators highlight different areas of deficiency. (Steele et al., 1998) point to the fact that many of the elderly do not have a good dentition. This obviously impacts on their nutritional intake in their choice and ease of eating food. Unsurprisingly, they found that those of the elderly who had their own dentition did have measurably better nutritional and mineral intake than those who did not. Those with poor teeth tended to eat significantly less fruit, nuts and food generally that was hard to chew.
All of these factors show us that the elderly are indeed a special group when it comes to consideration of their nutrition. We shall examine just how different they are with a critical analysis of some of the peer-reviewed papers on the subject.
Literature Review
When dealing with a subject that is a broad and diverse as the consideration of the how the effect of both cultural influences and dietary patterns impacts on the nutritional health of the elderly, any consideration of the literature is going have to be both selective and critical, as the choice of material is vast. In this review therefore, we intend to select out papers which are worthy of consideration because of the special insight that they give to a particular area of the topic under consideration.
A good place to start is with the consideration of the elderly vegetarian, who may find that the diet has a number of impacts upon their nutritional health. This particular aspect of nutrition may be either a cultural consideration or a purely dietary one, or even a combination of both factors. The paper by Segasothy & Phillips (1999) looks at the whole spectrum of the vegetarian diet and its nutritional consequences, but we shall confine our consideration of it to those aspects of it that are relevant to the nutritional status of the elderly. The paper itself is exceptionally well written and takes reference from a multitude of reputable sources and even the most critical reviewer would consider it a tour de force of the subject.
The authors start with an overview of the possible benefits that a vegetarian diet can produce. They particularly cite examples where it can lower cholesterol and triglyceride levels and improve the diabetic insulin requirement, both of which are important to our considerations, as both hyperlipidaemia (Anderson 1980) and Diabetes Mellitus (Simpson et al. 1981) occur with greater frequency in advancing years. (Hjollund et al.1983). The authors wisely also cite the necessity of a healthy lifestyle and balanced vegetarian diet to ensure the best metabolic results. They also point to the fact that there appears to be an inverse relationship between fruit and vegetable consumption and the incidence of cerebro-vascular accident in the elderly. (Vecchia et al 1998)
Eye problems are a frequent accompaniment of age with cataract and macular degeneration both having age-related incidences (Reidy et al. 1998). The authors suggest that there is another inverse relationship between spinach and green leaf vegetables and senile macular degeneration.
They also point to a decrease in the incidence of malignancies, particularly of the colon and breast, together with a reduction in gallstone occurrence and diverticular disease being associated with a high residue diet (which vegetarian diets almost invariably are). The incidence of breast cancer has also been shown to be reduced with soy bean products. (Block et al. 1992). The authors suggest that this is primarily due to the presence of large quantities of :
"monounsaturated and polyunsaturated fatty acids, minerals, fibre, complex carbohydrate, antioxidant vitamins, flavanoids, folic acid and phytoestrogens"
The authors point to the down side of a vegetarian diet as being high incidence of abdominal gas overproduction and occasional B12 deficiency.
Diseases of the elderly include an increased incidence of Diabetes Mellitus as we have commented earlier (Simpson et al. 1981). The specific advantages of a vegetarian diet are that a diet high in complex carbohydrate and restricted in fat intake improves the glycaemic control (Simpson et al 1983), delays glucose absorption (Jenkins et al. 1976) and lower insulin requirements (Anderson 1980).
The authors quote studies that report a 40% reduction in the insulin requirement of the elderly vegetarian (Kiehm et al.1976) together with a 6-27% reduction in the mean glucose levels of the diabetic (Anderson & Ward. 1979)
It is well known that improved glycaemic control reduces the incidence of complications (Stratton et al 2000), which can be a major factor in the health of the elderly. Neuropathy, and cardiovascular disease can seriously impair the quality of life of the elderly diabetic. It therefore follows that better control generally equates with fewer complications in the elderly.
The paper looks in similar detail at the effects of a vegetarian diet on cardiovascular disease. We will not examine this in great detail but the major findings reported are a positive correlation between nuts and a reduction in myocardial infarction deaths (Fraser et al.1992) and angina (Vecchia et al. 1998).
Figures and results are quoted in considerable detail and on the face of it they are impressive both in terms of statistical significance and indeed in the size of many of the studies examined and quoted ( some involving cohorts of 45,000 and 30,000). (Ornish et al. 1990). Some of the post myocardial infarction intervention studies quote reduction rates of 20-24% for total cholesterol. 37% for LDL and 15% for triglycerides compared to a control group which is remarkable by any measure.(Gould et al.1992)
Arguably the most significant part of this paper is the section devoted to the possible explanation and postulation of the mechanisms of cardiovascular protection. Overall factors are cited as being a general hypolipidaemic effect combined with weight reduction and secondary blood pressure reduction. This is clearly completely rational as all three are known to be major risk factors for cardiovascular disease. (Ross 1993)
Soybeans are thought to produce their lipid lowering effect by compounds such as isoflavones, phytoestrogens and saponins. (Carroll et al. 1995). Legumes and nuts also appear to have specific hypolipaemic properties although the mechanism of action is not yet known. (Dreher et al. 1996)
Anti-oxidants are plentiful in a vegetarian diet. It is known that oxidation of LDL cholesterol is an important stage in the aetiology of atherosclerosis.(Steinberg et al. 1989) The abundance of anti oxidants in the diet may well be responsible for a further reduction in the morbidity and mortality found with the vegetarian diet (De Whalley et al. 1990). The authors also cite evidence to support the view that anti oxidants help to reduce the incidence of malignancies of the "breast, lung, oral, pancreas, larynx, oesophagus, bladder and stomach". (Steinmetz & Potter 1991)
In the best traditions of scientific endeavour, the authors include a section specifically on the disadvantages of the vegetarian diet which we will not examine in detail other than to observe the little known fact that coconut milk contains more saturated fats than red meat.
In conclusion, this paper has great relevance to our hypothetical elderly population as nearly all the disease modifying strategies will inevitably have a greater impact in this age group than in the others.
The second paper that we have chosen for review is a long paper but with a simple message. Bannerman and her colleagues (1997) challenged a long held precept that various anthropometric measurements were adequate to assess the nutritional status of the elderly. ( Morgan et al. 1986). Skin-fold thickness and BMI have often been cited as reliable indicators of malnutrition in the elderly. (Chumlea et al. 1989).
Bannerman's findings showed that they did not correlate to a significant degree with the nutritional status of the typical elderly patient. As the authors point out, if papers are relying on such measurements to quote the incidence of malnutrition then this is a serious source of both bias and inaccuracy. The authors also observed that different measurements varied by different amounts in different parts of the country.
Part of the consideration required by the title of this article was an evaluation of the cultural differences in the nutritional status of the elderly. With this particular end in mind we will turn to a fascinating and well observed paper by Vespa & Watson (1995) who considered the plight of the elderly in Bosnia-Hercegovina. The paper actually sets as its objective, the identification of the nutritionally vulnerable groups in Bosnia-Hercegovina. As virtually every criteria is met by the elderly in that community, it is particularly suitable for our consideration in this article.
The cohort size was nearly 2,000 which is big enough to give the outcomes from the study statistical significance. In specific relation to our considerations the opening sentence of their conclusions bears repeating verbatim:
"Elderly people in Bosnia-Hercegovina are at greater risk of undernutrition than other age groups. Undernutrition may be precipitated in elderly people by sickness, cold, stress, and problems related to food preparation."
It is probably significant that no signs of malnutrition were found in any of the children assessed. The strong implication being that the children were selectively fed in preference to the elderly. The authors point out that it is theoretically possible that all fractions were fed in the same way and that the elderly had lower absorption rates, but direct questioning and questionnaire use suggested strongly that the former premise is correct. The authors also comment upon the fact that for reasons that they could not explain, there was a marked statistical difference in the BMI once the age of 70 was passed. It appeared to drop more quickly that in the 60-69 yr. age range. The greatest weight loss (as an indicator of malnutrition) was seen in elderly people living alone. Part of the reason for this seemed to be the prevalence of chronic disease. The authors report that more than one third of the elderly said that they had had a recent illness that had prevented them from leaving their house in the preceding month. The main cause of such illness was chronic disease.
The authors concluded that one of the major factors that contributed to a disproportionate incidence of malnutrition in the elderly was the fact that the elderly required a disproportionately greater increase in their energy intake due to the cold weather and the difficulties and physical exertion in collecting fuel to keep warm, water and food rations. This is particularly relevant as the elderly have reduced ability to maintain body temperature.(Bennett & Ebrahim 1992). The authors identified many factors which were particularly relevant to the nutritional status of the elderly:
"age related disabilities which cause problems with vision and manual dexterity may have affected ability to prepare and cook meals. Violence, separation from families, isolation, and breakdown of formal and informal support systems may have triggered depressive illness, which is known to be accompanied by weight loss and ill health."
(Murphy E. 1985).
The authors also point to another, less obvious factor which may also have contributed to their findings, and that is the fact that because of the fighting and political unrest in the area, there was a disproportionate number of elderly in the area because of the able-bodied population had either largely left or was involved in the fighting. This meant that the normal support mechanisms were no longer operative and the elderly, being a particularly vulnerable group, were more likely to suffer from neglect-related problems.
The next paper that we shall review is rather a surprise. It purports to be a study of cognitive impairment in the elderly, but it's findings are that a great deal of cognitive impairment is secondary to dietary deficits. Gale (et al 1996) studies nearly 1,000 people intensively over a twenty year period, so the results are quite authoritative.
The major finding of the work was that cognitive impairment was positively correlated with an increase in mortality. The authors quote that those subjects who has a cognitive impairment greater than 7 on the Hodkinson mental test had the chance of dying from an ischaemic cerebro-vascular stroke increased by a factor of nearly 3. The interesting fact, from the point of view of this article, is that both cognitive impairment (and therefore risk of stroke) were independently linked to a reduction in Vitamin C intake. The authors were therefore able to conclude that Vitamin C status may be a factor in determining cognitive impairment in the elderly - presumably mediated through its effect on atherogenesis.
There have been a few other studies in this field. A Dutch study (Hachinski 1992) also found that a similar mechanism linked carotid atherosclerosis with cognitive impairment, so the results are likely to be a genuine finding. If you add to this the fact that the authors also found that cognitive impairment was commoner in lower socio-economic groups and manual workers, this correlates well with the findings of the
Vecchia (et al 1998) paper and "Our Healthier Nation" (DH: 1998) that the diet of the lower socio-economic groups tended to be deficient in vegetables ( and therefore anti oxidants ). The authors state that none of the other dietary variables correlated with the increase in cognitive impairment.
Because the study was a 20 year follow up study, a significant proportion of the subjects died during the follow up (nearly 90%). It was found that the death risk from all causes was raised by a factor of 2.2 for those subjects with significant cognitive impairment. Clinical signs of increased diastolic blood pressure and cardiovascular disease on admission to the study were the greatest predictors of "all risks" death and of the dietary variables, reduced Vitamin C intake was the strongest predictor of mortality.
Other studies have linked dietary intake with cognitive impairment Goodwin (et al 1983) reported poor cognitive performance with lower dietary intakes of Vitamin C, folic acid, riboflavin and Vitamin B12.
The authors make the very relevant criticism of their own paper that it is possible that a low Vitamin C level may be a consequence rather than a cause of cognitive impairment. This does seem unlikely in the light of the findings of Hachinski (1992) who was able to link cognitive impairment with atherosclerosis and the findings of Liu (et al 1990) and Swan (et al 1995) who were able to link the anti oxidant effects of the anti oxidants vitamins with a reduction in the atherosclerotic process. It is postulated that these anti oxidants vitamins work by protecting the LDL fraction from oxidation and thereby increasing their potential to carry cholesterol in solution in the blood stream and reducing the atherosclerotic potential.
Predictably, the authors call for further studies to assess the effects of prophylactic anti oxidants vitamins on cognitive impairment, atherosclerosis and all cause mortality.
We will consider the next paper in passing as it follows on from the discussions regarding dietary patterns and health in the elderly. Christen ( 2000) looked at the issue of anti oxidants in the role of Alzheimer's Disease. This is not thought to have (generally) an atherosclerotic aetiology, but due to inaccuracies in the ubiquitin-proteasome system and the inability to remove degraded protein. This paper is very technical and the findings are not - in the main - relevant to this article. However it is relevant in one respect. It quotes recent work which shows that anti oxidant activity prevents certain forms of nerve damage. (Chadman et al. 1997) and this, it is suggested, may help to prevent the general deterioration of motor function in the elderly.
They point to work which suggests that the anti oxidants may perform a protective role in a number of cerebral pathologies (Hartman 1995) (Halliwell & Gutteridge 1989). The authors point to a number of dietary constituents that have been shown to produce positive "anti ageing" effects including Vitamin E, selegiline and extracts from Ginko biloba (EGb 761). The authors also point to the fact the Parkinson's disease, Huntingdon's disease and others that have a similar aetiology to Alzheimer's Disease also show signs of response to anti oxidants.
In the last article that we shall review, we have chosen an article which again, considers cultural differences in diet as it's raison d'être. It considers the problem of diet in the Asian diabetic community. Greenhalgh (et al 1998) provide an excellent overview of the problems faced by the Asian population which has a high incidence of diabetes. This is thought to be partly a genetic phenomenon and also due to the high fat content of the typical Asian diet (Gittlesohn et al 1996). We will not concern ourselves here with the factors that are related to the diabetic control, but focus on those issues which come within the remit of the title of this article.
One striking feature of this particular study is the fact that all of the interviews were carried of by investigators who were from the community and therefore fully conversant with the culture. They comment on the fact that many of the respondents gave explanations for their dietary habits and beliefs that they were decided as a result of "God's will". The authors noted that:
"such views were usually held in parallel with acceptance of individual responsibility and potential for change. Indeed, both stoicism and adherence to particular dietary choices were perceived as the duty of the ill person."
One major cultural difference was highlighted by way of contrast with another study (Crawford 1984)
"Youth and health were usually viewed as virtually synonymous, and physical degeneration and weakness as an inevitable consequence of ageing" Once you are 40 eyes tend to give trouble. I am almost 55. So I am expected to have bad eyesight" (Bangladeshi man).
In contrast, Crawford's study of white women in the United States indicated that "health" for them was not merely the absence of illness but had to be earned by taking positive action in terms of diet and exercise in leisure time."
With regard to nutrition generally, the Asian subjects equated increased body size with increased health
Cultural differences impacted heavily on the ability to understand explanatory dietary leaflets and therefore directly on health. This, together with the common use of children as interpreters could lead to considerable difficulty in obtaining food that was both culturally acceptable and palatable. (Helman 1994)
Other discernible cultural differences included the belief that raw foods or those that had been baked or grilled, were generally considered "indigestible" and therefore not suitable for the elderly. The standard recommendation to the elderly diabetic to grill food rather than fry it was often ignored in the face of the persistence of cultural habits. (Airhihenbuwa 1995)
The authors point to other areas of conflict such as the frequency of feasts and festivals in the Asian culture. These are often accompanied by excessive eating of sweet foods. The elderly Asian cognitive impairment tends to make a compromise between culture and diet.
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