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Nutrition and Quality of Life in Older Adults

^a Frances Stern Nutrition Center, New England Medical Center, Boston, Massachusetts
^b Schools of Medicine and Nutrition, Tufts University, Boston, Massachusetts
^c Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts

Johanna Dwyer, Frances Stern Nutrition Center, 750 Washington Street, Boston, MA 02111 E-mail: jdwyer1{at}lifespan.org.

	Abstract

Top Abstract Definitions Reasons for Concern Dimensions of Quality of... Uses of Health-Related Quality... Relationship Between Nutrition... Recommendations for Assessing... Appendix References

 
Good nutrition promotes health-related quality of life (HRQOL) by averting malnutrition, preventing dietary deficiency disease and promoting optimal functioning. However, definitions of quality of life also encompass life satisfaction and both physical and mental well-being. Nutrition and diet have not been a part of mainstream research on quality of life and are not included among key quality of life domains. This article explores connections between diet and nutritional status in relation to HRQOL measures and overall well-being among older adults.

THE goals of this review are fourfold. First, we define terms such as health-related quality of life (HRQOL), functional impairment, and functional status. Second, we describe some common methods for measuring quality of life. Third, we examine some of the relationships between nutrition, nutritional interventions, and HRQOL in older persons. Finally, we provide recommendations for assessing and monitoring nutrition and HRQOL in older adults. This article focuses primarily on diet and nutritional status as they relate to HRQOL and functional status. However, the need for assessing and taking into account other sensory, psychological, and social aspects of food and eating is recognized.

	Definitions

Top Abstract Definitions Reasons for Concern Dimensions of Quality of... Uses of Health-Related Quality... Relationship Between Nutrition... Recommendations for Assessing... Appendix References

 
Appendix Table 1 provides definitions for such terms as quality of life, functional impairment, functional status, and nutritional status that are used in the article. The term functional status is usually restricted to physical status (as assessed by such measures as the activities of daily living [ADLs] or the Karnovsky Index) ⁽¹⁾⁽²⁾ and the behavioral competence to carry out very simple tasks that involve cognitive components, such as those in the instrumental activities of daily living (IADLs). Nutritional status is a multidimensional concept that includes dietary, anthropometric, biochemical, and clinical indicators of nutritional health. Thus, nutritional status is essentially a description of medically related characteristics and, as such, the concept is somewhat circumscribed in its focus. It fails to include sensory, psychological, and social aspects of food and eating that may also be important to the individual. Quality of life is also a concept with multiple dimensions that include the subjective sense of physical and/or mental well-being. In its broadest and most inclusive sense, it is sometimes referred to as "life satisfaction." A more specific and circumscribed use of the term is HRQOL. HRQOL focuses on the changes in physical and mental health dimensions that may occur with disease, aging, or alterations in functional status.

	Reasons for Concern

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The reasons for measuring HRQOL and functional status are that they provide a means of identifying and monitoring the impact of disease and interventions on the physical and mental health of elderly individuals as they themselves perceive this impact. Health-related quality of life is especially important among older persons because many of them are affected with chronic health problems and therefore traditional indices, such as reduced morbidity, may be less meaningful to them than subjectively assessed symptomatic improvement. Some of the causes of decreased HRQOL may be preventable and others are treatable with appropriate interventions. Thus, the potential for improving quality of life is considerable. Health-related quality of life is also more relevant to the subjective reality of the individual's daily life and to life satisfaction than are traditional measures of morbidity and mortality. Patient perspectives are especially important in chronic diseases since changes in HRQOL occur as the disease waxes and wanes, as well as with advancing age. Health care professionals may forget or fail to inquire about patients' HRQOL and emotional status because other urgent tasks intrude. Short questionnaires that ask about these issues and are incorporated routinely into patient visits can provide information on HRQOL that alerts clinicians to changes that otherwise might go unrecognized. If health-related quality-of-life measurement tools are included in the visit, professionals are more likely to spend time on such issues with patients ⁽³⁾. Medical and scientific technology has sustained and prolonged the lives of many older people. Although life extension is an advance, some older individuals survive but suffer a good deal of discomfort and disability. HRQOL measures help to highlight and quantify these problems, alert health professionals to their occurrence, and may trigger interventions that can ameliorate these problems. HRQOL measures may also help clarify the psychological implications of various interventions and procedures and help in tailoring interventions so that individual well-being is maximized ⁽⁴⁾.

	Dimensions of Quality of Life

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Researchers in the social and biomedical sciences conceptualize and use the term "quality of life" differently. The broadest use of the term quality of life by social scientists refers to overall life satisfaction. Some of the dimensions (constructs or domains) that are covered in life satisfaction include general behavioral competence, perceived quality of life, psychological well-being, physical/physiological status ⁽⁴⁾, and other environmental factors (such as living alone) that can be objectively assessed and that may also influence one's satisfaction with his or her lot ⁽⁵⁾. Appendix Table 2 describes each of these dimensions in greater detail. The domains and constructs encompassed by the HRQOL measures are much narrower and more specific than those employed by social scientists. The HRQOL concept is more biomedically oriented, focusing upon physical and mental health dimensions that change with disease, changes in functional status, or treatment of these changes.

Some researchers find it helpful to think of the various measures of life satisfaction and quality of life as constituting a hierarchy, similar to that popularized by Abraham Maslow ⁽⁶⁾ in his "hierarchy of basic needs." The most basic needs are simply measures of functional status, such as ADLs ⁽¹⁾, which focus on physical function, and minimal psychological and social functioning required for independent living (IADLs) ⁽⁷⁾. Although these basic functions have some nutritional aspects, few are specified precisely or evaluated when these tools are used. For example, the ADL ⁽¹⁾ has an item that evaluates the ability to eat independently, and the IADL ⁽⁷⁾ has items that evaluate the ability to shop and cook, but none of the dimensions of these tools are specific to nutrition except as they relate to these basic functions. Other measures of functional status, such as the Karnovsky Index ⁽²⁾, also involve very basic needs. More complex or higher level functions related to food and eating, such as the ability to choose one's own diet or enjoyment of food, are not included in any of these instruments. Food-, eating-, and nutrition-related functions and dimensions tapped by HRQOL tools are also limited in their scope and focus on "basic needs" or vegetative functions rather than on higher order sensory and cognitive dimensions of food and eating. This is understandable, since much of the initial interest in nutrition focused on nutritional status as it was associated with medical treatments and HRQOL. However, other dimensions of food and eating that involve enjoyment are also important, especially for older persons. Global tools that measure overall life satisfaction and quality of life do not explicitly tap these nutritional dimensions.

	Uses of Health-Related Quality-of-Life Measures in Nutrition

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It is important to determine which dimensions are of greatest interest when one is selecting tools to measure quality of life. Many or only a few dimensions may be involved, even when the focus is limited to HRQOL. The uses to which HRQOL measurements will be put largely determine what dimensions the tools need to include. Common uses include the following: providing data to assist in clinical decision making; evaluating differences in quality of life between populations and/or individuals; helping to elucidate factors that contribute to changes in quality of life; determining this dimension in surveys of health care quality; and evaluating the effectiveness of interventions. HRQOL measures are also used as screening tools for improving management of chronic diseases and illnesses in patients.

	Relationship Between Nutrition and Changes in Quality of Life in Older Adults

Top Abstract Definitions Reasons for Concern Dimensions of Quality of... Uses of Health-Related Quality... Relationship Between Nutrition... Recommendations for Assessing... Appendix References

 
Age-Associated Changes That Affect Quality of Life
The relationships between nutrition, aging, and quality of life are recursive. Aging-caused or aging-associated factors alter certain aspects of nutrition, such as the sense of smell and taste, ability to chew and swallow, and gastrointestinal and bowel function, and these in turn may influence quality of life. At the same time, poor nutrition and lack of physical activity can lead to lack of appetite, inability to perform ADLs, changes in quality of life, morbidity, and mortality.

Appendix Table 3 summarizes some of the physical and psychological changes that occur with aging that have potential adverse impacts upon the nutritional aspects of HRQOL ^(8)(9)(10). These include changes in body composition, physiology, disease burden, and social functioning. All of these changes potentially influence the individual's HRQOL. Poor nutrition causes many of the changes in functional status that take place during aging. Therefore, it is important to assess diet and nutritional status when evaluating HRQOL and to alter poor nutritional status whenever it is possible to do so ^(8)(11)(12). It is also important to tap other dimensions of experience associated with dietary behaviors, such as taste, enjoyment, and social aspects of an elderly person's eating experiences. There is therefore a need to measure functional status and HRQOL, in addition to nutritional status.

Benefits of Food and Nutrition on Quality of Life
Good nutrition improves HRQOL by promoting health, preventing dietary deficiency disease, and ameliorating or averting secondary malnutrition that is caused by or associated with other disease. Food and nutrition are essential components of "the good life." Good food is a sensory and psychological pleasure in its own right. Meals may also add a sense of security, meaning, order, and structure to an elderly person's day; imbue that person with feelings of independence, control, and sense of mastery over his or her environment; and provide opportunities for making food choices. Eating with others may increase social interactions. When the social aspects of eating are attended to, food consumption may increase, thereby improving nutritional status ⁽¹³⁾. The positive psychological and social aspects of eating are important pleasures of life, which can persist into old age. They have potent contributions to well-being that must not be forgotten ⁽¹⁴⁾.

The sequelae of malnutrition include physical, mental, and social disability. If inadequate dietary intake continues for a long time (e.g., weeks or months), undernutrition results. If undernutrition is extreme, it results in diminished muscle mass and vigor, functional impairment, and decreased HRQOL ^(15)(16). Malnutrition also causes lack of enjoyment in eating and anorexia, which may generate psychological, medical, and social problems. Some relevant examples are noted in Appendix Table 4. The associations between malnutrition and disability can operate in both directions. Malnourished individuals are likely to be disabled, and disabled individuals are at greater risk for nutritional problems because of their greater dependence on others ⁽¹⁷⁾. Undernutrition can also cause stigmatization of the afflicted elderly person by others. For example, very thin, cachectic individuals are viewed as being ill and are often singled out by healthier elderly individuals as being "old and sick" ⁽¹⁸⁾.

Excessive dietary intake and insufficient physical activity also may pose health and mental health problems, especially when they result in obesity, as studies of obese elderly individuals in rural Pennsylvania have shown ⁽¹⁹⁾. The consequences of obesity include increased risk of diabetes, cancer, cardiovascular disease, and premature death ⁽²⁰⁾. Excessive intake of alcohol also has a well-known toxic effect on mental health, social interaction, physical health and well-being, and HRQOL. Both inadequate and excessive intakes of some vitamins and minerals may also cause health and mental problems in older individuals ⁽²¹⁾.

Specific Nutritional Problems and Associations With Functional Status and Health-Related Quality of Life
Some common nutritional conditions and problems associated with aging that may affect quality of life were described in Table 3. Table 4 describes examples of some of the types of malnutrition and their possible association with two measures of functional status. These conditions have been studied extensively from the pathophysiological standpoint, with an emphasis on how their occurrence modifies health status, but links between them to quality of life have rarely been studied.

Each of these malnutrition-related conditions may affect functional status differently. The specific nutritional dimensions affected are usually not documented completely, nor is the degree to which malnutrition is associated with each disease or how it adversely impacts outcomes.

Tools for Measuring Quality of Life
Many measures and scales have been used to address and quantify the impact of nutrition on HRQOL. Until recently, most were used only in research studies. Today they are used increasingly in clinical settings as well.

Different types of HRQOL tools are needed for each purpose. HRQOL measures include general/generic tools (see Appendix Table 5) that can be used in many conditions, and disease-specific tools (see Appendix Table 6) that are designed for specific conditions. The generic tools, such as the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) ⁽²²⁾, assess general health from a holistic standpoint. Disease-specific tools focus on specific health, functional, and other problems (e.g., psychological and social) associated with a specific disease or condition, and also contain some general questions. One example of such a tool is the Kidney Disease Quality-of-Life Questionnaire (KDQOL) ⁽²³⁾, which is used extensively among patients in end-stage kidney disease ⁽²⁴⁾.

Appendix Table 7 provides examples of some recent studies of HRQOL among persons who varied in their nutritional status or who were afflicted with diseases that have nutritional implications. These variations affected HRQOL differently.

	Recommendations for Assessing and Monitoring Nutrition and Quality of Life in Older Adults

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Selecting a Tool
The search for the perfect HRQOL measurement tool has led to the development of many tools, but none has been universally recognized as perfect or adopted as a "gold standard." However, useful criteria for sorting out the "better" tools among those that exist include practicality, content, scaling, aggregation, reliability, validity, and specificity for the target group ⁽²⁵⁾. These are provided in Appendix Table 8.

The most appropriate tool depends on the goals of the user, the resources available, and how the results or data will be used. Performance assessment or patient-related decision making requires one sort of tool, while a research study may require another. Measurement strategies for each application also vary. For example, an immediately accessible, computerized, HRQOL assessment that is self-administered permits the patient or health care professional to identify and quantify perceived HRQOL, and may be more appropriate for clinical purposes than an interviewer-administered paper-and-pencil tool that takes weeks to analyze ⁽²⁶⁾. One-item and/or one-concept tools may be better suited for population surveys. In outcomes research, a short form with additional, more specific questions may be of greatest assistance. For example, the KDQOL ⁽²³⁾ is useful in outcomes research involving kidney disease, whereas a multi-item short form may be more appropriate for evaluating the quality of health care (e.g., SF-36) ⁽²²⁾.

The content of the quality-of-life measurement tool is important. For some purposes, not only HRQOL but additional dimensions of the food and eating experience and functional status are all relevant and should be measured. At the very least, some of these dimensions need to be assessed.

The form in which output of data is produced from the use of the measuring tool is also important, especially if many different health care providers must use and interpret these data. Some tools, such as the Nottingham Health Profile ⁽²³⁾, that present data as profiles provide independent scores or subscales for each of the categories examined within the measurement tool ⁽²⁷⁾. This type of scoring makes it easy to pinpoint areas that are of concern and permits comparisons to norms. It also provides a means of examining changes within each domain or between individuals and helps in tracking an individual longitudinally. If the instrument provides scores compared with an appropriate normative population, the profile also permits one to assess the patient in comparison with others. A second method of presenting results involves assigning a single score that encompasses all categories contained in a tool (e.g., Campbell's Index of Well-Being) ⁽²⁸⁾. Some tools (e.g., the Sickness Impact Profile [SIP]) ⁽²⁹⁾ can be presented in both ways, as a composite score and with subscores by categories ⁽²⁷⁾.

Two potential problems related to data collection are "floor" and "ceiling" effects. Sometimes a tool is designed with questions targeted to a "healthier" group. These tools are unable to pick up differences on the lower end of functioning and result in low scores across the board when individuals, such as those who are extremely disabled, are evaluated. This phenomenon is referred to as the "floor effect." For example, if one were to ask a population of terminal cancer patients if they liked the hospital food, the responses would probably be negative. However, it would be false to assume that the food was unacceptable based on the results in this single population.

The higher end of the scale can also be overlooked, resulting in a "ceiling effect." For example, if a group of healthy, older bodybuilders were asked about their ability to eat without assistance, to shop, or to carry groceries home from the supermarket, all would report carrying out activities with ease, and all would obtain high scores. However, it would be impossible to distinguish between them. One way to avoid floor and ceiling effects is to make sure the questions being asked appropriately assess the relevant aspects of HRQOL that are being studied. A current need is to develop more complete inventories of nutrition and eating-related factors at varying levels of function.

Finally, it is critical that the HRQOL tool being used has been validated in the specific population being studied (e.g., elderly renal patients). Many disease-specific tools, such as the Osteoporosis Quality-of-Life Questionnaire ⁽³⁰⁾, and the KDQOL have been well validated and are available. They should be given priority in use.

Recommendations
In quality-of-life studies, it is critical to define the dimensions of HRQOL, functional status, and other relevant aspects of the food and eating experience (as they relate to sensory, psychological, and social dimensions) pertaining to the person or study in question ⁽³¹⁾. It is also important to obtain a detailed description of the measurement tool(s) to be used, including dimensions explored and the reliability and validity of the instrument ⁽²⁷⁾. Such information should be available when the research is planned and presented when research is reported. It allows researchers to compare their results with other quality-of-life studies.

For clinical determination of HRQOL, our preferred instrument is the versatile SF-36 ⁽²²⁾. There is an abundant amount of research on its validity and reliability among elderly individuals in clinical and free-living settings ⁽³²⁾. It provides enough detail to be useful; it is easy to administer, brief, and well accepted with relatively high participation rates (82% among those aged 65–74 years and 73% among those aged >75 years according to one study). Also, it has already been used in several large studies involving the health of elderly individuals.

For research, the tool selected depends on the purpose of the study. In addition, if a specific disease is being studied, it may be advantageous to use disease-specific tools in addition to generic tools. For example, study ⁽²⁴⁾ of hemodialysis patients uses a combination of the Karnovsky Index, Campbell's Index of Well-Being ⁽²⁸⁾, SF-36 ⁽²²⁾, and the KDQOL ⁽²³⁾.

The measuring tools specified for assessing achievement of national goals, such as the Healthy People 2010 ⁽³³⁾ objectives in relation to nutrition and quality of life may be more appropriate for public health purposes. Specific tools specified for gathering this information include the Healthy Days and Years of Healthy Life measures ⁽³³⁾. The Healthy Days measures consist of Self-Rated Health, a Healthy Days index, and Activity Days. These are defined and described in greater detail in Appendix Table 9.

For descriptions of nutritional status in a clinical setting, the Nutrition Screening Initiative checklist may be useful, but it does not directly measure HRQOL ^(34)(35). The Nutrition Screening Initiative checklist ⁽³²⁾ examines clinical features of the patient, eating habits, living environment, functional status, and mental/cognitive status. In short, it is valuable in exposing barriers to good nutritional status and can be adapted according to the setting in which it is administered. Two observer-administered instruments of functional status are the ADL ⁽¹⁾ and the Karnovsky Index ⁽²⁾.

Conclusions
A broader conceptual model of the nutritional dimensions of health-related life satisfaction, including affect and cognitive sense of control, is needed. Proper nutrition prevents health problems; it can improve health, help avert impairments in functional status, and increase quality of life and well-being in older adults. This statement may be obvious to nutrition professionals, but still needs to be recognized and made operational in the rest of the health care community (as well as by providers and policymakers). Nutrition and diet therapy are adjunctive interventions that can improve outcomes of medical treatment among elderly individuals ⁽³⁶⁾. Many diseases that are known to be related to nutrition also affect functional independence and status. Most research in the field of nutrition has omitted investigations on the role of nutrition therapies on quality of life ^{(12)(23)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)}. Most quality-of-life tools in use today include very few or no items that directly relate to nutrition. There is a need to develop generic tools that do so ⁽²³⁾. In the meantime, the existing tools can be used to assess the impact of nutritional status and quality of life. More studies relating nutrition to quality of life will illustrate and strengthen claims that nutrition improves quality of life. In a sector where many are competing for limited reimbursement dollars, health-related quality-of-life outcomes are an asset. In fact, health economists have used health-related quality-of-life measures for valuation and decision making in health care ⁽²⁵⁾.

At present, the most widely accepted methods for measuring quality of life that can be self-administered include the SF-36 ⁽²²⁾, the SIP ⁽²⁹⁾, and the Nottingham Health Profile ⁽²³⁾. Other dimensions of life enjoyment involving food need to be developed.

In assessing associations between nutrition and quality of life in older persons, it is helpful to control for coexisting diseases. These associations vary by disease severity, as well as type of disease (e.g., kidney disease vs arthritis). The most salient aspects of nutrition that affect quality of life also vary by setting. For example, among free-living older persons, convenience of food preparation may be very important, whereas in assisted care, a menu that includes choices and favorite foods is more important. In brief, nutrition's impact on quality of life in each setting and disease will vary depending on all of these factors.

Quality-of-life measures should be routinely employed in clinical, research, population, and policy-related situations. Standardized measures are vital. In the future, perhaps decisions for reimbursement for health services related to nutrition should include quality-of-life measures.

The Appendix Table 10 provides nutrition-related resources that may be useful for older persons.

	Appendix

Top Abstract Definitions Reasons for Concern Dimensions of Quality of... Uses of Health-Related Quality... Relationship Between Nutrition... Recommendations for Assessing... Appendix References

 

	Acknowledgments

We also acknowledge the contribution of Grace Kang, MS, RD, in the completion of this article, and Sharon Ployer, who typed the final draft.

	References

Top Abstract Definitions Reasons for Concern Dimensions of Quality of... Uses of Health-Related Quality... Relationship Between Nutrition... Recommendations for Assessing... Appendix References

 

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